Gynaecological Cancers

There are 5 types of gynaecological cancers;


  • Endometrial or Uterine Cancer

  • Ovarian Cancer

  • Cervical Cancer

  • Vulval Cancer

  • Vaginal Cancer

 

Cancer of the Womb




Other names include Uterine Cancer or Endometrial Cancer and it is the most common of the 5 gynaecological cancers. It is also the 4th most common cancer overall, affecting UK women.

9,300 women in the UK are diagnosed each year, most of these women are over 50y


Endometrial Cancer originates in the cells that form the lining of the womb. These abnormal cells change, grow and duplicate at a much faster rate than normal cells to eventually form a growth, or tumour. As it gets bigger, it invades nearby structures. If it invades a blood vessel, the cancer cells will enter the blood stream and spread to other areas of the body, where they form more tumours. This process is called metastasis.


Symptoms

Abnormal vaginal bleeding is the most common symptom. This may be bleeding after the menopause or in between periods, sometimes it may only be a change in the heaviness of blood flow or a persistent blood-stained vaginal discharge. Although it is very important to report any unusual bleeding to your doctor, it is also important to remember that the majority of abnormal bleeding has a non-sinister cause, such as Vaginal Atrophy.

Risk Factors

1. Excess Oestrogen 

2. Faulty Gene- found in Lynch Syndrome

Excess Oestrogen may occur from a raised BMI (because fat cells store more oestrogen)




Diagnosis

Diagnosis of Uterine Cancer is made by 2 procedures

1. TVU (trans-vaginal ultrasound)

2. Taking a sample of the womb lining (the endometrium)

Diagnosis CANNOT be made by a cervical smear because uterine cancer grows much deeper than the cervix and therefore the smear does not pick up the abnormal cells. Don't be reassured by a negative Cervical  smear if you continue to have abnormal bleeding or discharge.

Treatment

1. Hysterectomy- removal of the uterus. This is sometimes all that is required if the cancer is caught early and has not invaded nearby structures. Both ovaries and fallopian tubes are also removed.

2. Chemotherapy or Radiotherapy may be required if there is a concern that the cancer has spread to other places.

3. HRT is prescribed to women who are still actively menstruating, to help with the symptoms of a surgically induced menopause.


The TVU  is a type of internal ultrasound scan where a small probe is placed directly inside your vagina so the technician can visualise the utuerus with more clarity. The probe is more narrow than the width of a penis and is not painful. Some women who are anxious or suffer from vaginismus, however, may experience some discomfort.


If the TVU shows a thickened lining the clinician will take a biopsy (a sample of cells). This is often done under a local anaesthetic during outpatient clinic but you can opt to have it done under a general anaesthetic.


Another diagnostic procedure that can be done under a general anaesthetic is a hysteroscopy ( a special microscope used to do a more thorough internal examination of the womb). Having this procedure allows the surgeon to remove any surplus or thickened lining which may be responsible for very heavy bleeding. This tissue is also sent to the laboratory for further examination.

 

Ovarian Cancer

  • This has been called the Silent Killer because of symptoms may be very subtle

  • It is the 6th most common cancer in women

  • 7,300 women in the UK are diagnosed each year, most of whom are post-menopausal



There are different types of ovarian cancer depending on which part of the ovary the cancerous cells originate from. Each type of ovarian cancer has a different set of survival rate statistics, treatment options and outcome. The types of ovarian cancer are;


  • Epithelial ovarian cancer – the most common

  • Fallopian tube cancer- many ovarian cancers start here

  • Germ cell ovarian cancer - rare and more common in  teenagers.

  • Stromal ovarian cancer

  • Metastatic – meaning the cancer originated from another part of the body and spread to the ovary.

     


If caught early, the chance of survival from ovarian cancer is much better. Ovarian cancer will continue to grow in the ovary until it breaks through the surface and invades structures within the abdomen. Many ovarian cancers are not detected until later stages because the symptoms can be vague or mimic non-sinster conditions such as irritable bowel syndrome and pre-menstrual syndrome.


Symptoms

  • increased abdominal size and/or persistent bloating (bloating that doesn't come and go)

  • Pain in the lower abdomen/pelvis (pain is usually perisistent)

  • Change in bowel habit that can't be explained

  • Difficulty eating, feeling very full or nauseas soon after eating


Other symptoms include pain during intercourse, lower back pain and increased frequency in urinating are reported symptoms but these also are very common symptoms present in non-sinister conditions.




Risk Factors

1. Age- 80% women diagnosed with ovarian cancer are post-menopausal

2. A Family History (This means there are 2 or more close relatives e.g. mum/sister/daughter who have had ovarian or breast cancer and the risk is higher if any of these relatives were under 59y at time of diagnosis).

3. Specific genes called BRCA1 and BRCA2 are linked to ovary and breast cancer. If there is suspicion of gene-based cancers, a blood test can be requested to look for either of these genes.

4. Endometriosis slightly increases the risk of developing one of the more rare forms of ovarian cancer.





Interestingly, several factors are known to reduce a woman's chance of developeing ovarian cancer. The contraceptive pill is known to be protective, as are having multiple pregnancies and breast feeding. This is due to a woman releasing less eggs from her ovary over her lifetime.




Diagnosis



1. GPs can request a blood test looking for the chemical marker Ca125 which rises when there is inflammation in pelvis or abdomen. Other conditions can cause a raised Ca125 e.g. endometriosis or Pelvic Inflammatory Disease (PID).

2. If the Ca125 is raised, an ultrasound scan is performed.

3. A CT scan and biopsy is performed to stage the newly diagnosed cancer.






Treatment



1. Surgery- removal of ovaries and fallopian tubes (bilateral salpingo-oophorectomy). The womb is sometimes removed too, along with other structures from the abdomen e.g. part of bowel, omentum and lymph nodes.


2. Chemotherapy- many different types of chemotherapy exist. The exact combination will be decided according to the type, stage and other individual factors.


 

Cancer of the Cervix






The cervix is the muscular structure that forms the neck of the womb. It is the passageway the connects the top of the vagina to the uterus. Cancer can develop in the cervix.

Most cervical cancers arise in squamous cells and the majority of these are caused by a common sexually transmitted infection called human papillomavirus (HPV). This is why the UK government is vaccinating girls at an early age before they are potentially exposed to the HPV virus (i.e. before most experience sexual activity). Sex is a normal, healthy activity, and the wearing of condoms is advised to protect both partners from unwanted pregnancies and reduce exposure to HPV, as well as other sexually transmissible conditions.




Because HPV is so common, most women will come into contact with HPV at some stage during their life, but the body often clears the virus without the need for any treatment.
HPV is a group of viruses, of which there are more than 100 different types. It is spread during sexual intercourse and other types of sexual activity (such as skin-to-skin contact of the genital areas).


However, if the body is unable to clear the virus, the virus causes changes at a cellular level and there is a risk of abnormal cancer cells developing over time. Cell changes are seen in cells of the cervix and the vulva and therefore HPV plays a role in the development of both these types of gynaecological cancer.


Before a cancer develops, cells undergo a process of steps before they turn into dangerous cancer cells. These pre-cancerous changes occuring within the cell can be seen under a microscope. Cervical cells are easily accessible and can be collected and screened for pre-cancerous changes.


Cells are collected during a relatively simple procedure called a Cervical Smear. The UK Cervical Screening Programme saves approximaelty 4000 lives each year.


  • Most women who have cervical cancer are aged 30-45y.

  • It is very rare in women under 25 years of age.


Symptoms


1. Unusual bleeding

2.Pain or discomfort during sex

3. unusual smelly discharge

Many women have no symptoms at all. It may not show itself until it is at an advanced stage and spread to other places. Thsi is why women are strongly encouraged to attend their regular cervical smear testing.



Risk Factors


  1. HPV infection (the virus that caused genital warts) although not all women harbouring this virus will be vulnerable to cervical cancer

  2. Smoking – the risk of developing cervical cancer is doubled

  3. Immunosuppression drugs – medication that weakens the immune system have increased risk of developing cervical cancer.





Diagnosis


The cervical smear may detect pre cancerous changes in the cells. It does not mean it is cancer and people may be referred to a colposcopy clinic or gynaecologist

GPs will also refer weomen whobhave other symptoms such as unusual bleeding, abnormal appearnace on examination etc


Colposcopy is type of examination procedure where a small microscope is used to examine the cervic more closely. It also allows boipisies to be taken. The layers of cells are taken from a deeper segment, rather than just the surface. It is much the same as having a smear but you are placed in abed with stirrups. The speculum is used in the same way and the uiage if the cervix is seen on closed circuit TV and scope.



Treatment

If the cancer is caught early, there is a very good chance that a woman can be completely cured. If the cancer has spread deeper into the cervix or to nearby structures, it will be given a Grade and this will give an indication of the survival rates.

Precancerous Cells- are removed using a diathermy wire by a Loop Excision or Cone Biopsy


Cancer of the cervix can be treated surgically by;


1. Radical trachelectomy – cervix and upper part of vagina and lymph nodes are removed. The uterus is left in place. This is only suitable for less advanced cancers.


2. Hysterectomy – the cervix and uterus are removed, plus lymph nodes.

3. Pelvic Exoneration – a major operation where the cervix, vagina, womb, bladder, ovaries, fallopian tubes and rectum are removed. This is done as a second procedure when the cancer has returned and there is a chance that it can be completely removed. 

4. Radiotherapy may be an alternative to surgery because it has a similar cure rate. It is used when surgery poses a risk to cancers that lie very close to the bladder or bowel and could be damaged when surgically removed.


 

Cancer of the Vulva

The Vulva is the part of the femal genitals that are visible. The vulva includes the labia, the clitoris and some glands.

Most vulval cancers occur in women over the age of 60y

A small percentage of vulval cancers occur in the younger age groups

There are several types of vulval cancers including a the skin cancer melanoma but this is very rare. A lot of vulval cancers arise from inflammatory skin conditions of the vulval skin such as Lichen Sclerosus and VIN.

VIN is vulval intraepithelial neoplasia which is a precancerous stage where cells have undergone changes that may develop into cancer. Sometimes VIN settles without treatment, but often it is carefully monitored by a gynaecologist or dermatologist. VIN takes about 10 years to develop so it is a very slow and gradual process. There are 2 types;

1. Usual or undifferentiated VIN – mainly affecting women under 50y, and due to the HPV
2. Differentiated VIN (dVIN) – affects women over 60y, more rare and more likely to cause cancer






Symptoms


  • Persistent Itching

  • Soreness of the vulva

  • Skin changes which may be patches of red, white, darkened areas that are raised and thickened

  • Open sores

  • Visible growth, lump or swelling of the vulva

  • Skin mole that is changing

Any of theses symptoms are more likely to have a non-sinister cause but should always be checked out by a doctor


Risk Factors


  • Age- most cases occur in older women

  • Diagnosed with VIN

  • Skin conditions such as Lichen Sclerosus

  • HPV (see above)  is present in 40% of women with vulval cancer

  • Smoking affects the immune system and may reduce the body's ability to clear HPV




Diagnosis


The vulva needs to be examined by a doctor who will look for any suspicious skin changes or swellings. If there are any lumps, ulcers, unexplained skin changes or abnormal bleeding, your doctor should refer you to a gynaecologist.


The gynaecologist will likely take a biopsy of the affected areas so that it can be looked at closely under a microscope to determine if there are pre-cancerous or cancerous cells present.

Treatment


Most women will require some form of surgery to remove the affected area.

Some women will also need radiotherapy and/or chemotherapy.

The extent of the surgery will depend how much of the vulva is affected and what stage the cancer is at. Women with smaller lesions will have a wide local excision, other women will require more extensive surgery called a radical vulvectomy. This procedure removes the labia, clitoris and lymph nodes.



 

Cancer of the Vagina

  • This is a rare cancer, only affecting 250 women per year in the UK 

  • The vast majority are over 60y 

  • These types of cancer are skin cancers such as squamous cell carcinoma or melanoma.



Symptoms

Early stage vaginal cancer does not usually present with obvious symptoms. Later stage cancers may have the following symptoms

  • Abnormal bleeding (BTB, PCB, IMB)

  • Discharge, smelly or blood stained

  • Painful intercourse

  • A lump or growth

  • Persisting itch

  • Pain on Puing

  • Persistent Pelvic and vaginal pain

Most of these symptoms are far more likley to have a non-sinister cause



Risk Factors

  • Age (much more common in women over 60y)

  • HPV - 66% women with vaginal cancer have the HPV

  • Precancerous changes in cervix (CIN) OR Vagina (VAIN)





Diagnosis


  • Examination by your GP

  • Referal to a gynaecologist who will examine and perform a colposcopy

  • Biopsy of affected or suspicious areas

  • Staging to see if the cancer has spread which includes xrays, CT, MRI and possibly a more detailed examination under anaesthetic

Treatment

Treatment is a combination of surgery to remove the cancer and radiotherapy and/or chemotherapy if it has spread

Radiotherapy is the main treatment used and can be administered in two ways

1. external beam radiotherapy – a machine beams high-energy rays at your vagina and pelvis
2. internal radiotherapy – a small radioactive device, is put into your vagina for a short period of time – normally a few hours. This is also known as brachytherapy

Surgery


There are four main types of surgery used to treat vaginal cancer, depending on the extent of the disease:


Partial vaginectomy – removing the upper section of your vagina
Radical vaginectomy – removing all of your vagina and pelvic lymph nodes
Radical vaginectomyand radical hysterectomy  removing all of your vagina, womb, ovaries,fallopian tubes and pelvic lymph nodes
Pelvic exoneration – removing all of your vagina and surrounding tissue, including the bladder and/or rectum (back passage)

 

Support and Advice

The Eve appeal

http://www.eveappeal.org.uk

Charity funding research focused on developing effective methods to predict, detect and treat gynaecological cancer and working to raise awareness of these cancers. The website includes information about cervical, ovarian, uterine, vaginal and vulval cancers.

Macmillan Cancer Support

http://www.macmillan.org.uk

Macmillan provides practical, medical and financial support and information to help improve the lives of people living with cancer, their families and carers. The website also includes information about the main types of gynaecological cancer.

Cancer Help UK

http://www.cancerhelp.org.uk/index.htm

Cancer information provided by the charity Cancer Research UK, including information on the different types of gynaecological cancer. Cancer Research UK also offer advice and support to patients, their families and carers on coping with cancer.

My Cancer Treatment

http://www.mycancertreatment.nhs.uk/

My Cancer treatment is a website that helps people to locate and compare NHS cancer services across England. Using the ‘Find Your Treatment’ search tool visitors to the website can easily search for information on NHS cancer services by postcode, hospital or cancer type.

Jo's Cervical Cancer Trust

http://www.jostrust.org.uk

Charity offering support and providing information to anyone affected by pre-cancer and cancer of the cervix.

Womb Cancer Support UK

http://www.wix.com/wombcancersupportuk/home

Organisation offering online advice and support to women who have been affected by womb cancer and their families.

Ovacome
http://www.ovacome.org.uk

Charity providing a UK-wide support network and information to anyone affected by ovarian cancer


Ovarian Cancer Action
http://www.ovarian.org.uk

Charity working to raise awareness and provide information and support to anyone concerned about ovarian cancer. The charity also provides funding for the Ovarian Cancer Action Research Centre.


Target Ovarian Cancer
http://www.targetovariancancer.org.uk/

Charity providing information and support to anyone affected by ovarian cancer and funding research to improve the diagnosis and treatment of the disease.