Gynecological Cancers

June 2, 2004

By Ann Hoffman, MD



The female genital tract includes the cervix and uterus, the ovaries and Fallopian tubes, the vagina, and the vulva (external genital area). Cancer can occur in any of these areas. What are the symptoms? How are they diagnosed? And what treatments are advised?

Cervix
Cancer awareness is probably highest in regards to the cervix. In the last 50 years, there has been a two-thirds drop in this type of cancer. This is due to consistent annual pap smears, which detect changes earlier. Risk factors include multiple sexual partners, sexual activity at a young age, human papilloma virus (HPV), smoking, and HIV.
The best screening for the cervix is a regular pap smear, which should be done in all women who have ever been sexually active. Since pap smears are only a screening tool, annual repetition is important. If the pap is abnormal, or there is a visible lesion on the cervix, a colposcopy is usually done. This exam of the cervix with a microscope uses solutions or stains to highlight the abnormal areas. From there, biopsies lead to a more accurate diagnosis.
Treatment options for precancerous changes include repeat paps, freezing, laser, or cone biopsies. These biopsies are often done in the office with a procedure called a LEEP, which removes abnormal areas and is an effective treatment. Follow-up includes more frequent pap smears.
For those diagnosed with cervical cancer, the treatment options include surgery, radiation, and chemotherapy, depending on the size and extent of the cancer. Sometimes all three treatments are used. One common misconception is surgery is always the answer. In reality, it is generally only done in early-stage cancers. For more advanced cancers, radiation and chemotherapy are the main treatments.

Uterus
Cancer of the lining of the uterus is the most common gynecological cancer. Risk factors include the use of estrogen without progesterone, obesity, women with no births or few births, diabetes, and high blood pressure. Women who have more pregnancies or who use hormonal birth control have less risk.
The most common symptom is abnormal bleeding, especially post-menopausal bleeding. This can be spotting or heavy bleeding. Evaluation is usually done by biopsy, hysteroscopy, or a D & C.
Treatment usually includes a hysterectomy and often removal of the tubes and ovaries. Often lymph nodes are removed for evaluation. This may be followed by radiation and/or chemotherapy, depending on the stage of the cancer. Precancerous changes can also occur in the uterus. Some of these have a small risk of progression to cancer and can be managed with hormonal treatment. A higher level of precancerous change is most commonly treated with a hysterectomy.

Ovary and Fallopian tube
Ovarian cancer accounts for a large percentage of the deaths from gynecological cancer, although a woman's risk of developing ovarian cancer is around one or two percent. Risks include infertility, few births, using talc in the genital area, a high-fat diet, lactose intolerance, previous breast or colon cancer, and a family history of ovarian cancer. Use of oral contraceptives seems to decrease risk.
There is no test for it ovarian cancer. Ovaries move freely in the pelvis, allowing them to enlarge significantly before symptoms appear. Cancer cells can also spread easily throughout the abdomen. By the time symptoms develop, such as pain, bloating, or digestive or urinary problems, the cancer can be advanced. Although the Ca-125 blood test is not very accurate for diagnosis, it may help. Ultrasound can also help, but benign changes cannot always be distinguished from malignant ones, leading to surgery for both. The best precaution is an annual exam.
diagnosis and determining the stage of the cancer are both done surgically. Most patients require chemotherapy, and radiation is sometimes used as well. A second-look surgery is sometimes done after chemotherapy to look for residual cancer. The rate this cancer reoccurs is largely dependent on the stage of the cancer at the time it is diagnosed.
Cancer of the Fallopian tubes is the least common gynecological cancer. The most common symptoms are pain and abnormal bleeding. Treatment is similar to that of ovarian cancer: surgery, followed by chemotherapy, a second-look surgery, and possibly more chemotherapy.

Vagina
Cancer of the vagina is also uncommon and occurs mostly in postmenopausal women. Precancerous changes can be noticed during a pap test and evaluated by colposcopy and possible biopsy. Treatment options include laser or surgical removal, or sometimes radiation or a topical chemotherapeutic cream.
Symptoms of malignancy can include abnormal bleeding or vaginal discharge, and, less frequently, pain or problems with urinary or bowel function. Radiation is the usual treatment, though in some cases, surgery may be of value.

Vulvar
This type of cancer is also most frequently seen in menopausal women, but it can occur in young women too. Risk factors include smoking, high-risk strains of HPV, other precancers or cancers of the genital tract, and immune changes.
Precancerous lesions may appear white, red, or dark. The area may be raised or look like genital warts. There may be itching or irritation. Diagnosis is made by examination, often including a colposcopy, and by biopsy. Treatment consists of surgical excision, laser, or (occasionally) a topical chemotherapeutic medication. Sometimes lymph nodes are sampled and radiation is used.
Conclusion
Prevention of cancer is always the best situation; catching a cancer early is the next best. Regular exams and pap smears are important as is talking to your doctor about any pain, abnormal bleeding, or other changes.