Cervical Screening
Definition
- Anyone with a cervix between 25-64yo
- Cervical sample tested for high-risk HPV
o Subtypes 16, 18, 33 = carcinogenic
- Pts recalled every 3yrs if 25-49, then every 5yrs if normal
- Screening in pregnancy usually delayed until 3mths post-partum
o Unless missed screening/prev. abnormal smears
- Low risk if never sexually active – may wish to opt-out
Outcomes
- -ve test = returned to routine recall
- +ve test = cytological testing
o Abnormal cytology referred to colposcopy
o Normal cytology repeat HPV test in 12 (and again at 24mths) if still +ve
o If still HPV +ve at 24mths referred to colposcopy
- Inadequate sample = repeat in 3mths
o If still inadequate = refer colposcopy
Cervical Intraepithelial Neoplasia
- Large loop excision of transformation zone (LLETZ)
- Can be done during initial colposcopy visit or later date
- Alternative = cryotherapy
Vaccine
- 12-13yo girls and boys offered HPV vaccine as part of NHS vaccination programme
- Protects against
o Cervical cancer
o Some mouth/throat cancers
o Cancers of anal/genital areas
o Genital warts
,Cervical Cancer
Anatomy & Risks
Normally squamous cell carcinoma
Other risk factors than HPV:
- Smoking
- HIV
- Early first intercourse/many sexual partners
- High parity
- Lower socioeconomic status
- COCP
Symptoms & Complications
- Asymptomatic (picked up via screening)
- Vaginal discharge
- Bleeding (postcoital/urine/stool)
- Vaginal discomfort
- Urinary/bowel habit change
- Suprapubic pain
- Abnormal white/red patches on cervix
- Pelvic bulkiness on PV examination
- Mass felt on PR examination
Investigations
CT TAP for cancer staging and management
- Determined by FIGO staging and fertility wishes of pt (Stage IA/IB – IV)
Treatment/Management & Side effects
Stage IA
- Gold standard = hysterectomy +/- LN clearance
o May result in ureteral fistula
- If maintaining fertility = cone biopsy with -ve margins
o May increase risk of preterm birth in future pregnancies
Stage ≥IB
- Radiotherapy with concurrent chemotherapy
,Ovarian Cancer
Definition & DDx
Peak age ~60yo
- Poor prognosis due to normally late diagnosis
Types
- Epithelial
- Germ cell
- Sex cord stromal
Anatomy & Risks
- FHx
- BRCA1/BRCA2 genes
- Early menarche/late menopause/nulliparity
o i.e., many ovulations
- HRT
- Obesity
- Advanced age
- Smoking
Protective factors
- COCP
- Multiparous
- Breastfeeding
- Late menarche/early menopause
Symptoms & Complications
Notoriously vague clinical features
- Abdominal distension
- Bloating
- Abdo/pelvic pain
- Urinary symptoms e.g., urgency
- Early satiety
- Diarrhoea
Investigations
CA125
- If raised – urgent USS abdo/pelvis
- Not used for screening in asymptomatic women
- Other causes raised CA125:
o Endometriosis
o Menstruation
o Benign ovarian cysts
Diagnosis difficult = normally via diagnostic laparotomy
- Staged I-IV (ABC at each stage)
Treatment/Management & Side effects
Combination of surgery and platinum-based chemotherapy
, Endometrial Cancer
Definition & DDx
Classically seen in post-menopausal women
Anatomy & Risks
Endometrial hyperplasia
- Abnormal proliferation of endometrium during menstrual cycle
- Can have intermenstrual bleeding
Risk factors: Excess oestrogen
- Nulliparity
- Early menarche/late menopause
- Unopposed oestrogen e.g., HRT
- Tamoxifen
Risk factors: Metabolic syndrome
- Obesity
- DM
- PCOS
- Hereditary non-polyposis colorectal carcinoma
Symptoms & Complications
Classic symptom: postmenopausal bleeding
- Usually slight and intermittent initially before becoming heavier
Other:
- Menorrhagia/IM bleeding premenopausal
- Weight loss
- Anaemia
- Pain (uncommon)
Investigations
2ww for ≥55F with post-menopausal bleeding
- TV USS (normal endometrial thickness <4mm)
- Hysteroscopy with endometrial biopsy
Treatment/Management & Side effects
If atypical endometrial hyperplasia = hysterectomy usually advised
- Localised cancer = total hysterectomy with bilateral salpingo-oophorectomy
Definition
- Anyone with a cervix between 25-64yo
- Cervical sample tested for high-risk HPV
o Subtypes 16, 18, 33 = carcinogenic
- Pts recalled every 3yrs if 25-49, then every 5yrs if normal
- Screening in pregnancy usually delayed until 3mths post-partum
o Unless missed screening/prev. abnormal smears
- Low risk if never sexually active – may wish to opt-out
Outcomes
- -ve test = returned to routine recall
- +ve test = cytological testing
o Abnormal cytology referred to colposcopy
o Normal cytology repeat HPV test in 12 (and again at 24mths) if still +ve
o If still HPV +ve at 24mths referred to colposcopy
- Inadequate sample = repeat in 3mths
o If still inadequate = refer colposcopy
Cervical Intraepithelial Neoplasia
- Large loop excision of transformation zone (LLETZ)
- Can be done during initial colposcopy visit or later date
- Alternative = cryotherapy
Vaccine
- 12-13yo girls and boys offered HPV vaccine as part of NHS vaccination programme
- Protects against
o Cervical cancer
o Some mouth/throat cancers
o Cancers of anal/genital areas
o Genital warts
,Cervical Cancer
Anatomy & Risks
Normally squamous cell carcinoma
Other risk factors than HPV:
- Smoking
- HIV
- Early first intercourse/many sexual partners
- High parity
- Lower socioeconomic status
- COCP
Symptoms & Complications
- Asymptomatic (picked up via screening)
- Vaginal discharge
- Bleeding (postcoital/urine/stool)
- Vaginal discomfort
- Urinary/bowel habit change
- Suprapubic pain
- Abnormal white/red patches on cervix
- Pelvic bulkiness on PV examination
- Mass felt on PR examination
Investigations
CT TAP for cancer staging and management
- Determined by FIGO staging and fertility wishes of pt (Stage IA/IB – IV)
Treatment/Management & Side effects
Stage IA
- Gold standard = hysterectomy +/- LN clearance
o May result in ureteral fistula
- If maintaining fertility = cone biopsy with -ve margins
o May increase risk of preterm birth in future pregnancies
Stage ≥IB
- Radiotherapy with concurrent chemotherapy
,Ovarian Cancer
Definition & DDx
Peak age ~60yo
- Poor prognosis due to normally late diagnosis
Types
- Epithelial
- Germ cell
- Sex cord stromal
Anatomy & Risks
- FHx
- BRCA1/BRCA2 genes
- Early menarche/late menopause/nulliparity
o i.e., many ovulations
- HRT
- Obesity
- Advanced age
- Smoking
Protective factors
- COCP
- Multiparous
- Breastfeeding
- Late menarche/early menopause
Symptoms & Complications
Notoriously vague clinical features
- Abdominal distension
- Bloating
- Abdo/pelvic pain
- Urinary symptoms e.g., urgency
- Early satiety
- Diarrhoea
Investigations
CA125
- If raised – urgent USS abdo/pelvis
- Not used for screening in asymptomatic women
- Other causes raised CA125:
o Endometriosis
o Menstruation
o Benign ovarian cysts
Diagnosis difficult = normally via diagnostic laparotomy
- Staged I-IV (ABC at each stage)
Treatment/Management & Side effects
Combination of surgery and platinum-based chemotherapy
, Endometrial Cancer
Definition & DDx
Classically seen in post-menopausal women
Anatomy & Risks
Endometrial hyperplasia
- Abnormal proliferation of endometrium during menstrual cycle
- Can have intermenstrual bleeding
Risk factors: Excess oestrogen
- Nulliparity
- Early menarche/late menopause
- Unopposed oestrogen e.g., HRT
- Tamoxifen
Risk factors: Metabolic syndrome
- Obesity
- DM
- PCOS
- Hereditary non-polyposis colorectal carcinoma
Symptoms & Complications
Classic symptom: postmenopausal bleeding
- Usually slight and intermittent initially before becoming heavier
Other:
- Menorrhagia/IM bleeding premenopausal
- Weight loss
- Anaemia
- Pain (uncommon)
Investigations
2ww for ≥55F with post-menopausal bleeding
- TV USS (normal endometrial thickness <4mm)
- Hysteroscopy with endometrial biopsy
Treatment/Management & Side effects
If atypical endometrial hyperplasia = hysterectomy usually advised
- Localised cancer = total hysterectomy with bilateral salpingo-oophorectomy
