Gynecologic Cancers. Risks, screening and prevention

In 1999, the Foundation for Women’s Cancer set September as the Gynecologic Cancer Awareness month, with the aim to acknowledge the importance of women’s health and to shed the light on the different gynecologic cancers, their risk factors and ways to screen for and manage them.

Even though, the topic of cancers or malignancies can be regarded as sensitive by some, yet I believe that I have a professional and personal duty to talk more about the different types of gynecologic malignancies as many misconceptions surround the topic.

There are 5 main cancers that are encountered by gynecology specialists; cervical, ovarian, endometrial, vulvar and vaginal cancers, however, in this article I will be tackling the most commonly seen ones; cervical, ovarian and endometrial.


Cervical Cancer

Cervical cancer happens when cells in your cervix (the bottom part of the uterus) start to grow out of control. It is the most common gynecologic malignancy in underdeveloped countries and one of the most common in developed countries.

Symptoms of Cervical Cancer

Most cervical cancers are early stage and thus do not cause any symptoms, however if it happens to be advanced enough to cause symptoms, the latter can include, abnormal uterine bleeding, inter-menstrual spotting, post-coital spotting (bleeding or spotting after penetrative sex) and post menopausal bleeding. In very rare scenarios, cervical cancer can be advanced enough to cause abdominal and back pains in addition to kidney failure (rarely seen nowadays).

What are the risk factors for Cervical Cancer?

The most important risk factor for cervical cancer is sexual intercourse, because almost all cervical cancer cases are caused by HPV which is a sexually transmitted virus. However, keep in mind that there are many types of HPV, and not all of them cause cervical cancer, so if you happen to be diagnosed with HPV, don’t panic as it may be a low risk HPV associated with warts and not cervical cancer (always follow with a professional for any abnormal test result). 

Having multiple sexual partners, and engaging in unprotected intercourse increase the risk of acquiring high risk HPV strains and thus increase the risk of cervical cancer.
Smoking has also been associated with cervical cancer, so quit smoking while you still can!
A low immunity state (acquired or congenital) and HIV infection can increase your chances for developing cervical cancer as your body would be less capable of clearing the HPV infection.
Even though cervical cancer is not regarded as inherited or familial, however some studies have reported potential familial preponderance of the disease, and researchers are hypothesizing the connection to be secondary to an inherited capability in clearing an HPV infection. Even though the latter hypothesis is plausible, the most important risk factor for cervical cancer remains to be SEX! This applies to women who have sex with women.

Can I screen for Cervical Cancer?

The discrepancy in cervical cancer incidence between developed and developing countries, is secondary to the implementation of regular screening methods in the former. Pap smear and HPV testing are used to screen for changes in the cervix that can precede the occurrence of cancer, so they can diagnose pre-cancerous lesions that can be managed promptly avoiding their evolution into advanced disease. If your doctor notices any abnormalities in your pap test, he/she might ask for a cervical biopsy to make a better judgment about the condition of your cervix, or they may recommend having tighter cervical screening and monitoring schedules.  
To know more about the target population for pap smear/HPV testing please check my article “Screening Checklist” on https://onlinewomenhealth1.blogspot.com/2020/06/screening-checklist.html

Can you prevent Cervical Cancer?

The best thing about cervical cancer is our ability to prevent it!
In addition to regular gynecologic follow-ups and the implementation of routine screening methods, we have available vaccines to protect against HPV infection.
An anti cancer vaccine! I will not go through the details about these vaccines as it will be targeted in future articles, however I encourage you to ask your provider about them.


Ovarian Cancer

Now let us shift gears and talk about ovarian cancer. It is also one of the commonly encountered gynecologic malignancies and unfortunately the deadliest!
It tends to occur around the age of 50-65, but it can occur in younger or older women.
Some ovarian cancers even run in families, and some others are associated with other malignancies (such as breast cancer).

Symptoms of Ovarian Cancer

The reason why ovarian cancers are considered to be one of the deadliest cancers worldwide, is because they are silent and tend to cause symptoms only when they become advanced in stage. Early stage cancers rarely cause symptoms and are mostly incidentally diagnosed during surgeries done for benign reasons. However, advanced stages ovarian cancers can cause abdominal pain, bloating, early satiety, weight loss, fatigue and changes in bowel or urinary habits. These symptoms can be secondary to ovarian cancer or other conditions as they are nonspecific in nature, and thus you are encouraged to always check with a specialist in the setting of any of the above mentioned symptoms.

What are the risk factors for Ovarian Cancer?

There are many known risk factors for developing ovarian cancer, such as:

  • Genetic predisposition: BRCA1/BRCA2/Lynch Syndrome
  • Advanced age
  • Family history of ovarian cancer (even in the absence of the above mentioned genes)
  • Early menarche (slight increased risk)
  • Late menopause
  • Nulliparity (having no kids before)
  • Smoking
  • Environmental exposures (such as Asbestosis)

What about protective factors?

The factors that have been most strongly associated with a reduced risk of ovarian cancer are:

  • Surgical removal of the ovaries
  • Combined oral contraceptive pills! (especially with prolonged use; >50% ovarian cancer risk reduction is observed in women who are on combined oral contraceptives for more than 10 years)
  • Tubal Ligation and bilateral salpingectomies (removal of the fallopian tubes)
  • Breastfeeding
  • Having more kids

Can I Screen for Ovarian Cancer?

Unfortunately till today we do not have any good screening methods to detect early ovarian cancers. One of the biggest misconceptions about ovarian cancers is that they can be detected by a pap smear!
Ultrasound and blood tests (such as CA-125) have been used in the screening for ovarian cancer, however studies did not show any cost effectiveness in their use, in addition, their implementation in ovarian cancer screening was not associated with an earlier detection of the disease, nor with a better survival, on the contrary, it has been linked to a higher rate of unnecessary surgical interventions for false positive results.

You should keep in mind that imaging modalities and tumor markers can help in the diagnosis of a suspected ovarian cancer (based on the right clinical picture) and not to screen the asymptomatic low risk general population. Moreover, they have a good role in monitoring the disease progression once treatment is initiated.

Can I prevent Ovarian Cancer?

Reducing the risk factors for ovarian cancer can help reducing the risk of developing the disease. And the implementation of risk reducing strategies (breastfeeding, combined oral contraceptives…) can help further in decreasing the risk of ovarian cancer. However, the main risk factor remains to be genetic, and thus women at high risk for ovarian cancer (i.e. strong family history and inherited genetic cancers) should be refereed to genetic counseling, and would benefit from risk reducing surgeries (removal of the ovaries and fallopian tubes). This again is beyond the scope of this article and should be discussed in details with your provider.


Endometrial Cancer

Finally let’s talk about endometrial cancer, which is characterized by a malignant transformation of the cells lining the inside of the womb. This is the most commonly encountered gynecologic cancer in the developed countries (versus cervical cancer in the developing countries).
There are 2 different types of endometrial cancers (Type I (classical) and Type II) which will be discussed further in details in the risk factors section below.

Symptoms of Endometrial cancer

The good thing about endometrial cancers (unlike ovarian cancers) is that they show symptoms early on. The main symptoms can be collectively called as AUB or abnormal uterine bleeding patterns (seen in 75-90% of cases). Heavy or irregular cycles, inter-menstrual spotting and post-menopausal bleeding… all can be signs for endometrial cancer. If advanced in its stage, it can cause symptoms similar to ovarian cancer (abdominal pain, bloating, early satiety …).

Moreover, some women with endometrial cancer can be incidentally diagnosed on routine pap smear, however the latter test is not the routine screening modality used for endometrial cancer diagnosis.

What are the risk factors for Endometrial Cancer?

As previously mentioned, there are two major types of endometrial cancers with different risk factors. Type I (classical endometrioid, which comprises 80% of cases) has been associated with chronic unopposed estrogen exposure and thus the major risks factors are:

  • Older age
  • White race
  • Nulliparity (having no kids)
  • Polycystic ovary syndrome
  • Obesity
  • Diabetes type II, hypertension and thyroid disease
  • Infertility
  • Unopposed estrogen
  • Tamoxifen exposure (medicine used in the treatment and prevention of breast cancer)
  • Early menarche
  • Late menopause (not very strongly associated with the disease)
  • Hereditary factors (lynch syndrome: ovarian, endometrial and colon cancer syndrome…)
  • Family history of a first degree relative with endometrial cancer

Whereas the type II cancer is not associated with estrogen over-exposure, it is seen in older ladies and has a worse prognosis than type I. The risk factors for type II endometrial cancer are:

  • Smoking
  • Non-white race
  • Advanced age
  • Genetic predisposition (p53 mutation)

Are there any protective factors?

The use of combined oral contraceptive pills has been associated with a protective benefit against type I endometrial cancer (30-40% reduced risk). Also, progesterone only contraceptive methods (Mirena IUD, DEPO shot, progesterone implant) have been associated with a lower risk of endometrial cancer.
Also, getting pregnant, having more kids and breastfeeding have endometrial protective benefits!
Regular exercise has also been known to decrease the risk of endometrial cancer, and this is secondary to the lower obesity rate which is a known risk factor for this malignancy.

Can I screen for endometrial cancer?

There are no good screening methods for endometrial cancer for the low risk general population. However in high risk women (genetic predisposition, tamoxifen use) regular ultrasound assessment of the endometrial lining might be warranted (follow with your physician about your respective risks).
As for symptomatic women (women with abnormal uterine bleeding), endometrial cancer should always be kept in the back of our minds in order to rule it in or out.
Depending on your risks for endometrial cancer (stated above), your provider might elect to do an ultrasound assessment of the endometrial thickness and check for the need of an office based biopsy for a better diagnosis.
All women with abnormal bleeding patterns and risk factors (PCOS, tamoxifen use, unopposed estrogen…) should have an endometrial biopsy after the age of 35, regardless of the endometrial thickness on ultrasound.
All pre-menopausal women after the age of 40, with abnormal uterine bleeding should have an endometrial biopsy regardless of their risk factors or ultrasound findings.
All post-menopausal women with vaginal bleeding, should have an ultrasound assessment of their endometrial lining before deciding on the need for a biopsy; if the lining is >4 mm then a biopsy is indicated. However, I personally believe (based on my training) that post-menopausal women with abnormal uterine bleeding should be biopsied regardless of the endometrial lining thickness as some endometrial cancers grow on an atrophic lining (i.e. Type II cancer).

Persistent abnormal uterine bleeding should prompt tissue diagnosis and biopsy regardless of age and ultrasound findings.
Sometimes your provider might request a curettage procedure or hysteroscopic procedure (to see via a camera the insides of the uterus) instead of an office based biopsy for better assessment of the endometrial cavity.

Can I prevent Endometrial Cancer?

Modifying your risk factors can alter your risks for developing endometrial cancer. Despite the fact that some risk factors are out of your control, such as genetics, age and race, yet the control of obesity, diabetes, hypertension and period irregularities can be beneficial in reducing your chances for developing endometrial cancer.
Oral contraceptive pills and progesterone-only contraceptives are also likely to be effective in risk reduction.
When childbearing is complete, high risk women (mainly those with genetic syndromes) can benefit from risk reducing total hysterectomy (removal of the uterus)

 

In conclusion, keep in mind not to overlook or ignore your symptoms. The topic of malignancy can be quite scary and worrisome, however with earlier detection and treatment, survival is promising. Spread your knowledge about the topic among your friends, family and colleagues in order to have a better control for the cancer incidence in your respective communities.
Don’t hesitate to message me for any further details (my contact information are in the toolbar on your left) 


Karam 

 

 

 

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