Cancers of the female genital system

Female Genital System Diagram

Facts and figures

Uterine cancer is the 4th most common female cancer in the UK. There are approximately 8,500 new cases diagnosed each year and it has been increasing over recent years.

Age related, incidence rises sharply from the age of 40 years with 75% of cases occurring in the 40-74years age group, the highest incidence being in those 70-74 years of age. 95% of these tumours are adenocarcinomas.

Risk factors include genetics, being nulliparous (not had children), being overweight/obese, diabetes, lack of physical activity, hormone replacement therapy, polycystic ovary syndrome PCOS, polyps, Parkinson’s disease and breast cancer patients who have been taking tamoxifen long term.

Longer than average oestrogen exposure, therefore an early menarche and/or late menopause will increase risk. Some oral contraceptives reduce the risk.

Symptoms may include:

  • Post-menopausal bleeding Irregular bleeding in pre-menopausal women.
  • Heavier periods.
  • Blood stained or watery vagina discharge.
  • Pain/discomfort in pelvis, legs or back.
  • Pain/discomfort during sex.

Diagnosis

Investigations may include:

  • Physical examination (including internal).
  • Blood tests.
  • Ultrasound scan (transvaginal).
  • Biopsy - tissue samples will be taken for analysis (there are several different ways this may be carried out).

Treatment

Depends on several factors:

  • The type of cancer.
  • The stage of the cancer.
  • Age and general health.

Surgery

Surgery is the main treatment and the extent of this will depend on the stage of the disease. In early stage the uterus will be removed (hysterectomy) and usually both ovaries and fallopian tubes, occasionally in younger women, one ovary may be left. This may be adequate to cure the disease.

During surgery lymph nodes from around the uterus may be taken for biopsy to enable the extent of the disease to be assessed.

In some cases, surgery will be more involved and include removing the cervix, lymph nodes and other tissues in the region (radical hysterectomy).

In advanced cases, debulking surgery may be performed to remove as much of the cancer as possible to slow down it’s progression.

Radiotherapy

Radiotherapy to the pelvis is often used post-operatively if a radical hysterectomy was required and/or there is thought to be a risk of recurrence.

Chemotherapy

Chemotherapy may be given after surgery to reduce the risk of recurrence; this can be with radiotherapy or may be on its own.

Hormone therapy

Hormones may be prescribed for advanced cases or if the disease has recurred as it may help to shrink the tumour and control symptoms.

Cervical cancer

Facts and figures

Cervical Cancer is the 12th most common female cancer in the UK, accounting for approximately 2% of all female cases. Age related but unlike most cancers it is more common in younger females with the highest incidence occurring in the 30-34 year age group and a further peak in those aged 80-84 years.

Dramatic decrease following the introduction of a national screening programme in 1988, though rates have increased in recent years in the 25-34 year age group which is thought to be due to HPV infection and smoking.

85% of these tumours are squamous cell carcinoma, 10% adenocarcinomas and others are few rare types. Risk factors are HPV exposure and infection, multiple partners, early sexual intercourse (14 years old or younger), possibly other sexually transmitted diseases and use of oestrogen-progestagen oral contraceptives.

Risk is reduced by 50% in those whose partner is circumcised (HPV prevalence is lower in circumcised males).

Symptoms may include:

  • There may be no symptoms as sometimes pre-cancerous abnormal cells or very early stage.
  • cancer may be detected at cervical screening.
  • Post-menopausal bleeding.
  • Irregular bleeding in pre-menopausal women.
  • Pain/discomfort during sexual intercourse or bleeding afterwards (post-coital bleeding).
  • Foul smelling vaginal discharge.
  • Pelvic pain.

Diagnosis

Investigations may include:

  • Physical examination (including internal).
  • Blood tests.
  • Colposcopy: enables a more detailed examination of the cervix, tissue samples may be taken for analysis. If abnormal cells are detected a large loop excision of the transformation zone (LLETZ) may be performed. This involves cutting away the area of the cervix to remove them.
  • Cone biopsy: this is a minor operation that involves cutting out a cone of tissue from the cervix (whole area of the cervical canal) and sending it for analysis.

Treatment

Depends on several factors:

  • The type of tumour.
  • The position of the tumour.
  • The stage of the cancer.
  • Age and general health.

Surgery

Surgery alone may be adequate to cure the disease. In very early stage cervical cancer, this may just be a cone biopsy or removal of the cervix (radical trachelectomy).

Surgery for early stage usually involves removing the cervix and uterus (hysterectomy) and may include removing the lymph nodes if the disease has spread into the tissues of the cervix.

Post-operative radiotherapy may be advised to reduce the risk of recurrence. Extensive surgery to remove other pelvic organs may be required in advanced cases where it has spread within the pelvis, but this is only recommended in a small number of cases.

Radiotherapy

Radiotherapy is also an effective treatment for early stage cervical cancer and may be used if the patient is unfit for surgery or declines it and for larger tumours it can be recommended as it may be difficult to surgically remove all the disease. Also, radiotherapy may be advised post-operatively or in combination with chemotherapy (chemoradiation) for larger tumours.

Radiotherapy can be given externally or internally, external radiotherapy being planned to treat the cervix, uterus and surrounding tissues if main treatment or pelvis if post-surgery.

Internal radiotherapy involves small radioactive sources being placed inside the vagina to give a high dose of radiation directly to the cervix and uterus.

Chemotherapy

Trials have shown that the combination of radiotherapy and chemotherapy (chemoradiation) have improved the outlook for locally advanced disease.

Cisplatin is one of the drugs that have been shown to reduce the risk of recurrence or spread. It is thought to increase the sensitivity of the cancer cells to radiotherapy.

In more advanced disease, chemotherapy may be used to treat disease that has spread to other parts of the body.

Ovarian cancer

Facts and figures

Ovarian Cancer is the 5th most common female cancer in the UK, accounting for approximately 4% of all new female cancer cases.

Age related, rising sharply from 35 years of age, 75% are diagnosed in the 55+ years age group and an average 25% being 75+ years. 90% are epithelial tumours.

Risk factors include hormone replacement therapy (HRT), smoking, asbestos exposure, having a first degree relative diagnosed with ovarian cancer, family history of breast cancer, BRCA1 and BRCA2 gene mutation, being nulliparous (not had children), diabetes, endometriosis, previous breast cancer and being overweight/obese may also increase the risk.

Unfortunately, many of these patients are diagnosed at an advanced stage.

Symptoms may include:

  • Pain in the lower back/abdomen.
  • Swollen abdomen/feeling bloated.
  • Irregular bleeding in pre-menopausal women.
  • Post-menopausal bleeding.
  • Urinary frequency and/or urgency.
  • Changes in bowel habits (constipation or diarrhoea).
  • Painful sexual intercourse.
  • Weight gain/loss.
  • Loss of appetite.
  • Unexplained fatigue.

Diagnosis

Investigations may include:

  • Physical examination (including internal).
  • Blood tests (will include CA 125 tumour marker).
  • Ultrasound scan.
  • CT scan.
  • Image guided biopsy- using CT or ultrasound a needle is passed into the ovary to take tissue samples.
  • Laparoscopy/Laparotomy- tissue samples will usually be taken during this.

Treatment

Depends on several factors:

  • The type of tumour.
  • The grade of the tumour.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is used in most cases of ovarian cancer. In very early stage, low grade tumours it may be adequate to remove just the affected ovary and fallopian tube. Biopsies will be taken during surgery to assess the stage of the disease and this may indicate further surgery.

In post-menopausal patients or those not wanting more/any children, patients are usually advised to have both ovaries, fallopian tubes and uterus removed.

Post-operative chemotherapy (adjuvant) will be advised if there is a risk of recurrence due to stage or grade of the tumour. In all cases where the disease has spread from the ovary it is classified as advanced disease.

Surgery may be used to remove as much of the cancer as possible (debulking surgery) depending on the patient’s general health and stage of the disease.

Post-operative chemotherapy would be advised in the majority of cases either to try and cure the disease or control it.

Radiotherapy

Radiotherapy is rarely used to treat ovarian cancer. Occasionally used to treat recurrences after surgery and chemotherapy. It is usually palliative to treat symptoms such as bleeding or pain.

Chemotherapy

Chemotherapy is commonly used post-operatively. In all cases where the staging is 1C or above and the tumour is high grade, chemotherapy is likely to be advised. The most frequently used drug is carboplatin.

Chemotherapy can also be recommended if the tumour has recurred.

Biological therapy

Bevacizumab is a type of monoclonal antibody that blocks the protein to the blood vessels of the cancer cells and consequently stops their growth; this is being used alongside chemotherapy for some patients and is thought to be improving the length of survival.

Fallopian tube cancer

Facts and figures

Fallopian tube cancer is very rare, it accounts for only 1% of all cancers of the female reproductive system. Age related, being most common in females aged 50-60 years.

Risk factors are not known but may include a family history of breast or ovarian cancer (possible link to the BRCA gene mutation) and chronic infections.

Symptoms may include:

  • Painful/swollen abdomen.
  • Post-menopausal bleeding.
  • Irregular bleeding in pre-menopausal women.
  • Blood stained/watery vaginal discharge.

Diagnosis

Investigations may include:

  • Physical examination (including internal).
  • Blood tests (will include CA 125 tumour marker).
  • Ultrasound scan.
  • CT scan.
  • MRI scan.
  • Laparoscopy/Laparotomy- tissue samples will usually be taken during this for analysis.

Treatment

Depends on several factors:

  • The stage of the cancer.
  • Age and general health.

Surgery

Surgery is the main treatment. In very early stage this may be removal of the affected fallopian tube only to enable organ preservation but if the cancer has spread beyond the fallopian tube a radical hysterectomy bilateral salphingo-oophorectomy (removal of the uterus, ovaries, fallopian tubes and part of the cervix) is usually performed.

More extensive surgery may be required for more advanced disease.

Radiotherapy

Radiotherapy is rarely used to treat fallopian tube cancer. It may be used palliatively to treat symptoms if disease recurs after surgery and chemotherapy.

Chemotherapy

Chemotherapy is post-operatively if not all the disease could be removed or if there is thought to be a risk of spread o recurrence. Frequently used chemotherapy drugs are carboplatin, cisplatin and taxol.

Hormone therapy

Occasionally treatment may include using hormonal drugs such as tamoxifen or letrozole as part of the treatment.

Vaginal cancer

Facts and figures

Vaginal cancer is very rare in the UK, accounting for only 0.2% of all new female cancer cases. Age related, incidence rises sharply from 45 years of age, 70% are diagnosed in women 60+ years and on average 35% arise in those over 75 years of age. 90% are carcinomas ( 80% of these are squamous cell carcinomas and 14% adenocarcinomas).

Risk factors include HPV exposure/infection, previous cervical cancer, possibly HIV infection and there are a small proportion of adenocarcinomas that are clear cell carcinomas and these are linked to women who were exposed to the drug diethylstiboestrol (DES) in utero, due to their mothers being prescribed this in pregnancy to reduce the risk of miscarriage. The highest incidence of these cases is in the late teen/early twenties age group.

Symptoms may include:

  • There may be no symptoms, 20% are detected at a very early stage during routine cervical screening.
  • Post-menopausal bleeding.
  • Irregular bleeding in pre-menopausal women.
  • Blood stained or foul smelling vaginal discharge.
  • Bleeding after sexual intercourse (post-coital bleeding).
  • Pain during sexual intercourse.
  • Persistent irritation in the vagina.
  • Lump or growth in the vagina that is sometimes detected during an internal pelvic examination.

More advanced symptoms may be:

  • Constipation.
  • Swelling in the legs (oedema).
  • Persistent pelvic pain or pain when passing urine.
  • Urinary frequency and/or blood in the urine.

Many of these symptoms can be caused by other conditions such as infections.

Diagnosis

Investigations may include:

  • Cervical screening.
  • Physical examination (including internal and possibly rectal).
  • Colposcopy and biopsy.
  • Chest X-ray.
  • Ultrasound scan.
  • CT scan.
  • PET-CT scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The type of tumour.
  • The stage of cancer.
  • Age and general health.

Surgery

Surgery is frequently used to treat vaginal cancer; in cases of pre-cancerous vaginal intraepithelial neoplasia (VAIN), laser surgery is an effective treatment.

The extent of surgery depends on the stage of the disease, in early stage a wide local excision to remove the tumour and surrounding tissue will be performed.

In some cases part or all of the vagina will be removed (reconstruction may be possible) or if the disease has spread outside of the vagina, a radical hysterectomy may be advised.

Radiotherapy

Radiotherapy may be the main treatment, may be post-operative or may be given in combination with chemotherapy. It may be external or internal radiotherapy.

External radiotherapy will involve treating the pelvis with external radiation where internal radiotherapy can be interstitial or intracavity. Interstitial is the implantation of radioactive wires or seeds into the tumour for a few days, intracavity is where a radioactive source is placed in the vagina for a specifically calculated period of time.

Internal radiotherapy is sometimes given after a course of external radiotherapy to give an additional dose of radiation to the site of the primary tumour.

Radiotherapy is the treatment of choice if the patient is unfit for surgery and for some younger women. It is sometimes advised after surgery to reduce the risk of recurrence, particularly if malignant cells are found in the lymph nodes at surgery or if it was not possible to remove all the disease.

In advanced cases, palliative radiotherapy may be prescribed to help shrink the cancer and relieve symptoms.

Chemotherapy

Chemotherapy combined with radiotherapy (chemoradiation) is proving to be effective and it is thought that the chemotherapy makes the cancer cells more susceptible to radiation.

Cisplatin is usually given once weekly during the course of radiotherapy. It is rarely used on its own just very occasionally to try and shrink the tumour to slow the disease progression and relieve symptoms.

Vulval cancer

Facts and figures

Vulval Cancer is the 20th most common female cancer in the UK, accounting for 0.7% of all new female cancer cases.

Age related, approximately 73% diagnosed are in those aged 60+ years and an average of 46% arise in those aged over 75 years. 85% are squamous cell carcinomas and 10% are malignant melanomas.

Risk factors include smoking, HPV exposure/infection (the younger patients tend to be HPV positive), genital warts, previous cervical cancer or having a first degree relative that has been diagnosed with cervical cancer, possibly HIV infection.

Symptoms may include:

  • Persistent irritation, burning sensation or soreness of the vulva.
  • Lump, swelling, wart-like growth or ulcer on the vulva.
  • Thickened, raised red, white or dark patches of skin.
  • Post- menopausal bleeding or blood stained discharge.
  • Irregular bleeding or blood stained discharge in pre-menopausal women.
  • Tenderness or pain in the area.
  • Burning sensation when passing urine.
  • Lump in the groin.
  • Changes in a mole on the vulva.

Some of these conditions can be caused by other conditions such as infection.

Diagnosis

Investigations may include:

  • Physical examination.
  • Biopsy: tissue samples will be taken for analysis.
  • Chest X-ray.
  • Cytoscopy: examination of the inside of the bladder.
  • Proctoscopy: examination of the rectum.
  • CT scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The type and size of the tumour.
  • The stage of the cancer.
  • Age and general health.

Surgery

Surgery is usually the first treatment for vulval cancer, in precancerous vulval intraepithelial neoplasia (VIN) laser surgery or a combination of laser and regular surgery is an effective treatment.

In early stage disease, surgery will usually involve removing the affected tissue with some of the surrounding healthy skin. It is likely that some of the groin lymph nodes will be removed during surgery for analysis.

In advanced cases, part or all of the vulva may need to be removed (vulvectomy), reconstruction is sometimes possible. More advanced cases may require more extensive surgery.

Radiotherapy

Radiotherapy may be the main treatment if surgery is not possible. Also, it may be advised post-operatively if the lymph nodes are found to contain malignant cells or if the cancer was found to be deeper than 5cms or not adequately cleared at surgery to reduce the risk of recurrence.

Occasionally it is used to reduce the tumour prior to surgery. In advanced disease it may be used to relieve symptoms.

Chemotherapy

Chemotherapy may be advised if the disease has spread to other parts of the body, cisplatin is the most frequently used drug.

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