Gynaecological cancers include cervical, uterine, and ovarian cancer.
Prevention and early diagnosis of any gynaecological malignancy should be part of every womans health care program. Screening tests are a part of “well woman” consultations and should be performed routinely at specified intervals.
Screening tests when normal are reassuring.
Premalignant changes can be treated and will prevent cancer from developing.
If a cancer is diagnosed early treatment can be curative.
“Gynaecological screening tests are important”
Screening for Cervical Cancer
The Pap test
The commonest gynaecological cancer screen has been the cervical Pap smear and should be performed every two years on all sexually active women.
The test is simple and involves insertion of a speculum into the vagina to visualise the cervix.
The test is reasonably comfortable and involves wiping the cervix with a cytology brush to sample the cervical cells.
The Pap test is used to check on the presence of human papilloma virus and any premalignant cells called dysplasia or CIN (cervical intra epithelial neoplasia).
Causes of Dysplasia
There are a number of possible causes of cervical dysplasia. Since the renowned work of Prof Fraser it has become clear that there is a strong link between the presence of the human papilloma virus and the process of developing cervical dysplasia and cancer. HPV is usually sexually transmitted and is more commonly found in women who have had multiple sexual partners. There are more than 100 types of human papilloma viruses (HPV). Some are high risk HPV.
Currently pap tests are principally cytological screens looking for abnormal cells and HPV is reported when seen. Very soon the test will focus first on identifying women with HPV and performing cytology only on the group who are positive for HPV. There is currently a screen for High Risk HPV.
Types of Dysplasia and grading of abnormalities
The cervix is effectively made up of two parts. The ecto cervix which is that part of the cervix that we can see when performing a speculum examination. The other part is the cervical canal (endo cervix), which is not so easily seen. The ecto cervix is lined by squamous cells and the endo cervix by glandular cells. Abnormalities can occur in either cells type. A pap test should be sampling both parts.
More than 90% of cervical abnormalities are squamous cell abnormalities. A small number are glandular abnormalities. These are more difficult to interpret and I usually refer these on to a gynaecological oncologist for further assessment.
Low-grade abnormalities can be observed for 6 – 12 months and may spontaneously resolve. Any high grade or persisting abnormality needs to be investigated further and this involves performing a colposcopy.
The colposcopy examination involves looking at the cervix through a pair of binoculars to magnify the cervix. It involves application of acetic acid (vinegar) and in turn Iodine (Lugols) to the cervix to highlight any abnormal tissue. If seen any abnormality needs to be biopsied.
The focus of colposcopy is to identify the presence and severity of an abnormality and also to confirm if the abnormality is “in range” or “out of range”. If the abnormality were completely seen it is in range. If it extends up into the canal and cannot be completely seen it is out of range. Abnormalities need to be treated and the treatment will be dependent on the position of the abnormality.
Treatment of Cervical dysplasia
In range abnormalities are easily treated. This may involve cryo therapy (freezing), diathermy (burning), Laser therapy or most commonly LLETZ excision of the abnormal area by performing a loop biopsy.
Out of range abnormalities often require a cone biopsy where the canal of the cervix is excised. All treatments are performed under a general anaesthetic and are very effective in curing the problem of dysplasia in one treatment.
Failure of treatment can involve incomplete excision of the abnormality but often it represents recurrence of dysplasia because the original cause e.g. HPV is still present. There is no viral therapy for HPV. It disappears by means of the immune system over several months. It is therefore necessary to continue ongoing review by having frequent Pap tests and screening for high risk HPV. When two consecutive Pap tests and two consecutive HPV tests are normal then the patient will be deemed cured and she can return to the normal two yearly smears.
It is important for those women who have been diagnosed with cervical dysplasia to understand that dysplasia is not cancer and dysplasia is easily treated and cured. The screening process is to diagnose, treat and prevent cervical cancer. If cancer were suspected the patient would be referred to a Gynaecological Oncologist.
Screening for uterine Cancer
Screening for uterine malignancy is targeted to women who have abnormal uterine bleeding. These women are either peri or post menopausal.
The importance of investigating abnormal menstrual bleeding and detecting premalignant changes such as complex endometrial hyperplasia has been discussed previously.
Perimenopausal women may have hormonal imbalance, which may cause endometrial hyperplasia. This can be premalignant, and needs to be treated.
Some menopausal women may have postmenopausal bleeding and all of these women need to have investigations to exclude uterine malignancy.
The majority of these women will have a minor cause for their bleeding such as atrophic endometritis or benign polyps. Some will have endometrial cancer. To identify a cause, all of these women need to be investigated.
Although an ultrasound scan may identify endometrial thickening or the presence of a polyp, all such women who have abnormal uterine bleeding should have a hysteroscopy and curettage to obtain a tissue sample and a histological diagnosis.
Uterine cancer is easily diagnosed and treatment is very effective.
Screening for ovarian cancer
Ovarian cancer is serious and often identified late. It may affect about 1 in 90 women. Some women may have a family history of ovarian cancer and need to be screened closely. They may be candidates for genetic screening which may be available through The Peter McCallum Clinic. Such screening is not offered to all women.
Many women may develop ovarian cysts. The vast majority of these cysts are either physiological or sometimes neoplastic. They are uncommonly malignant. . Ovarian tumour markers are not diagnostic of ovarian cancer. They are blood tests, which are usually performed in women with ovarian cancer to monitor the effectiveness of treatment.
A pelvic ultrasound scan may identify concerning features, such as a complex appearance with solid, cystic areas, the presence of growth nodules and abnormal blood flow patterns. Sometimes both ovaries are involved and there may be free peritoneal fluid.
If ovarian cancer were suspected these women would be referred to a Gynaecological Oncologist for further assessment and treatment.
Other problems of the perineum, vagina or cervix
It is wise to adopt a broad perspective on problems that need to be screened.
Some problems of the vulva or vagina such as irritation or itchiness, which persist or have failed various treatments, need investigation.
Some incidental findings seen by your G.P. such as cervical polyps seen at the time of a pap smear should also be investigated. Cervical polyps are usually benign but should be biopsied and excised.
Vulval and vaginal irritation may be as simple as thrush infections, which have been inadequately treated. They could however be vulval dystrophy, which can sometimes be premalignant.
Vaginal or perineal lumps or cysts can be Bartholin cysts (normal vaginal gland), Skenes duct cysts (embryonic remnant) or infected sebaceous cysts. They are not malignant but they will cause problems later and they need to be excised.
Prevention of cancer and early diagnosis is the focus of all screening tests.
If present, early diagnosis of cancer will allow early treatment with better results.
After diagnosis all patients with gynaecological cancer will be referred to a Gynaecological Oncologist for surgery and ongoing care.
‘Screening for gynaecological cancer is important’.