Gynaecological Cancers

Ovarian cancer

Ovarian cancer Over 90% of women with ovarian cancer are over the age of 40 years on diagnosis. Among women in Scotland with no family history the lifetime risk of developing ovarian cancer is estimated to be 1 in 59. Approximately 610 new cases of ovarian cancer are diagnosed in Scotland every year. Ovarian cancers are usually diagnosed late and approximately 30% of cases have a palpable pelvic mass. Symptoms are often non-specific abdominal symptoms but are characterised by their persistency and frequency.

Family history (both maternal and paternal) of breast or ovarian cancer can be used to identify women who have a higher risk of developing ovarian cancer. Guidance for referral to regional genetic centres (Appendix 5) for those with a family history is available within SIGN guideline 135 Management of epithelial ovarian cancer10.

10 SIGN 135 Management of epithelial ovarian cancer https://www.sign.ac.uk/our-guidelines/management-of-epithelial-ovarian-cancer/

Endometrial cancer

Most people (95%) with endometrial cancer present with postmenopausal bleeding. This cancer is uncommon in premenopausal women (< 5%). Approximately 690 new cases are diagnosed in Scotland each year. Risk factors for endometrial cancer include: tamoxifen, obesity, age over 45 years, nulliparity, family history of colon or endometrial cancer and exposure to unopposed oestrogens. A higher suspicion of risk should be used in these women. Note that thrombocytosis is a risk marker for underlying malignancy including endometrial cancer.

Cervical cancer

Cervical cancer affects all adult age groups, with 50% of cases occurring between the ages of 30 and 50 years. The incidence of cervical cancer in Scotland is around 12.3 per 100,000 population and its estimated lifetime risk around 1 in 106.

The majority of cases (80%) are diagnosed on speculum examination and up to 40% are screen detected. Typical symptoms include vaginal discharge, postmenopausal bleeding, postcoital bleeding and persistent intermenstrual bleeding. A cytology test is not required before referral, and a previous negative result is not a reason to delay referral.

Vulval cancer

Most cases of vulval cancer occur in women over 65 years and 90% of patients have a visible tumour on clinical examination. Patients usually present with bleeding, discomfort, itch or a burning sensation. There are about 106 new cases of vulval cancer diagnosed every year in Scotland.

Vaginal cancer

Vaginal cancer is rare and comprises less than 1% of gynaecological cancers. It is most commonly diagnosed in women above 60 years and is rare in women less than 40 years. Approximately 25 new cases of vaginal cancer are diagnosed in Scotland every year.

Urgent suspicion of cancer referral

Ovarian cancer
  • Abnormal ultrasound scan and/or CA125 level.
  • Ascites and/or ultrasound-confirmed pelvic or abdominal mass (that is not obviously uterine fibroids, gastrointestinal or urological in origin).
Endometrial cancer
  • Any woman on hormone replacement therapy (HRT), presenting with persistent or unexplained postmenopausal bleeding, after cessation of HRT for 4 weeks.
  • Unscheduled vaginal bleeding in a patient taking tamoxifen
  • Postmenopausal bleeding.
  • Persistent intermenstrual bleeding, especially with other risk factors despite a normal pelvic examination
  • A woman presenting with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids, gastrointestinal or urological in origin should be referred urgently for ultrasound scan and, if significant concern, simultaneously to a specialist. Awaiting results of the ultrasound scan should not delay referral.
Cervical cancer
  • Any woman with clinical features (vaginal discharge, postmenopausal, postcoital and persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix.
Vulval cancer
  • Any unexplained vulval lump found on examination.
  • Vulval bleeding due to ulceration.
  • Any suspicious abnormality of the vagina on speculum examination.
Vaginal Cancer
  • Any suspicious abnormality of the vagina on speculum examination

 

Good practice points

An abdominal palpation should be undertaken, CA125 blood serum level measured and urgent pelvic ultrasound scan carried out in:

  • any woman over 50 years who has experienced new symptoms within the last 12 months that suggest irritable bowel syndrome or
  • women (especially those over 50 years) with one or more unexplained and recurrent symptoms (most days) of:
    • abdominal distension or persistent bloating
    • feeling full quickly or difficulty eating
    • loss of appetite
    • pelvic or abdominal pain
    • increased urinary urgency and/or frequency
    • change in bowel habit.

A full pelvic examination, including speculum examination of the cervix, should be carried out in women presenting with:

  • significant alterations in their menstrual cycle
  • intermenstrual bleeding
  • postcoital bleeding
  • postmenopausal bleeding
  • vaginal discharge, or
  • pelvic pain.

A vulval examination should be carried out for any woman presenting with any vulval symptom.

If there is significant concern, awaiting the results of any investigation should not delay referral.

Primary care management

  • Symptoms (as above) persisting or worsening for any woman who has a normal CA125 with normal ultrasound, assess for other clinical causes and investigate as appropriate or refer to appropriate secondary care services, depending on local arrangements.
  • Women presenting with vulval symptoms of pruritus or pain should be examined prior to initiation of any treatment and follow up should also include examination until symptoms are resolved or a diagnosis is confirmed
  • Refer urgently or routinely, if symptoms persist, depending on the symptoms and the degree of concern about cancer
Quick Reference Guideline