Gynaecological cancers - recognition and referral
Exam Tips
- For suspected ovarian cancer in adults: persistent/frequent bloating, early satiety, pelvic pain, urinary symptoms, fatigue, weight loss, or bowel change -> check CA125 first in primary care.
- Use the threshold accurately: CA125 >=35 IU/mL -> arrange abdominal/pelvic ultrasound; suspicious ultrasound -> suspected cancer pathway referral.
- Normal CA125 (or raised CA125 with normal ultrasound) does not end the assessment: investigate alternative causes and provide explicit safety-netting.
- Postmenopausal bleeding in women >=55 is a two-week-wait style red flag for endometrial cancer; in younger women with PMB, referral is still strongly considered.
- Suspicious cervix on examination, unexplained vulval lump/ulcer/bleeding, or palpable vaginal mass should trigger urgent suspected cancer referral consideration.
- In OSCEs, score marks by stating symptom frequency (>12 times/month for ovarian symptom clusters), age context, immediate referral criteria, and safety warnings not to delay referral while treating symptoms.
Definition
Gynaecological cancers in UK practice include ovarian, endometrial (uterine), cervical, vulval, and vaginal malignancies, and the core clinical task in primary care is early recognition of red-flag symptom patterns followed by time-appropriate referral. NICE-based recognition and referral pathways aim to identify women at highest risk using symptom frequency, age thresholds, examination findings, and first-line tests (especially CA125 and pelvic ultrasound) so that histological diagnosis can be expedited in secondary care.
Pathophysiology
These cancers arise from distinct tissues and molecular pathways: ovarian cancer is often epithelial and may spread transcoelomically within the peritoneal cavity (causing ascites and abdominal distension); endometrial cancer commonly reflects prolonged oestrogenic stimulation of the endometrium with progression from hyperplasia to carcinoma; cervical cancer is strongly linked to persistent high-risk HPV infection causing dysplastic progression from CIN to invasive disease; vulval and vaginal cancers are less common and may relate to HPV-associated neoplasia or chronic inflammatory/epithelial disorders. Clinical features reflect local invasion (abnormal bleeding, discharge, pelvic pain, ulceration or mass) plus systemic effects (fatigue, weight loss, anorexia).
Risk Factors
- Increasing age (especially postmenopausal women for endometrial and many ovarian cancers)
- High-risk HPV exposure/persistence (especially cervical, also vulval/vaginal subsets)
- Obesity and metabolic risk (notably for endometrial carcinoma)
- Unopposed oestrogen exposure (e. g, chronic anovulation, oestrogen-only HRT in women with a uterus, tamoxifen exposure)
- Family history/genetic predisposition (e. g, BRCA1/2, Lynch syndrome)
- Smoking (important cofactor for cervical neoplasia)
- Previous lower genital tract dysplasia/cancer
- Chronic vulval dermatoses such as lichen sclerosus (for some vulval cancers)
Clinical Features
Symptoms
- Persistent/frequent abdominal distension (often described as bloating), especially >12 times/month
- Early satiety and/or loss of appetite
- Persistent/frequent pelvic or abdominal pain
- Urinary urgency/frequency (new and persistent)
- Unexplained fatigue, weight loss, or change in bowel habit
- Postmenopausal bleeding (key symptom for endometrial cancer; unexplained bleeding >12 months after menopause)
- Intermenstrual bleeding or post-coital bleeding (suggestive of cervical pathology)
- Unexplained vaginal discharge
- Vulval bleeding, vulval itch/redness, vulval lump or ulceration
- Palpable vaginal mass or ulcerative vaginal lesion
Signs
- Ascites on examination
- Pelvic or abdominal mass not obviously uterine fibroids
- Cervix with malignant-looking appearance on speculum examination
- Unexplained palpable mass in or at the entrance to the vagina
- Vulval lump/ulceration or suspicious vulval lesion
- Associated laboratory flags in women >=55 with visible haematuria/discharge context: thrombocytosis, low haemoglobin, or raised blood glucose
Investigations
Management
Lifestyle Modifications
- Urgent safety-netting: advise return if symptoms become more frequent/persistent, even after normal CA125 or normal ultrasound
- Explain red flags clearly (postmenopausal bleeding, persistent bloating, early satiety, pelvic mass, vulval/vaginal lesion) and document escalation plan
- Support smoking cessation, weight optimisation, and cervical screening attendance as preventive risk-reduction measures
- Use suspected cancer pathway referral for qualifying presentations (e. g, postmenopausal bleeding >=55, suspicious cervical appearance, pelvic mass/ascites, suspicious vulval/vaginal lesion)
Pharmacological Treatment
Analgesia while awaiting specialist assessment
- Paracetamol 500 mg-1 g orally every 4-6 hours when required (maximum 4 g/day)
- Ibuprofen 400 mg orally three times daily with food (typical adult dose range 1.2-2.4 g/day in divided doses)
Symptom relief only; do not delay referral. Avoid/limit NSAIDs in peptic ulcer disease, significant renal impairment, heart failure, anticoagulant use, or NSAID hypersensitivity; use lowest effective dose for shortest duration.
Antiemetic for nausea if clinically needed
- Cyclizine 50 mg orally up to three times daily
Use short-term supportive care only. Counsel about drowsiness and anticholinergic effects; avoid if contraindicated (for example severe heart failure) and review if symptoms persist/worsen.
Surgical / Interventional
- No definitive curative surgery is initiated in primary care; urgent referral is the key management step
- Secondary-care diagnostic procedures include endometrial biopsy, colposcopy-directed cervical biopsy, and biopsy of vulval/vaginal lesions
- Definitive oncological surgery is tumour-specific (for example staging/debulking for ovarian cancer, hysterectomy-based surgery for endometrial cancer) after MDT assessment
Complications
- Delayed diagnosis with progression to advanced-stage disease
- Peritoneal spread and malignant ascites (especially ovarian cancer)
- Anaemia from chronic genital tract bleeding
- Ureteric obstruction or renal impairment in advanced pelvic malignancy
- Bowel obstruction, venous thromboembolism, and cachexia in advanced cancer
- Psychological morbidity (anxiety, depression, sexual dysfunction, body-image impact)
Prognosis
UK 5-year survival is variable and stage-dependent: ovarian about 45%, endometrial about 75%, cervical about 60%, vulval about 65%, and vaginal about 25%. Earlier recognition and prompt referral are strongly associated with better outcomes, especially for cancers that commonly present with non-specific symptoms.