Gynaecological Cancer

Gynaecological cancers are cancers that originate in the female reproductive system. They arise as a result of the uncontrolled and abnormal growth of cells found in the organs of the female reproductive system.

The types of cancers that arise in the female reproductive system are categorised based on the organ and the cell type from where it begins.

Ovarian cancer

There are 3 main cell types that make up the ovaries. These cells are the epithelial cells (cells that cover the outer surface of the ovary), germ cells (cells that produce the ova) and structural tissue cells (also produce female hormones). Tumours can arise from any of these cells.

• Epithelial tumours – 85-90% of ovarian cancers develop from epithelial tumours. These are called epithelial carcinomas. There are further subtypes of epithelial carcinomas based on their features
• Stromal tumours – malignant tumours that involve the hormone-producing cells. Usually found at an early stage and have a good outlook
• Germ cell tumours – cancerous tumours are relatively rare, but may be life threatening. There are subtypes of germ cell tumours including teratomas

Endometrial cancer (cancer of the uterus/womb)

The uterus is comprised of 3 layers, one of them being the endometrium, which is the cells of the inner lining of the uterus. Endometrial carcinomas are categorised based on the cell type the cancer develops from. Cancers of the endometrium include:

• Adenocarcinomas
• Uterine carcinosarcomas
• Squamous cell carcinoma
• Small cell carcinoma
• Transitional carcinoma
• Serous carcinoma

Cervical cancer

Cervical cancer is the 10 most common cancer in Singaporean women. The cervix is made up of 2 parts, and covered with 2 different types of cells. There is the endocervix, which is covered by glandular cells. This is the opening of the cervix that leads to the uterus. The exocervix is the outer part of the cervix which is covered by squamous cells. The two cell types meet at the transformation zone. This is the part of the cervix where most cervical cancers begin. Cells in the transformation zone can gradually accumulate abnormal changes over time, which lead to cancer. These pre-cancerous changes include cervical intraepithelial neoplasia, and dysplasia. Only some women with pre-cancerous changes of the cervix develop cancer. The main types of cervical cancer are:

• Squamous cell carcinomas – 90% of cervical cancers, most often begin in the transformation zone
• Adenocarcinomas – develop from glandular cells, from the endocervix
• Adenosquamous carcinomas – cervical cancers that have the features of both squamous cell carcinomas and adenocarcinomas

Pre-cancerous changes can be detected by Pap smears, so it is important to discuss with your doctor when and how often you should go for a Pap smear.

Vaginal cancer

There are several different types of cells that are found in the vagina. This includes squamous cells which line the vagina (epithelium), connective tissue, muscle, lymphatic vessels and nerves, and glands that are found near the opening of the vagina. Like cervical cancer, pre-cancerous cell changes in the vagina can occur, and may develop into cancer over time. An example of a pre-cancerous change is vaginal intraepithelial neoplasia (VAIN). Vaginal cancer is quite rare, but there are many types. The more common types are:

• Squamous cell carcinoma – 90% of vaginal cancers, beginning in the epithelium of the vagina. Most commonly develop near the cervix
• Adenocarcinoma – about 10% of vaginal cancers, different types may be found in older women compared to younger women

Vulvar cancer

Cancers of the vulva tend to affect the labia majora or labia minora. These are 2 sets of skin folds around the opening of the vagina. The cells of the vulva can undergo pre-cancerous cell changes as well, and this may develop into cancer over time. This is known as vulvar intraepithelial neoplasia (VIN). Most vulvar cancers tend to develop from the squamous cells, which are the main type of skin cells on the vulva. Some types of vulvar cancer are:

• Squamous cell carcinomas – there are different subtypes with different prognosis
• Adenocarcinoma – cancers of the gland cells of the Bartholin glands (found just inside the opening of the vagina)
• Melanoma – develop from the pigment-producing cells that give rise to our skin colour

Ovarian cancer

• Bloating
• Pelvic or abdominal pain
• Difficulty eating
• High degree of urgency or frequency in urination
• Fatigue
• Back pain
• Pain during sexual intercourse
• Stomach upsets
• Constipation
• Heavier than normal or irregular menstrual bleeding
• Unexplained weight loss

Endometrial cancer symptoms

• Abnormal bleeding
  • Having longer or heavier menstrual periods than usual
  • Bleeding between periods
  • Increased frequency of vaginal bleeding or spotting during years leading to menopause
  • Bleeding after menopause
• Unusual discharge from the vagina – may contain blood, may occur between periods or after menopause. May appear pink, watery or white
• Pain during sexual intercourse
• Pain in the pelvic region
• Unexplained weight loss

Cervical cancer

Women with early cervical cancers and pre-cancers do not usually experience any symptoms. The symptoms tend to present only when the cancer is in the later stages, where it becomes larger and invades into the nearby tissue. When this occurs, the symptoms that a woman may encounter are similar to that of endometrial cancer:

• Abnormal vaginal bleeding
  • Bleeding after vaginal sexual intercourse
  • Bleeding after menopause
  • Bleeding and spotting in between periods
  • Having longer or heavier menstrual periods than usual
  • Bleeding after douching
• Unusual discharge from the vagina – may contain blood, may occur between periods or after menopause
• Pain during sexual intercourse
• Pain in the pelvic region
• Swelling of the legs
• Problems with urination
• Problems with bowel movement
• Blood in the urine

Vaginal cancer

Women who have earlier or small vaginal cancers may not experience any symptoms. When the cancer becomes bigger and spreads to nearby tissues, they may have the following symptoms:

• Abnormal vaginal bleeding, often after sex
• Abnormal vaginal discharge
• Mass or lump in the vagina
• Pain during sexual intercourse
• Painful urination
• Constipation
• Pain in the pelvic region
• Swelling in the legs
• Back pain

Vulvar cancer

Vulvar intraepithelial neoplasia (VIN) tends to lack symptoms. However, when it is symptomatic, an area of VIN often presents as persistant itching, appears thicker and lighter, or can appear red, pink or darker than skin around it. Women with invasive vulvar cancers will be symptomatic, and these symptoms could include:

• Area of vulva that looks different than normal (same as VIN)
• Bump or lumps on the vulva
  • Red, pink or white
  • Could have a wart-like or raw surface
  • Could feel rough and thick
• Thickening of the vulvar skin
• Itching
• Pain or burning
• Bleeding or discharge not related to normal menstrual cycle
• Open sore (especially if it lasts longer than a month)
• Cauliflower-like growths similar to genital warts

These symptoms may also present in other less serious conditions. If you are experiencing any of these symptoms, it is important that you bring this to your doctor’s attention. Some cancers may present with non-specific or few symptoms that are easily missed, and as a result, they may go undetected. Your doctor will be able to help you find the cause of the symptoms you are experiencing.

Having a blood relative who has had any of the gynaecological cancers will increase a woman’s chance of developing a gynaecological cancer herself. Risk factors for each type of cancer are listed below.

Ovarian cancer

• Older age (most ovarian cancers develop after menopause)
• Obesity
• Women who have had children later (after age 35)
• Women who have never carried a pregnancy to full-term
• Use of fertility treatment (in vitro fertilisation)
• Use of hormone therapy after menopause
• Family history of ovarian, breast or colorectal cancer
• Having an inherited syndrome
  • Hereditary breast and ovarian cancer syndrome
  • PTEN tumour hamartoma syndrome (Cowden disease)
  • Lynch syndrome
  • Peutz-Jeghers syndrome
  • MUTYH-associated polyposis
• Having or a history of breast cancer
• Smoking and alcohol use

Endometrial cancer (cancer of the uterus/womb)

• Older age
• Obesity
• Consumption of a high-fat diet
• Use of oestrogen medication after menopause without combination with progestin
• Polycystic ovarian syndrome
• Early onset of menstrual periods (menarche), before age 12, along with later onset of menopause
• Women who have never carried a pregnancy to full-term
• Infertility
• Women who have a granulosa cell tumour (ovarian tumour)
• Use of tamoxifen (low risk, discuss with your doctor)
• Polycystic ovarian syndrome
• Having an inherited syndrome
  • Lynch syndrome
• Endometrial hyperplasia
• Having or a history of breast or ovarian cancer

Cervical cancer

• Infection by human papillomavirus (HPV)*
• Becoming sexually active at a young age (below 18 years old)
• Having multiple sexual partners
• Having one sexual partner who has HPV infection, or who has multiple sexual partners
• Smoking
• Having a weakened immune system by:
  • Human immunodeficiency virus (HIV) infection
  • Taking immunosuppressive drugs for autoimmune conditions or for those who have had an organ transplant
• Infection by Chlamydia
• Long-term use of birth control

*Infection by certain strains of human papillomaviruses (HPV) is one of the causes of cervical cancers. This arises as HPV can infect the cells of the cervix, causing them to undergo abnormal changes. In most cases, the virus is cleared by the body’s immune system, and this allows the cells to heal and return to normal. However, in some, the infection can persist and this causes the cells to grow abnormally and uncontrollably. This eventually causes cervical cancer to develop. HPV types 16 and 18 causes approximately 70% of cervical cancer cases worldwide. The risk for developing HPV-positive cervical cancer can be lowered by getting vaccinated against HPV. If you wish to get vaccinated against HPV, please consult your doctor to find out more.

Vaginal cancer

• Older age, but it can happen at any age
• Vaginal adenosis (when squamous cells in the vagina are replaced by glandular cells)
• Infection by human papillomavirus (HPV)* see above
• Having or a history of cervical cancer
• Smoking and alcohol use
• Infection with human immunodeficiency virus (HIV)
• Chronic vaginal irritation

Vulvar cancer

• Older age, but it can happen at any age
• Infection by human papillomavirus (HPV)* see above
• Smoking
• Infection with human immunodeficiency virus (HIV)
• Vulvar intraepithelial neoplasia (VIN)
• Lichen sclerosus (a disorder that causes vulvar skin to become thin and itchy)
• Having or a history of other genital cancers, including cervical cancer
• Atypical moles

Your doctor will want to know your personal and family medical history, and he/she will conduct a physical examination of your pelvis, and a Pap test if necessary. If your doctor suspects you may have gynaecological cancer, there are several tests he/she may conduct in order to reach a diagnosis.

For some of the gynaecological cancers, there may be blood tests to look for certain tumour markers, such as CA-125, human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH). These chemical levels may be altered in your blood, and if so, may be an indicator for an underlying cancer. However, cancer cannot be diagnosed by a blood test alone.

Your doctor may recommend for you to undergo a scope. Depending on which gynaecological cancer your doctor is testing for, it may be a cystoscopy, procotoscopy, laproscopy or colposcopy. The different names indicate which structure your doctor is looking at with the scope.

If there are any abnormalities, your doctor may conduct a biopsy. This is the removal of a small sample of tissue to be examined under the microscope. Depending on the location of the abnormal tissue, the type of biopsy your doctor may use will be different.

The use of imaging may also help your doctor to detect any abnormalities or find the location of the tumour. Imaging modalities that are commonly used by doctors to find gynaecological cancers include ultrasound scans, magnetic resonance imaging (MRI), computed tomography (CT scans) or positron emission tomography (PET).

The tests used to diagnose gynaecological cancer depends on the location and type of cancer. It is important to consult your doctor to understand what he/she may plan to use in order to rule out or diagnose cancer.

Treatment options for gastrointestinal cancers depends on the location and stage of the cancer, as well as the patient’s age and overall health. If the cancer is caused by infection by human papillomaviruses (HPV), treatment will vary as well.

There are a variety of treatment options available, and is personalised to each patient. Sometimes, different options may be used in combination as well. The options include:

• Surgery
• Chemotherapy
• Radiation therapy
• Targeted drug therapy
• Immunotherapy

Once the diagnosis is made, a consultation with an oncologist is essential in order to understand which treatment options are the most suitable.