Assessment of suspected gynaecological cancers
Recognising gynaecological cancers in primary care can be challenging, as many symptoms (e.g. bloating, pelvic pain) are non-specific and often caused by benign disease33. There are different investigations required depending on the cancer suspected.
Ovarian cancer:
Presenting features often include non-specific abdominal symptoms that are persistent and frequent - there may be a palpable pelvic mass34.
An abdominal palpation should be undertaken, CA125 blood serum level measured, and USC pelvic ultrasound scan (USS) arranged in:
Women (especially those aged 50 or over) with one or more of the following unexplained symptoms occurring most days over the last four weeks:
- abdominal distension or persistent bloating
- feeling full quickly, difficulty eating or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- change in bowel habit
- Women aged 50 or over who have experienced new symptoms within the last 12 months that suggest irritable bowel syndrome
- CA125 is not raised in all cases of ovarian cancer and therefore this test should always be done in conjunction with a pelvic USS in those with symptoms or signs that are suspicious of ovarian cancer.
Endometrial, cervical, and vaginal cancer:
Most women with endometrial cancer present with postmenopausal bleeding35. For the purpose of this guideline we define postmenopausal bleeding as vaginal bleeding occurring 12 months or more after periods have stopped.
Typical symptoms of cervical cancer include vaginal discharge and abnormal vaginal bleeding.
A full pelvic examination, including speculum examination of the cervix, should be considered in women presenting with:
- Abnormal vaginal bleeding (including postmenopausal bleeding, post-coital bleeding, and persistent intermenstrual bleeding)
- Unexplained vaginal discharge
- Pelvic pain
- 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 for a USC priority ultrasound scan.
Vulval cancer:
Women with vulval cancer usually present with bleeding, discomfort, an itch, or a burning sensation36. The majority of patients have a visible ‘tumour’ on clinical examination36. Failure of treatment for ‘benign conditions’ should prompt consideration of further assessment or referral.
A vulval examination should be carried out for any woman with vulval symptoms.
Good Practice Points:
Referral guidance:
If there is significant concern, awaiting the results of any investigation should not delay referral.
It is important to remember that transmen may still have female reproductive organs and, therefore, are still at risk of gynaecological cancers.
Ultrasound for assessing the pelvis:
Transvaginal USS is more sensitive for assessment of the female pelvis than transabdominal USS. It is important to request the correct test based on the information required. Local pathways should be followed when requesting a USS.
Abnormal vaginal bleeding:
Abnormal vaginal bleeding is a common presentation to primary care. Endometrial cancer is uncommon in pre-menopausal women. An urgent gynaecology referral or pelvic USS request should be considered for women with premenopausal abnormal vaginal bleeding that persists after medical management. A woman with abnormal vaginal bleeding on HRT should be assessed for endometrial cancer risk according British Menopause Society Guidance.
CA125:
CA125 may be elevated in many physiological and pathological conditions (Raised CA125 – what we actually know), which may be gynaecological or non-gynaecological. The physiological causes include menstruation, so it is advisable to avoid sample taking during this time if possible. CA125 can be elevated in other cancers (e.g. pancreas, breast, lung and colon). If the person has a normal USS, then referral guidelines for other cancers or non-specific symptoms should also be considered.
Overlap with other pathways:
Patients with intra-abdominal cancer can present with symptoms that overlap. A Quantitative Faecal Immunochemical Test (qFIT) should be considered if there is a change in bowel habit - please see Upper and Lower gastrointestinal cancer and Kidney cancer guidelines.
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