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  4. Gynaecological cancers

Urgent suspicion of cancer (USC) referral

Refer a woman with any of the following to the Gynaecology Service as a USC:

 

Ovarian cancer:

  • An ultrasound scan (USS) suggesting ovarian cancer or abdominal/pelvic mass (not obviously uterine fibroids, gastrointestinal or urological in origin)
  • A raised CA125 (a level of 35 International Units per millilitre (IU/ml) or greater)
  • Unexplained ascites

 

Endometrial cancer:

  • Postmenopausal bleeding in a person with an intact uterus who is:
  • Abnormal vaginal bleeding in a person who currently takes or has previously taken Tamoxifen
  • A USS suggesting endometrial cancer

 

Cervical cancer:

  • An abnormal cervical examination and symptoms suggestive of cervical cancer:
    • vaginal discharge
    • postmenopausal, postcoital or persistent intermenstrual bleeding
    • pelvic pain

 

Vaginal cancer:

  • A suspicious abnormality of the vagina

 

Vulval cancer:

  • Unexplained vulval lump, bleeding, or ulceration

 

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.

 

Background

Gynaecological cancer is an umbrella term for ovarian, endometrial, cervical, vaginal and vulval cancers. These cancers tend to present with different symptoms and have different stage distributions and outcomes.

In 2021, 19.8% of corpus uteri cancers, 32.3% of cervix uteri cancers, and 39.8% of ovarian cancers were diagnosed at stage 3 or 429.

Evidence has shown inequalities in cervical screening uptake, with those from areas of deprivation demonstrating lower uptake30. Further research is required to understand risk of reproductive cancers in transgender people and any barriers to timely recognition and referral in a symptomatic context.

 

Ovarian cancer:

Approximately 585 new cases of ovarian cancer are diagnosed in Scotland every year1, more than 90% of which are in women aged 40 years or over1. 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. See Regional Genetics Centres for advice on referral.

 

Endometrial cancer:

Approximately 800 new cases of endometrial cancer are diagnosed in Scotland each year31. Fewer than 5% of cancers of the corpus uteri (which includes endometrial cancer) occur in women below the age of 451.

Risk factors for endometrial cancer include:

  • Obesity
  • Age over 45 years
  • Nulliparity
  • Exposure to unopposed oestrogens
  • Tamoxifen usage
  • Family history of endometrial or colon cancer

Thrombocytosis is a risk marker for underlying malignancy including endometrial cancer17. There should be a higher index of suspicion for women with associated risk factors.

 

Cervical cancer:

Cervical cancer affects all adult age groups, with above 50% of cases occurring between the ages of 30 and 50 years1. 40% of new cervical cancer cases in women of screening age (25-64 years) were screen detected in Scotland in 20221.

Taking a cervical sample in symptomatic individuals is not necessary before referral. Cervical sampling is intended to be used as a screening tool to detect pre-cancerous changes in asymptomatic people, not for diagnosing symptomatic cancers. A previous negative screening result is not a reason to delay referral.

 

Vaginal cancer:

Vaginal cancer is rare and comprises less than 1% of gynaecological cancers. It is most frequently diagnosed in women aged 60 years or over and is rare in women aged under 401. Approximately 30 new cases of vaginal cancer are diagnosed in Scotland every year1.

 

Vulval cancer:

There are about 155 new cases of vulval cancer diagnosed every year in Scotland1, approximately 60% of which are in women aged 65 years or over1. Lichen sclerosis increases the risk of developing invasive squamous vulval cancer, but the overall risk remains low32.