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It is important that all health care professionals are aware of the common signs and symptoms associated with gynaecological cancer and respond appropriately to the red flags.

Risk factors

The risk factors for gynaecological cancer include: being post-menopausal, with a family history of ovarian cancer or cancers of the uterus, colon or breast, infertility problems or having had no children, in women who are overweight, smokers or those with comorbidity such as  hypertension or diabetes, not engaging in cervical screening or persistent HPV, taking tamoxifen or unopposed oestrogen, first intercourse before sixteen, having multiple sexual partners or women who are HIV positive. 

'There are 22,050 new cases of gynaecological cancer every year in the UK' (). 

Signs and symptoms

Abnormal vaginal bleeding is a common sign of most gynaecological cancers. The signs and symptoms may be different for every woman however abnormal vaginal bleeding is a common sign of all gynaecological cancers except vulval cancer. Women who report feeling full or a difficulty eating, feeling bloated, and abdominal or back pain are all common symptoms with ovarian cancer. Pelvic pain or pressure symptoms are common with ovarian and uterine cancers. Women report an urgent need to urinate or with constipation are commonly associated with ovarian and vaginal cancers. Itching, burning, tenderness or pain of the vulva, and changes in vulva colour or skin, such as a vulval ulceration, rash or warts, are found only in vulval cancer. If you identify any red flags, you should consider a suspected cancer pathway referral (for an appointment within 2 weeks).

Main types of gynaecological cancer

Ovary

Ovary cancer can affect women at any age but is rare under the age of 30 and more common in women after 65. It can start in the ovary, fallopian tube or peritoneum. Approximately 7,000 women are diagnosed every year. Ovary cancer divides into subtypes of which some are more common than others. The most common subtype is epithelial ovarian cancer which comes from the cells on the surface of the ovary. Diagnosis is often delayed because women present with non-specific abdominal symptoms which can be confused for other conditions such as IBS. CT scans and abdominal ultrasound are used to confirm the diagnosis. Ovarian cancer is associated with an increased level of a tumour marker called ca125. Treatment is with chemotherapy and surgery including hysterectomy and removing the ovaries, appendix and omentum. Women who carry the BRCA1 and BRCA2 gene are at increased risk from developing the disease and may consider prophylactic ovary removal to decrease their cancer risk. There is no national screening programme.

Endometrium (lining of the womb)

Endometrial cancer is rare in women under 40 and becomes more common after 55. Approximately 9,200 women are diagnosed annually. At least 1 in 3 womb cancers may be caused by obesity and lack of exercise. Other causes include exposure to oestrogen and a rare genetic condition called Lynch Syndrome. The most common symptom is irregular vaginal bleeding and bleeding after the menopause. Diagnosis includes biopsy of the endometrium, abdominal ultrasound and CT scan. Treatment includes hysterectomy and ovary removal, external beam pelvic radiotherapy and internal brachytherapy. There is no national screening programme. 

Cervix

Each year more than 3,200 women are diagnosed with cervical cancer in the UK it can affect women at any age. There are two main types of cervical cancer, the most common is squamous cell cancer the other is adenocarcinoma. The main risk factor is infection from the Human Papilloma virus (HPV) other risk factors include a weak immune system caused by conditions such as HIV and smoking. Symptoms include abnormal vaginal bleeding, offensive discharge and lower back pain. Diagnosis is made by a biopsy from the cervix, MRI, CT and Positron emission tomography (PET) CT.  Early stage cancers are treated with a Large Loop Excision of the Transformation Zone (LLETZ), Needle Excision of the Transformation Zone (NETZ) and cone biopsy. More advanced cancers are treated with surgery, chemotherapy and radiotherapy. There is a national screening programme to detect pre-cancerous changes to the cervix which can treat abnormalities at an early stage.

Vulva

Cancer of the vulva is rare with 1,300 diagnosed a year. It is most common in women over 65 only 15% develop vulval cancer under 50. It can affect any part of the external female sex organs but the most common are the inner edges of the labia majora and any part of the labia minora. There are several different types of which the most common is squamous cell cancer which affects 90% of all diagnoses.

Other types include

Other types of Gynaecological cancers include: Vulval melanoma, basal cell carcinoma, sarcoma, adenocarcinoma and Bartholin gland cancer. In older women vulval cancer is linked with a skin condition called lichen sclerosis. Other skin conditions linked to vulval cancer are lichen planus and Paget’s disease. It is also linked to HPV and a pre-cancerous condition called vulval intraepithelial neoplasia (VIN). Smoking, a reduced immune system and cervical intraepithelial neoplasia (CIN) increase the risk of diagnosis. Symptoms include vulval burning, soreness, ulcerated areas, bleeding, moles, lumps in the groins, pain passing urine.  Diagnosis is through visual inspection of the area and biopsy, CT and MRI. Treatment is with surgery, chemotherapy and radiotherapy.

Women’s health issues are still taboo and the nature of certain ‘embarrassing’ symptoms means that some women we are less willing to seek help. As nurses we need to ensure our patients know it is ok to voice their worries and concerns about women’s health. By investigating suspected gynaecological cancer promptly can mean an earlier diagnosis and a better outcome.

Diagnosis

A number of tests and investigations are required when diagnosing a gynaecological cancer these might include:

• pelvic examination
• ultrasound scan
• colposcopy or hysteroscopy plus biopsies
• tumour markers
• MRI or CT.

Treatment

The treatment required will depend on the prime location of the cancer, its grade and stage but may include:

• hysterectomy and possibly bilateral salpingo oophorectomy
• chemotherapy
• external beam radiotherapy 
• internal brachytherapy.

The role of the GynaeOncology Clinical Nurse Specialist (CNS)

The role of the GynaeOncology Clinical Nurse Specialist (CNS) ensures continuity of care and is essential in supporting women following their cancer diagnosis, throughout their treatment and beyond. They ensure high quality compassionate care relaying information to assist with informed decision-making around treatment. Nurse led clinics have been shown to have a positive impact on patient outcomes, patient satisfaction, access to care and cost effectiveness. The CNS is empowered to make clinical decisions, initiate and lead discussions within the GynaeOncology team meeting.