Module 7: Female Reproductive Issues

Question 1

Cervical Cancer

Answer 1

Was a common cause of cancer-related death
 Mortality rates have significantly declined due to
prevention
 Vaccination for human papilloma virus (HPV)
 And detection
 HPV testing
 Papanicolaou test or Pap smear (PAP test)

Question 2

Cervical Cancer
Etiology and Pathophysiology

Answer 2

Risk factors
 Infection with high-risk strains of HPV 16 and 18
 Immunosuppression
 HIV infection
 Being exposed to drug DES
 Giving birth to many children
 Smoking

Question 3

Cervical Cancer
Clinical Manifestations

Answer 3

No symptoms in early stages
 Eventually, unusual discharge, AUB, postcoital
bleeding occurs
 Discharge initially thin and watery; becomes dark and
foul smelling
 Vaginal bleeding first presents as spotting; becomes
heavier and more frequent
 Pain, weight loss, anemia, cachexia are late
symptoms

Question 4

Cervical Cancer
Diagnostic Studies

Answer 4

Co-testing
 Pap (papanicolaou) test
 Helps find changes in cervical cells
 Obtained from cervix during speculum exam

HPV test
 Can identify high-risk HPV types 16 and 18
 Cervical scrapings are tested for viral DNA or RNA

U.S. Preventive Services Task Force recommends
 Cervical cancer screening
* 21 to 29 years old—every 3 years
* 30 to 65 years old—every 5 years
 American cancer society recommends
 Screening low-risk females starting at age 25
 Ages 25 to 65- primary HPV testing every 5 years

Question 5

Cervical Cancer
Interprofessional care

Answer 5

Abnormal Pap test followed with a colposcopy
 Examines cervix and biopsy may be taken
 Removal of abnormal cells and prevent progression
to cervical cancer can be achieved by
 Cryotherapy
 Loop electrosurgical excision procedure (LEEP)
 Laser therapy
 Cone biopsy
 Early cancer treatment
 Surgery or radiation therapy

Vaccines against HPV
 Begin before 1st sexual contact
* Ages 11 to 12; may be given as early as age 9
 Gardasil—types 6, 11, 16, 18
 Gardasil 9—types 6, 11, 16, 18 plus 5 other types of
HPV
 2 to 3 IM doses over 6-month period

Question 6

Ovarian Cancer

Answer 6

5th leading cause of cancer deaths in women
 About 21,000 new cases each year
 About 14,000 women die
 Often affects postmenopausal women

Risk factors include
 Personal or family history of cancer
 Genetic predisposition
 Family history of Lynch syndrome
* Hereditary nonpolyposis colorectal cancer (HNPCC)
 Endometriosis
 Women who have never been pregnant (nulliparity)
 Infertility

Reduced risk of ovarian cancer
 Women who have given birth, breastfed
 Used hormonal contraceptive pills for 5 or more years
 Protective factors as they reduce the number of
ovulatory cycles over the lifetime

Question 7

Ovarian Cancer
Etiology and Pathophysiology

Answer 7

90% of ovarian cancers are epithelial cancers from
malignant transformation of surface epithelial cells
 3% are germ cell tumors
 2% are sex cord stroma

Histologic grading
 Grade I—well-differentiated
 Grade II—Moderately well- differentiated
 Grade III—Poorly differentiated
 Grade IV—Undifferentiated
* Poorer prognosis than other grades

Intraperitoneal dissemination is common
 Metastasizes to uterus, bladder, bowel, and omentum
 In advanced disease metastasizes to stomach, colon,
liver, and other parts of body

Question 8

Ovarian Cancer
Clinical Manifestations

Answer 8

May be nonspecific symptoms
 Pelvic or abdominal pain
 Bloating
 Urinary urgency or frequency
 Difficulty in eating or feeling full quickly

Later stage disease
 Abdominal enlargement with ascites
 Unexplained weight loss or gain
 Nausea
 Abnormal vaginal discharge or bleeding
 Adnexal mass or lymphadenopathy on physical
exam

Question 9

Ovarian Cancer
Diagnostic Studies

Answer 9

No accurate screening test exists for early detection
 Annual bimanual pelvic exam
 Ovaries should not be palpable in postmenopausal
women
* Ovarian masses can be detected with abdominal or
transvaginal ultrasound or MRI
* Exploratory laparotomy can establish definitive
diagnosis and stage of disease

For women at increased risk
 Screening in addition to annual pelvic
 Tumor marker CA-125 and pelvic ultrasound
* CA-125 positive in 80% of cases
* CA-125 can be elevated with other cancers or with
benign conditions

Question 10

Ovarian Cancer
Interprofessional Care

Answer 10

Prophylactic care for women at high risk
 Removal of ovaries and fallopian tubes
* Oophorectomy does not completely eliminate the risk
for cancer in the peritoneum
 Oral contraceptives (OCPs)

Initial treatment for all stages
 Total abdominal hysterectomy
 Bilateral salpingo-oophorectomy
 Removal of as much of tumor as possible (tumor
debulking)

Treatment options depend on
 Grade
 Stage of cancer
* Intraperitoneal and systemic chemotherapy
 Taxanes—paclitaxel or docetaxel
 Platinum agents—carboplatin or cisplatin
* Intraperitoneal instillation of radioisotopes
* External abdominal and pelvic radiation therapy

Targeted therapy
 Bevaciumab (Avastin)
 Rucaparib (Rubraca)
 Olaparib (Lynparza)
* Block enzymes involved in repairing DNA
* For women with cancer associated with defective
BRCA genes

Question 11

Endometrial Cancer

Answer 11

Most common uterine cancer
 Affects 1-2% of females in the United States
* Mainly over the age of 50
 Low mortality rate when diagnosed early
* Survival rate over 88%

Major risk factor is exposure to estrogen
 Especially unopposed estrogen
 Obesity is a risk factor
 Adipose cells store estrogen

Additional risk factors
 Family history of cancer
 Lynch syndrome
 Infertility
 Use of tamoxifen

Protective factors include
 Increased number of pregnancies
 Breast feeding
 Use of OCPs
 Physical exercise

Most tumors are adenocarcinomas
 Can invade myometrium and regional lymph nodes if
not diagnosed early
 Common metastatic sites include
* Lung, liver, bone, brain
 Prognosis depends on
* Tumor size, cell type, degree of invasion into
myometrium, metastasis

Question 12

Clinical Manifestations

Answer 12

Early symptoms
 Abnormal uterine bleeding (AUB)
 Especially post-menopause

Later symptoms
 Dysuria
 Dyspareunia
 Unintentional weight loss
 Pelvic pain

No routine screening test is available
 Most cases are diagnosed early due to
postmenopausal bleeding
 Thickened endometrium may be seen on
ultrasound
 Endometrial biopsy

Treatment
 Total hysterectomy
 Bilateral salpingo-oophorectomy
 Lymph node biopsies

For complex cases
 Radiation
 Chemotherapy
 Hormone therapy

Question 13

Vaginal and Vulvar Cancer

Answer 13

Rare
 6 to 7% of all gynecological cancers
 Both associated with HPV infection
 Most are squamous cell cancers
 Primary vaginal cancer is rare
* Often result of metastasis from another gynecologic
cancer

Often affects post-menopausal females
 Risk factors
 Smoking
 Multiple sex partners
 Immunodeficiencies (HIV)
 Chronic vulvar itching/burning
 Having other gynecologic cancers
 Vulvar lichen sclerosis increases risk for vulvar
cancer