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Mm So we are going to talk about gynecological cancers in this session. Uh This is a series and every Monday we have a session from 7 to 8. And so we will send out more information about the following uh sessions closer to the date. So keep checking it. So um in this section, this is created by students. So make sure that this is not the only resource that you're using for um your revision and thank you very much for attending. So basically, we're gonna cover cervical cancer, endometrial ovarian and cancer. And there's gonna be a couple of case studies and like quite a few Bs at the end. So case 31, we have a 35 year old woman who presents to her GP with a postcoital bleeding. She's worried that it's getting worse, what could be causing it to use the chest function or if you can, you can on yourself and give some differentials for postal bleeding in a 35 year old woman. It's quite an interactive session. So the more you inside, the more it will be Patak, anything that would cause postcoital bleeding, ok? And so these are a couple. So cervical ectropion, cervical polyps, cancer or infections can cause uh postcoital bleeding just to name a few. So can vaginal dryness as well. So, what questions would you ask her when you asked about history? So again, you can type in a couple of questions into the chat. Yeah. Any pain? That's, that's a good one. Yeah. Great. How long she's had the problem for? Anything else crossed your mind? Yeah. Great. With cervical smears. Great. So, yeah. Um So with Gyne history taking, you want to take a thorough history of the presenting complaints. So that would be like pain. How long she's had the problem for kind of screen hours or so, whichever you prefer. Um And then you want to get into the Gyne side of things. So, but uh vaginal bleeding may that be um in intermenstrual bleeding, postcoital bleeding or postmenopausal bleeding. And then you would want to ask about any vaginal discharge, itching or skin changes and then also menstrual history, any dysuria infertility problems and then you would go into past medical history and that's where I put the cervical screenings, STIs s pregnancies. Again, drug history, allergies, family history of any cancers, for example. Um And then social history and that sort. Ok. So out of these, which cause is the most likely. So you can click on one from the poll. Which one do you think is the most likely cause? So as far as I know ectropions are the most likely cause they're definitely much more likely than cancer. So, without screening your mind should go into the non-cancer direction. So she tells you that she's never attended any of her cervical screens. Nor has she received any vaccinations as a child. She has a 10 b year smoking history and she has had many sexual partners at what age should she have received the vaccine? That would decrease her chances at cervical cancer? Yeah. Great. Yeah. So Gardasil nine is um one of the vaccines that they use. Now, I think it's the main one and it protects against nine types of HPV, which is uh the main risk factor for cervical cancer. Um 611 are types that cause kind of warts and then 16 and 18 are the ones that cause uh cervical cancer and teenagers are given this at 12 to 13 years old. Um And if someone hasn't really received it, then, um as far as I know they can receive it up until they're 25. Ok. So here are some risk factors for cervical cancer. So HP is, is the biggest one, having a weakened immune system, smoking long term contraceptive use. Uh and then pregnancy history, genetics and low socioeconomic status. And they are usually detected around 35 to 44 ages. So in terms of symptoms, we can have vaginal discharge, regular vaginal bleeding, uh pelvic or abdominal pain, post total vaginal bleeding and more symptom, uh systemic issues later on. So, when should she have done the cervical screening? So, from what age, she's 35 when was the last time she should have gone for a cervical screen. Yeah. Great Sonia. So, between the ages of 25 and 49 women are invited, uh, every three years for a screen and then after that, so from 50 until 64 they are invited every five years. And, uh, basically, uh, they do your screen. Um And if it's HPV negative, then they go back into the routine of either three year or five year. And then if it's HPV positive, then they do cytology, uh which determines if it's kind of a normal or abnormal. If it's normal, then they have a repeat smear in 12 months because it's likely that the body will just kind of deal with the virus. And then if it's an abnormal smear in terms of cytology, then they go on to have Colposcopy. Um And then if it's kind of an in the gut smear, then they have to repeat within three months and then go to Colposcopy. Um if it's, if it remains in liquid, if it, if it's abnormal. So in terms of investigation, he would do the cervical screen, as I said to identify uh the scoliosis. If there is, then you would go into Colposcopy which directly visualize the cervix. And then uh if there is abnormalities um moderate to severe, then you would do either a cone or a large loop excision biopsy. And then if it's very advanced, you would do CP chest abdo PPIs pelvis for fecal staging and then you would do sti checks as well um as well as just kind of visualizing the genital area to see if anything else could be causing the vaginal bleed. So this is the staging um and it shows how the cancer can spread uh from the cervix up to the uterus, some kind of like outside of it. Um And in terms of management, if it's quite localized, then you would do the colonization. So like the or like the large loop excision, if it's uh further than that, they can take out a bigger part of the cervix, it's further than that, then you would do a hysterectomy and then you can use um additions of chemotherapy and radiotherapy, but it's very unlikely that these are needed at this point. So next up, we have endometrial cancer. So the question here is what are the risk factors for endometrial cancer? And while you kind of think about that and type it into the chat, hopefully the some of the protective factors I listed, which are multiparity continuous combined. HRT and C OB. So if you have a think about what could be risk factors for endometrial cancer. Yeah, great. So, here are the ones I listed. So you have um no parity, obesity, early and late menopause PCOS estrogen only H RT uh Tamoxifen use uh diabetes and limb syndrome. So how would they present? What symptoms would they be complaining of? Yeah. Anything else that pops your mind? So, besides that you can, the main one is postmenopausal bleeding. Um but as you mentioned, intermenstrual bleeding is another one. abnormal discharge, dysemia, pelvic pain, and then kind of abdominal distension and discomfort, weight loss or the systemic ones as in weight loss, anemia and then if it's uh a large tumor, um and it can be felt, uh the uterus can be felt on by Manel examination as well. So you have a 75 year old female presents with postmenopausal bleeding, pelvic pain, weight loss and abdo discomfort. How would you investigate? Mm. Anything else that pops to your mind later down the line? Yeah. So as you said, you would do the transvaginal ultrasound first. Um And if it's the endometrium is thicker than five millimeters with postmenopausal bleeding, then there is a 7.3 chance of cancer. Um If it's less than five millimeters with the post menopausal bleeding and there's like a significantly less less risk of uh cancer, you would do an endometrial biopsy, which can be the PPI biopsy, as you said, Jennifer. Um uh it can also be dilation and uh cartage and then you would do a hysteroscopy um which allows direct visualization. And then for staging, you would do a CT chest abdomen pelvis for the fetal staging and as you said. So you would do uh a thorough examination um and a history as well. So, in terms of histology, um endometrial hyperplasia is the pre malignant condition. Um And it basically means a thick endometrium and then carcinoma, most of the cases are adenocarcinoma, um which is type one and then type two would be serous or clear cell uh carcinomas. So you can see the fecal staging uh about like where uh the cancer is localized if it's like within the uterus, closer to the cervix uh involving other. Um So like the, the ovaries as well. And then if it's metastasized to different locations in the body and then for management, depending on the stage, you have a total hysterectomy and bilateral Salyer Salyer overy for stage one and then radical hysterectomy for stage two. And then for stage three and four, it's mostly debulking and kind of palliative and chemo and radiotherapy. So, moving on to ovarian cancer um type and to chat the protective factors of while we go through the risk factors which are obesity, smoking. No, um having an early menarche, late menopause only HRT having BRCA one or two genes and then a Lynch syndrome. So, quite similar to the previous ones really. So if you think about it, what would be the protective factors for this one? Mm Yeah, pseudo ones I listed for multiparity, breastfeeding, early menopause cop and sterilization. So how would they present if you think about it. What kind of symptoms would they complain of? Yeah. Anything else? Yeah. So the main one is abdominal distension and discomfort, early satiety, as you guys said, urinary frequency. And um, so it's quite nonspecific and because of that, it's quite difficult to diagnose early on. Um, in later stages, they can have changes in bowel habits. As you mentioned, constipation would be one of them. You can also have this paranaemia. Um And then just as mentioned above uh abdominal pain, but also uh and back pain, ascites uh from the mass and then um uh palpable abdominal or pelvic mass, especially if it's further along the line. So how would they investigate a patient with these symptoms? What would be the first one, let's say A GP, if a GP is worried about a patient who presents it bloating there? 75. Yeah, great. So you would test ca 125. That's great. Um So you would do that. Um And, and, and you can get the risk of malignancy and by combining the results from uh the ca 125 to pelvic abdominal ultrasound uh findings and then the menopausal status and then later down the line. Um you can check uh the different markers if it's especially if it's confirmed. So you can check for germ cell cancers, um which would be ha which would have raised the FD and be the A H CG. Uh And this is especially in women under 40. And then for fecal staging, you would do a chest abdomen, pelvis, CT and then for surgical staging, you would do laparotomy in terms of histology. Most of the cases are epithelial. Um these are usually the ones so like in an, in an older woman would be epithelial. And then in the youngest, it said in the previous slide, if they are kind of below 40 they're more likely like m more likely than the older women to have germ cell tumors. And then the other ones are just kind of rare, but they can happen as well. So in terms of management, you would do surgery for the staging and the walking, especially because in most of these cases, unfortunately, they present quite late. Um, you can give them chemotherapy um to help with other symptoms such as palliatively. So last one, we we consider this is quite run through, this is quite rare. So very rare and most of them are squamous cell carcinoma. The breast are a mix and the risk factors are very similar to the previous ones, especially cervical. So HPV, multiple sexual partners, early age at first sexual intercourse, cigarette smoking, low social economic status would be the main ones. And there's a presentation uh they mostly occur on the labia majora. Um and it can be itchiness, soreness, bleeding, pain and lump, um obviously a very clearly abnormal picture. And then in terms of investigation, you would do a punch biopsy and staging is again fal um and management is your surgery. So you would want to get rid of it. Uh ASAP. Um And that's how you manage it. So we have a number of sds and I will be using the polls uh to help you choose the answers. So we have in the first one, a 62 year old female who presents at the clinic with postmenopausal vaginal bleeding. The ultrasound shows endometrial thickness of 10 millimeters with no other significant findings. Which of the following is the most appropriate next step in management. So you can choose the one you think is the most appropriate. Next step. Yeah, you guys are great. So it's endometrial biopsy. So for the next one, you have an uh a 59 year old woman who presents to her GP with an eight month history of vaginal bleeding. She says it occurs almost daily and has progressed from a brown discharge to dark red blood. She has also lost approximately three K GS in weight and also during the past six months with uh in the past six months with no major changes to her diet. The endometrial biopsy confirms endometrial cancer and she referred for further investigations, which of the following is used to stage the endometrial cancer. So it's uh the fecal staging. Next one, you have a 73 year old woman who presents her GP with symptoms of bloating early society and weight loss. She has no changing her bowel movements or blood in the stool. She believes she may have IBS and would like advice and foods to avoid. She has no family history of note and has had, uh, ha hasn't had any Children. What is the most important initial investigation? So the correct answer is the ca 125 level. Uh, so at GP level, you can send the blood test off kind of immediately. Uh and then refer to, to Gyne is the reasoning behind that. So we have a 27 year old woman who attends her GP with unexplained abdominal bloating over the last six weeks. She's not currently sexually active. She has a 32 day regular menstrual cycle. Stool culture is negative a trial of gluten-free diet and dairy free diet has not improved her symptoms on examination. A suprapubic mass is palpated serum tissue transplant. Uh glutaminase and in immunoglobulin A are negative alpha fetoprotein and beta human chorionic uh gonadotrophin are found to be raised. An abdominal ultrasound is performed which one that identifies in a, a pelvic mass and she's referred to G for further investigation, which of the following is the most likely diagnosis. So, the correct answer is germ cell tumors because of the A FP and the beta HCG. So the for the ones of you with epithelial c uh cell tumors in an elderly woman, that would be the case, but because she's young. Um and has the uh, the mayo markers for the germ saler. That's the correct answer. I hope that makes sense. So, the next one is a 68 year old woman who attends the GP with elicit ty and altered bowel habit. Her sister died of breast cancer in her forties. She's known to be positive for BRCA one medication. A routine mammogram eight weeks ago showed no signs of breast cancer. Her C 15 is found to be raised. An ABDO ultrasound is performed which shows a suspicious large ovarian mass. She's referred to gynecology for further management, which of the following uh is the most likely histological diagnosis. So, yeah, so epithelial cell tumors are the most likely. Um but she's 68 and um has a BRCA one mutation and no signs of breast cancer. So the next one is a 61 year old woman who has been referred to Gynae as she is suspected of having ovarian cancer. She has a high C 125. The pelvic ultrasound is abnormal and so a chest abdo pelvic CT is progressed. The CT shows that the cancer has seeded into peritoneum and the liver. What uh one of the following is which one of the following is the most appropriate next step. So, in my opinion, it's the surgery, I mean to remove the mac uh macroscopic disease, I think they all in the macroscopic disease. It might be a bit misleading, but basically um, you would want to do a debulking surgery and before starting palliative care as far as I know. So you have a 35 year old woman who attends your clinic after receiving the results of her cervical screening test, which show borderline changes in squamous cells and is negative for high risk HPV. She's anxious and asks when she would, should have her next cervical screening test according to the NHS Cervical screening program, what is the most appropriate place? Mhm. So as she's HPV, negative, um you would repeat the screen in three years. So she would go back to the kind of the in the pool uh and just be uh screened in three years. So next one is a 27 year old woman who attends her cervical smear appointment at the practice. She asks what a screening test is, which of the following is the criteria of a screening test they must fulfill. So if the one most of you put, which is untreated, natural history of the disease must be known um before the screening test can be created. So the other one that was quite popular was must be an acceptable surgical treatment. So it doesn't have to be surgical. The next one is a 26 year old woman who is newly diagnosed with cervical cancer, which of the following viruses is the most associated with cervical cancer. Yeah, great. So it's page three B 16 and 18. Excellent. Which of the following substances using corpus cos colposcopic procedure are taken up by the abnormal cervical cells to enhance their appearance. So the question is which uh which substance is taken up by the abnormal cervical cells? And that's the acetic acid? So they paint the cervix with that. First, it's taken up, provide the abnormal cells and then they paint it with the iodine solution which paints the normal cells around it so that the ones that took out the acetic acid are even more visible. Ok. So you have a 31 year old woman who attends a Gyne clinic to receive the results of her most recent smear test. The results are positive for HPV normal cytology. She has had normal smears previously, the patient asks what the next steps would be for her ongoing management. What is the most appropriate next step in the management of this sleeping? So as most of you put it, reassure and repeat screen at 12 months time, and that's because it's positive for HPV. So you can't put them back into the pool of every three years. Um but it's been normal cytology. So you wouldn't do anything more serious because uh in most cases, it can go away on its own in a year's time. So you have a 75 year old woman who presents to her GP with a six month history of burning sensation. She also reports pruritus soreness and occasional bleeding. She reports no urinary symptoms no abnormal vaginal discharge and her appetite and weight are stable. She's taking ramipril 5 mg once daily for essential hypertension. On examination, there is an ulcerated lesion in her left labium J there is evidence of previous bleeding on bimanual examination. Her uterus is nontender and no masses are palpable. What is the most likely diagnosis? So as most of you put it, it would be carcinoma and that's because it's an ulcerated lesion. Um whereas a lichen sclerosis wouldn't be generally see you. I'm fairly sure this is the last one. So you have a 55 year old woman presenting to her GP with a bone healing ulcer on her left labia majora. She states that, that this has been present for two months and is not improving. She denies any weight loss on her. And other than the ulcer feels well in herself. Her only his history of note is her last two smears, both of which confirm presence of HPV, but not no dysplastic cells. The GP suspects cancer and refers to the patient on a two week grade pathway for biopsy. What is the most common type of cancer? Yeah, great. So it's squamous cell carcinoma. So we covered um cervical cancer, endometrial ovarian vulval cancer. We did uh quite a few cases and you guys were amazing. Um So thank you very much for attending. Um Please fill out the feedback form that I just sent into the chat. Um And if you have any questions, send them in to chat as well. Um Probably either today or tonight, uh upload the slides and the recording. Um So just like the previous ones, you will have access to them. Um There's another session next week, so keep an eye out for that. Um My name is PAA and thank you very much for attending.