Gynecologic Cancers

Family physicians provide preventive care for women of all ages. We screen patients for cancer and other diseases, and we often are the first to evaluate them for signs and symptoms that may ultimately prove to be cancer, including gynecologic cancers. Gynecologic cancers cause significant morbidity and mortality and may be difficult to recognize because of presentation with nonspecific symptoms. Yet, I wonder how many of us can recall many details about these conditions from our medical training. To care for our patients effectively, we need to know how to do more than perform a Papanicolaou test and refer to a gynecologist. This issue of FP Essentials will arm you with current information and better tools to help you diagnose and manage cervical, endometrial, ovarian, and vulvar cancers.

Section One addresses cervical cancer. Cervical cancer has a high incidence and mortality rate but is largely preventable and easily identifiable through proper screening. Although this type of screening is the most familiar to family physicians, recommendations for screening and triaging abnormal cervical cytology results have changed significantly in recent years.

In Section Two, we discuss endometrial cancer, which is increasingly common and deadly because of its association with obesity and type 2 diabetes. We review the roles of endometrial biopsy and transvaginal ultrasonography, diagnostic tools that most family physicians have at their disposal.

Section Three focuses on ovarian cancer. Less common but more lethal than other gynecologic cancers, ovarian cancer often manifests with nonspecific symptoms that are difficult to recognize and diagnose in a timely fashion. In this section, we discuss what to look for and how to evaluate patients properly.

In Section Four, we discuss vulvar cancer. Although less common than cervical cancer, vulvar cancer also is often associated with infection with oncogenic human papillomavirus. This cancer is easy to miss if primary care physicians do not examine the vulva as a routine part of their physical examination. Diagnosis usually can be made with in-office biopsy.

I hope you find this issue of FP Essentials as helpful as I did for updating your knowledge about gynecologic cancers and for enabling you to care for your patients more effectively.

S. Lindsey Clarke, MD, FAAFP, FP Essentials Editorial Board Member
Professor, Medical University of South Carolina
Area Health Education Consortium
Self Regional Healthcare, Greenwood, South Carolina

Bindusri Paruchuri, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center, College of Medicine–Nashville. She completed a fellowship in advanced women’s health and obstetrics. Dr. Paruchuri serves as core faculty providing full-spectrum care, including obstetrics, within family medicine. She has published more than five articles related to obstetrics and gynecology relevant to the field of family medicine. She has helped spearhead scholarly activity in her program, serves as an Advanced Life Support in Obstetrics (ALSO) instructor, and is a manuscript reviewer for the American Academy of Family Physician’s FPM, the Society for Teachers of Family Medicine’s Peer-Reviewed Reports in Medical Education Research (PRiMER) and Family Medicine.

Amanda Miller, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center, College of Medicine–Nashville. She completed a fellowship in advanced women’s health and obstetrics. As the clerkship director for third-year medical students and core faculty for the family medicine residency, Dr. Miller practices and teaches comprehensive family medicine, including operative obstetrics and complex prenatal care. She is an ALSO program instructor and serves as a peer reviewer for American Family Physician.

Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

• Outline cervical cancer screening recommendations for average- and high-risk patients.
• Describe the next steps for evaluating patients with abnormal cervical cytology results, including indications for colposcopy.
• Explain the roles of and indications for endometrial biopsy and transvaginal ultrasonography in evaluating patients for possible endometrial cancer.
• Discuss surgical and fertility-sparing options for managing premenopausal patients with endometrial intraepithelial neoplasia or atypical endometrial hyperplasia.
• Name at least one risk factor and two protective factors associated with ovarian cancer.
• Describe the recommended diagnostic evaluation of a patient with suspected ovarian cancer.
• Explain the importance of the physical examination in identifying patients with vulvar cancer.
• Describe the initial diagnostic evaluation, including in-office biopsy, for a patient with a vulvar lesion that is suspicious for cancer.