Preparatory Mindset
Cervical and endometrial cancer are the two most important gynaecological malignancies — and both are screenable and survivable if caught early (2018CM exam tested). The exam mindset:
- Cervical cancer: HPV-driven (types 16/18 cause ~70%), preceded by CIN (cervical intraepithelial neoplasia), detected by screening (HPV test ± cytology/LBC), diagnosed by colposcopy + biopsy, treated by LLETZ/conization (CIN/early) or radical hysterectomy ± chemoradiation (invasive). Vaccination (9-valent HPV) prevents it.
- Endometrial cancer: the most common gynaecological malignancy in developed countries; type I (endometrioid, 80%, estrogen-driven — obesity, anovulation, PCOS, tamoxifen, unopposed estrogen) vs type II (serous/clear cell, aggressive, TP53). Postmenopausal bleeding is the hallmark (90%) → endometrial biopsy (TVS thickness >4 mm + sampling) → surgical staging (hysterectomy + BSO ± lymphadenectomy) + adjuvant per risk.
The rule that never changes: postmenopausal bleeding = cancer until proven otherwise — never ascribe to atrophy without endometrial sampling.
Core Concepts
1. Cervical cancer
Epidemiology and aetiology:
- HPV (high-risk: 16, 18, 31, 33, 45...) is the necessary cause; sexual transmission; ~70% of cervical cancers are HPV 16/18.
- Risk: early sexual debut, multiple partners, smoking, immunosuppression (HIV), long-term OCP, high parity, poor screening.
Premalignant lesion — CIN (cervical intraepithelial neoplasia):
| Grade | Findings | Likelihood of regression |
|---|---|---|
| CIN 1 (LSIL) | Low-grade changes (lower third of epithelium) | High (spontaneous regression ~60%) |
| CIN 2/3 (HSIL) | High-grade (middle → full thickness) | Progressive → invasive cancer risk |
The squamocolumnar junction / transformation zone is where CIN and cancer arise.
Screening:
- HPV DNA test (primary) ± cytology (LBC/Pap) — co-testing; HPV 16/18 positive → colposcopy regardless of cytology; other high-risk HPV + abnormal cytology → colposcopy.
- Abnormal cytology (ASC-US/ASC-H/LSIL/HSIL) → follow-up/colposcopy per algorithm.
- Colposcopy → directed biopsy → diagnosis.
- Frequency: 25-65 years (China screening programs; WHO 30-49 every 5-10 years with HPV).
Clinical features:
- Early: asymptomatic (screening-detected).
- Invasive: postcoital/intermenstrual bleeding, contact bleeding, blood-stained discharge, pelvic pain, painless but heavy vaginal bleeding in late stages, urinary/bowel symptoms (fistula, obstruction), leg oedema (nodal obstruction), renal failure (ureteric obstruction).
Diagnosis: colposcopy + punch biopsy / cone biopsy; MRI for staging (parametrial invasion); cystoscopy/IVU if bladder involvement; chest X-ray/CT for mets.
Staging (FIGO — clinical): I (confined to cervix), II (vagina upper 2/3 / parametrium), III (lower vagina / pelvic wall / hydronephrosis), IV (bladder/rectum / distant mets).
Management:
| Stage | Treatment |
|---|---|
| CIN 1 | Surveillance (regression likely) |
| CIN 2/3 | LLETZ (loop excision) / cold-knife conization — fertility-sparing; follow-up cytology/HPV |
| IA1 (microinvasive) | Conization (fertility) or simple hysterectomy |
| IA2-IB1/IIA1 | Radical hysterectomy + pelvic lymphadenectomy OR chemoradiation (equivalent outcomes) — fertility-sparing radical trachelectomy in select early cases |
| IB2-IIB+ | Concurrent chemoradiotherapy (cisplatin-based) — the standard for bulky/locally advanced |
| IV | Palliative chemo/RT; exenteration in select central recurrence |
Vaccination: 9-valent HPV vaccine (types 6/11/16/18/31/33/45/52/58) — recommended for 9-26 years (ideally before sexual debut); catch-up to 45 in some regions; also prevents genital warts (6/11).
2. Endometrial carcinoma
Definition: malignant epithelial tumour of the endometrium; primarily affects postmenopausal women; the most common gynaecological malignancy in developed countries (~67% confined to uterus at diagnosis — because it bleeds early).
Pathological classification (histological subtypes):
| Type | Proportion | Features |
|---|---|---|
| Type I — Endometrioid adenocarcinoma | ~80% | Estrogen-driven (unopposed estrogen); well-differentiated; better prognosis; risk: obesity, anovulation (PCOS), unopposed estrogen therapy, tamoxifen, late menopause, nulliparity, diabetes |
| Adenocarcinoma with squamous differentiation | ~5% | Malignant glands + benign squamous metaplasia |
| Adenosquamous carcinoma | 10-20% | Malignant glands + malignant squamous epithelium |
| Type II — Papillary serous (UPSC) | 1-10% | Aggressive (peritoneal spread like ovarian cancer); TP53 mutations; not estrogen-driven; older women |
| Clear cell | Rare | Aggressive |
Clinical features:
- Postmenopausal bleeding (90%) — the hallmark; perimenopausal abnormal bleeding; ~20% of postmenopausal bleeding has cancer (12-15% endometrial carcinoma); never ascribe PMB to atrophy without sampling.
- Hematometra (cramping from trapped blood behind stenosed cervix), abscess/sepsis if infected.
- Advanced: pelvic pain, pressure, urinary frequency, constipation, ascites, fixed uterus (parametrial spread).
Diagnosis:
- TVS: endometrial thickness >4 mm (postmenopausal) → further evaluation; irregular thickening/mass.
- Endometrial sampling: office endometrial biopsy (Pipelle), or fractional D&C (endocervical + endometrial curettage — the definitive diagnostic procedure), or hysteroscopy-guided biopsy.
- MRI/CT for staging (myometrial invasion, nodal spread); chest imaging; LFT.
Staging (FIGO 2023, surgical): I (confined to uterus — IA <50% myometrial invasion, IB ≥50%), II (cervical stromal invasion), III (serosa/adnexa/vagina/parametrium/nodes), IV (bladder/rectum/distant).
Management:
- Low risk (G1-2, <50% invasion, no LVSI) → surveillance. - Intermediate/high risk (G3, >50% invasion, serous/clear cell, nodal+) → adjuvant radiotherapy (± chemotherapy — carboplatin/paclitaxel for high-risk/advanced).
- Surgical staging is the primary treatment: total hysterectomy + bilateral salpingo-oophorectomy (BSO) + peritoneal washings; pelvic ± para-aortic lymphadenectomy (or sentinel node biopsy) per risk.
- Adjuvant treatment by risk:
- Fertility-sparing (early, well-differentiated, no myometrial invasion, young, strong desire): high-dose oral progestogen (medroxyprogesterone/megestrol) with strict surveillance — only for Grade 1 endometrioid confined to endometrium.
- Advanced/recurrent: chemotherapy (carboplatin/paclitaxel) ± immunotherapy (pembrolizumab — MSI-H/dMMR), hormonal therapy for ER+ low-grade.
High-Yield Points
| Topic | Must-remember |
|---|---|
| Cervical cancer cause | HPV 16/18 (~70%) — necessary cause |
| CIN progression | CIN1 → regression often; CIN2/3 → invasive risk |
| CIN treatment | LLETZ/conization (fertility-sparing) |
| Invasive cervical | Radical hysterectomy ± nodes OR concurrent chemoradiation (cisplatin) |
| Cervical staging | Clinical (FIGO) — MRI helps parametrial assessment |
| HPV vaccine | 9-valent; 9-26 years pre-sexual debut |
| Endometrial cancer | Most common gyn malignancy (developed); postmenopausal bleeding 90% |
| Type I vs II | Endometrioid (80%, estrogen-driven) vs serous/clear cell (aggressive, TP53) |
| PMB workup | TVS >4 mm → endometrial sampling; never ascribe to atrophy |
| Definitive Dx | Fractional D&C / office Pipelle biopsy |
| Primary treatment | Hysterectomy + BSO + washings ± lymphadenectomy (surgical staging) |
| Fertility-sparing | Oral progestogen (only G1, no myometrial invasion) |
| Risk factors type I | Obesity, anovulation/PCOS, tamoxifen, unopposed estrogen, late menopause |
Topic Summary
Cervical cancer is HPV-driven and preventable by screening (HPV/cytology → colposcopy → biopsy) and vaccination; premalignant CIN is treated with LLETZ/conization, invasive disease with radical hysterectomy or chemoradiation. Endometrial cancer is the most common gyn malignancy — type I endometrioid (estrogen-driven, obesity/PCOS) vs type II serous (aggressive); postmenopausal bleeding → TVS >4 mm → endometrial sampling (Pipelle/fractional D&C); treatment = surgical staging (hysterectomy + BSO ± nodes) + risk-based adjuvant therapy (RT/chemo). The shared principle: screen, diagnose early, stage surgically, and treat by stage.
LMCHK OSCE Practice — Postmenopausal Bleeding
Station setup: A 58-year-old woman, 9 years postmenopausal, presents with 2 episodes of painless vaginal bleeding. She is obese (BMI 32), hypertensive, on no hormones. TVS: endometrial thickness 9 mm, normal ovaries.
Candidate tasks (8 min):
- Take a focused history (bleeding amount, tamoxifen use, PCOS, family history of colon/endometrial cancer).
- Explain that postmenopausal bleeding requires exclusion of endometrial cancer — the workup is mandatory regardless of atrophy.
- Order: TVS (done — 9 mm = abnormal), endometrial sampling (office Pipelle biopsy or fractional D&C) — the diagnostic step.
- Discuss staging if cancer confirmed (MRI for myometrial invasion; surgical staging).
- Counsel on the favourable outlook (type I endometrioid detected early is highly curable) and the surgical plan (hysterectomy + BSO, lymphadenectomy per risk).
Key marking cues:
- Never dismisses PMB as atrophy without sampling — the exam safety point.
- Orders endometrial sampling (Pipelle/fractional D&C).
- Knows TVS threshold >4 mm postmenopausal.
- Discusses surgical staging and type I vs type II implications.
- Counsels on the good prognosis when caught early.