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Gynaecological cancers are among the 10 common neoplasms affecting women in Singapore today. As we celebrate Cervical Cancer Awareness Month, it is only fitting that we discuss these problems and how we can detect them early. This is to help bring awareness of the importance of screening, and how it can save your life.
These diseases have become a great concern for women, but it is fortunate that these are preventable through early detection and treatment. If you found your way here, it is good that your curiosity and concern has brought you a step towards solving the problem. When you equip yourself with key learning points about these types of cancer, there is a good chance of reducing your risk or addressing the condition at an early stage.
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Uterine or endometrial cancer is the 4th most common gynaecological cancer in Singapore women, with incidence numbers on the rise. The endometrium is the lining of the womb or uterus, and it is in this lining that cancerous changes typically take place. Usually it occurs during a woman’s late 40s.
It is fortunate that more than 70% of cancers are diagnosed during the very first stage of development. This is because even early or pre-cancerous (endometrial hyperplasia) changes in the endometrial lining will result in bleeding that most women would find “abnormal.” Fortunately, women have a good chance of beating this kind of cancer. It just takes the courage to get tested.
Who are at risk of developing uterine cancer?
- Uterine cancer most often affects women over 50, the average is 60.
- The risk increases with an increase in body mass index (BMI), the ratio of a person’s weight to height. About 40% of uterine cancers are linked to obesity.
- It may present younger in those with polycystic ovarian syndrome with irregular periods.
- Uterine cancer risk may be present in families where colon cancer is hereditary.
- Women with diabetes, which is associated with obesity, also have an increase risk of uterine cancer.
- Women who are taking tamoxifen (Nolvadex) for the treatment of breast cancer have an increased risk of developing uterine cancer. However, the benefits of this drug usually outweigh the risk of developing the cancer.
- Women who have had colon cancer, ovarian cancer, or breast cancer.
Screening Tests for Uterine Cancer
Uterine cancer screening is not recommended for women with an average or increased risk for uterine cancer. However, high risk women should be offered annual screening for uterine cancer with Transvaginal Ultrasound and Endometrial Biopsy by the age of 30-35.
The ultrasound of the pelvis by way of the vagina can be useful to detect whether there is an abnormality or thickening of the endometrium.
To diagnose endometrial cancer, an endometrial biopsy is necessary. This can be done through an outpatient aspiration of endometrial contents or as a minor surgical procedure called hysteroscopy, dilatation and curettage. The samples taken are then sent for analysis in the pathology laboratory.
Consult your doctor if you experience any of these symptoms
- Bleeding between periods or prolonged heavy menstrual bleeding
- Vaginal bleeding after menopause
- An abnormal, watery or blood-tinged discharge from your vagina
- Pelvic pain
- Pain during intercourse
Ovarian Cancer is ranked 5th of the most common cancers affecting Singapore women, and is the most common cause of gynecologic cancer deaths. Mostly occurring in postmenopausal women over 50, its survival rate is directly related to the stage at which the cancer was diagnosed. This is why proper screening is important.
Who are at risk of ovarian cancer?
- A family history of breast, ovarian, or colon cancer
- A personal history of breast cancer
- Young age at menarche (the start of menstruation)
- Women who have never been pregnant or had a first pregnancy over 30 years of age
- History of fertility drug use
Types of Screening for Ovarian Cancer
Your family health history is the greatest risk factor for ovarian cancer. A positive history in one relative raises your lifetime risk to 5% and a positive history in two relatives increases the lifetime risk to 7%.
It is possible to detect ovarian cancers through a physical examination. However, it is rare to detect early stage tumors – even with the most skilled examiner- because of the location of the ovaries. During a pelvic exam, the health care professional palpates the ovaries for its size, shape, and consistency. Tumors that may be detected by physical examination are already at an advanced stage and have a poor prognosis.
The measurement of the serum concentration of the CA-125 glycoprotein antigen is considered the most widely studied biochemical method of screening for ovarian cancer.
Many women with ovarian cancer have high levels of CA-125. This test is a tumor marker that can help guide in the treatment of women known to have ovarian cancer since high levels often go down if the treatment is effective. However, CA-125 measurement is not recommended for screening for those women with an average risk of ovarian cancer due to its low specificity. There are other conditions, other than cancer, that may also cause high levels of CA-125.
Therefore, an elevated CA-125 doesn’t always mean the presence of ovarian cancer. Other conditions that can cause an elevated CA-125 include endometriosis, diverticulitis, uterine fibroids, normal menstruation, and cirrhosis. This test may be offered to screen women who have a high risk of ovarian cancer that stems from an inherited genetic syndrome.
The transvaginal ultrasound is deemed to be a promising imaging method for the routine screening of ovarian cancer. Studies even recommend it as a reliable tool for initial tests in ruling out ovarian cancer. It can show whether the ovaries are of the right size, have cysts, or are normal in texture.
Consult your doctor if you experience any suspicious persistent symptoms like:
- Abdominal bloating
- Pelvic pressure or abdominal pain
- Difficulty eating or feeling full quickly
- Unexplained weight loss
- Feeling tired often
- Urinary problems (having to go urgently or often)
There are no reliable screening tests for the early detection of ovarian cancer in asymptomatic women. Women who have a strong family history, or are at increased risk for ovarian cancer are strongly encouraged to have regular screening through CA-125 testing and transvaginal ultrasonography.
Cervical cancer earned that tenth spot among the most common types of cancer to afflict women in Singapore. Cervical cancer forms in the tissues of the cervix which is the organ connecting the uterus and vagina. It comes in several types, but the most common is squamous cell carcinoma (SCC). An infection with the Human Papilloma Virus (HPV) is a necessary factor in the development of this cancer. Although rare, the other types of cervical cancer (small cell carcinoma, adenosarcoma, melanoma and lymphoma) are rare and are not generally related to HPV. They are also not as preventable as SCC.
Thankfully for women, cervical cancer is unique in that there is a long period of pre-cancer (CIN) where cell changes due to chronic HPV infection are detected prior to becoming invasive cancer. Regular pap smear and/or HPV screening detects pre-cursor cancer cells and these CIN lesions are easily treatable with minor day surgery. In many countries without a cervical cancer screen programme, it is usually the first or second most common cancer. However, with proper screening, the burden of disease is now in the pre-cancer stage and that has drastically reduced the prevalence of cervical cancer. Early cervical cancer detection has a good cure rate. In young women, the treatment can even be tailored so that fertility is preserved. Before it is even visible to the naked eye, cancer in its infantile stage can be detected through a Pap smear screening test and diagnosis can be confirmed through a special examination known as colposcopy and biopsy.
Who Should Go for Cervical Cancer Screening?
- Women who are between 25 and 69 years of age and have had sexual intercourse should go minimum once every three years. Women can stop taking the test at 69 if their Pap tests taken at 69 and in the past have been clear. Certain categories of women may require more frequent screening. Based on studies, the efficacy of screening is dependent on age. Annual pap smear screening in a woman aged 20-39 years confers a protection of 76% whilst in a woman aged 55-69 years there is 87% protection against cervical cancer. The interval of screening may be increased to 3-5 years without a compromise in effectiveness by doing a HPV test (see below) or HPV test with pap smear concurrently.
- All women, regardless of family history of cancer, history of pregnancy and childbirth, number of sexual partners, and method of contraception.
Misconceptions of cervical cancer screening:
- I don’t need to go for screening because I am not currently sexually active and my last sexual encounter was many years ago.
- I don’t need to go for screening because I am widowed.
- I don’t need to go for screening because I am married.
- I don’t need to go for screening because I have taken the HPV cervical cancer vaccine.
This is all untrue. Many cervical cancer cases in advanced stages have been detected in precisely these categories of women. As long as a woman has had prior sexual intercourse, she is at risk of having a HPV infection and subsequent cervical cancer. With increasing age, our immunity decreases and that plays a part in progression of pro cancer changes in the cells of the cervix. The HPV vaccine although very effective, only still confers a 65-95% protection rate (depending on vaccine type and individual immune response to the vaccine) hence regular cervical screening is important.
Types of Screening for Cervical Cancer
This test detects changes in the cells of the cervix. During a Pap test, you will be positioned on an exam table and a device, called a speculum, is gently inserted into the opening of the vagina. This allows the healthcare provider to get a good view of the cervix and upper vagina. Once the provider can properly visualize the cervix, she uses a brush/spatula combination to collect the cells. The cells will then be sent to a laboratory so it can be checked for cancer cells or abnormal cells that could become cancer later on.
A regular Pap smear test should be able to detect the cancer in the early or pre-cancerous stage. At that point treatment is straightforward, side effects are few, and the prognosis is good. This screening test has shifted disease detection from cancer to pre-cancer, giving women a better chance of prevention should they be in the high-risk group.
There are more than 100 types of HPV (Human Papilloma Virus) with only about 14 that can cause cancer. These tests can detect any of the high-risk types of HPV, a virus spread through sexual contact, and are most commonly found in cervical cancer. The presence of any of the HPV virus types in a woman for several years can eventually lead to cell changes that need to be treated so that they do not lead to cervical cancer. An HPV test can be done concurrently with a Pap test, since they can be taken from the same sample.
Consult your doctor if you experience any of these symptoms:
- Unexpected bleeding between menstrual periods
- Pain during sex
- Unexpected bleeding after sex or douching
- Irregular menstruation or periods that are 1 1/2 – 2 times longer than normal for 3 months in a row.
- Severe vaginal bleeding that causes you to soak 1-2 pads or tampons in 1-2 hours
- Passing clots of blood from the vagina
- Abnormal vaginal discharge containing blood-tinged mucus.
Reminders when preparing for a Pap and/or HPV Test
- Schedule the test on a day when you don’t expect your menstrual period. If your period begins, try to reschedule your appointment.
- Do not douche 48 hours prior to the test.
- Avoid sexual intercourse 48 hours before the test.
- Do not use tampons, foams, vaginal creams, films or jellies for 48 hours before the test.
If the Pap tests reveal abnormal cells, additional tests may be performed. These tests include:
- Cervical Biopsy
- Endocervical curettage
- Cone biopsy
- LEEP (Loop Electro-Surgical Excision Procedure)
Sexually Transmitted Disease (STD) and Cancer
We include this topic because it also plays a critical role in the development of gynaecological cancers. Having an STD/STI (Sexually Transmitted Infection) may be associated with an increased risk for several types of cancer. In Singapore, the latest figures by the Department of Sexually Transmitted Infections Control (DSC) showed that 421 boys and girls between the ages 10-19 contracted an infection through sex in 2015. These numbers is a worrying social and health issue that puts our youth, and eventually, the general population at risk. This is why we stress the importance of protection and screening.
As mentioned earlier, certain high-risk types of HPV can cause cervical cancer in women and even vulval, vaginal, throat and anal cancer. With proper screening you can prevent, address, and even treat the problem early before it can even progress into something serious.
Screening for Sexually Transmitted Disease
Women who are at risk of sexually transmitted diseases should be screened yearly for these diseases, regardless if they have symptoms or not. Women who are at risk include the following:
- Women who are sexually active at the age of 25 and younger.
- Women who are just beginning sexual activity
- Women who have several sexual partners
- Women who have had sexually transmitted infections
- Women who usually do not use a barrier contraceptive and are not in a monogamous relationship
- Women who have unusual vaginal discharges
Women who think they may have a sexually transmitted disease can also request for screening. Most individuals with these infections won’t develop cancer, but it is a good idea to learn more about how to reduce your risk and how to take care of yourself.
Make use of the resources available out there or book a consultation now with Singapore gynae, Dr. Pamela Tan, so you can be well informed and guided on the proper screening tests. Our clinic offers Well Women and Gynaecological Cancer Health Screening. So, act now for early detection and maintenance of good health.
Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.