Gynelogical Risk Assessment
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Frederick R. Jelovsek, MD
Lung cancer kills more women but breast cancer is the most common cancer in women (32% of all cancers). There is approximately a 1 in 9-11 lifetime incidence of breast cancer in women. That makes it an epidemic. The main screening tests are self-breast exams and mammograms. Screening mammograms are recommended starting at age 40 in low risk women and at age 35 in women who have fibrocystic change or a positive family history of breast cancer. Screening should then be every two years until 50 after which time it should be performed annually.
Breast feeding an infant may reduce the risk of premenopausal breast cancer by 20%. Removal of the ovaries before the age of 35 reduces breast cancer by 70%. If you are of Asian ethnic extraction and living in Asia, your breast cancer risk is markedly lower than if you are from North American or Europe.
Factors which make a woman at high risk for breast cancer* are:
- Prolonged lifetime exposure to estrogens
- starting menstrual periods before age 12
- late menopause (over age 55)
- postmenopausal estrogen replacement therapy use longer than 5 years
- Genetic predisposition
- a mother with breast cancer
- two first degree relatives, sister(s), or daughter(s) with breast cancer
- having known genetic mutations, BRCA1, BRCA2, ataxia-telangiectasia, p53 and other genes
- Lifestyle risks
- first pregnancy after age 30
- increased alcohol intake
- increased weight (greater than the 90th percentile)
- Previous breast problems
- a breast biopsy showing moderate epithelial or atypical hyperplasia
- previous breast cancer (other breast)
See also Journal of National Cancer Institiute article
Breast Cancer in Younger Women
* Speroff, L, Glass, RH, Kase, NG. Clinical Gynecologic Endocrinology and Infertility. 1994, pp 562-66. Williams and Wilkins, Baltimore.
Ovarian Cancer
Frederick R. Jelovsek, MD
There is a 1 in 70 lifetime incidence of ovarian cancer. As many as 12 out of each 1000 women over the age of 40 will get ovarian cancer. Currently the only screening recommended is an annual pelvic exam over the age of 40. Screening postmenopausal women with either a serum Ca-125 blood test or a pelvic ultrasound has been suggested but neither are currently felt to be cost-justified. There are a considerable number of false positives with these tests which could lead to unnecessary surgery. They may be appropriate for women who have a positive family history of ovarian cancer, however. About 5% of ovarian cancers may be inheritable.
Long term users of oral contraceptives have a decreased incidence of ovarian cancer; approximately 60% of normal. Women who have had 5 children or more also have a significantly decreased incidence. Also tubal ligation and previous hysterectomy lower the risk of ovarian cancer by almost 40%. Talc and asbestos that are chronically used as perineal powders have been implicated as a possible causative agent in ovarian cancer but while they are associated, the cause and effect are less clear.
Factors which increase risk for ovarian cancer* are:
- having had no children (nulliparity)
- high fat diet
- history of two first degree relatives with breast or ovarian cancer
- history of breast, endometrial or colon cancer
- chronic perineal talcum power use
* Dunnihoo, DR. Fundamentals of Obstetrics and Gynecology. 1990. pp 207-8. J.B. Lippincott Company. Philadelphia.
Int J Epidemiol 1997 Aug;26(4):710-5
Surgical procedures associated with risk of ovarian cancer.
Kreiger N, Sloan M, Cotterchio M, Parsons P
Int J Cancer 1997 Jun 11;71(6):948-51
Tubal sterilisation, hysterectomy and decreased risk of ovarian cancer. Survey of Women's Health Study Group.
Green A, Purdie D, Bain C, Siskind V, Russell P, Quinn M, Ward B
Endometrial Cancer
Frederick R. Jelovsek, MD
The median age for endometrial cancer is 61 but the large share of cases occur in the 50-59 age group. Up to 5% of cases can occur before age 40. Endometrial cancer is second in frequency of gynecologic cancers to breast cancer. There are no screening tests for endometrial cancer except, perhaps, the historical question of a postmenopausal woman, "do you have any vaginal bleeding". Postmenopausal bleeding is an early sign of endometrial cancer and if quickly evaluated, a cancer can be found in an early, completely curable stage.
Long term use of oral contraceptives decrease the risk of endometrial cancer to 50% or normal. Smoking also is associated with a decreased incidence.
Factors that increase the risk for endometrial cancer* are:
- late menopause (over age 52)
- no children (nulliparity)
- obesity (50 lbs overweight, 5 times increased)
* from DiSaia, PJ, Creasman, WT, Clinical Gynecologic Oncology. 1993. pp 156-7, Mosby-Year Book, Inc., St. Louis.
Cervical Cancer
Frederick R. Jelovsek, MD
Invasive cervical cancer has decreased in recent decades probably due to the increased use of PAP smear screening. PAP smears can pick up premalignant changes which can be treated before developing into invasive cancer. Most recommendations for PAP smears are for yearly smears starting at age 18 or at start of sexual activity, whichever is earlier. After three consecutive negative PAP smears, women who are at low risk (have less than two lifetime sexual partners and whose partners have had less than two lifetime sexual partners) may have less than annual smears as determined by their physicians (commonly every three years). If a woman has had a hysterectomy and never had an abnormal PAP, many physicians will recommend smears every 3 years.
Risk factors* for cervical cancer are:
- early age of first intercourse (as teen)
- multiple sexual partners
- a sexual partner with multiple sexual partners
- smoking/tobacco use
- human papilloma virus infection
types 16, 18, 31, 33, 35, 39, 45, 51, 52
* from DiSaia, PJ, Creasman, WT, Clinical Gynecologic Oncology. 1993. pp 4-5, Mosby-Year Book, Inc., St. Louis.
Vulvar Cancer
Frederick R. Jelovsek, MD
Vulvar cancer represents between 5-12% of all invasive gynecologic cancer. The peak age for this cancer is age 65-75. There are no screening tests recommended other than self-vulvar exams and regular pelvic exams. Vulvar biopsy of any suspicious vulvar lesion is the main diagnostic test.
Factors that increase risk for vulvar cancer* are:
- a history of granulomatous venereal ulcers
(syphllis, granuloma inguinale, chancroid, lymphogranuloma venereum) - history of human papilloma virus infection, type 16
(condyloma accuminata) - chronic vulvar burning and itching
* from DiSaia, PJ, Creasman, WT, Clinical Gynecologic Oncology. 1993. pp 238-41, Mosby-Year Book, Inc., St. Louis.
Sexually Transmitted Diseases
Frederick R. Jelovsek, MD
Bacterial, viral and protozoal diseases are often transmitted during sexual intercourse. These infections can cause pain, illness, infertility and even death. Screening tests to pick up these infections are concentrated mostly in high risk populations (young, unmarried, having sexual relations with possibly multiple partners). Also at times of hospital admission, marriage license application and at initial pregnancy exam. Typically these tests now screen mostly for chlamydia and gonorrhea, but syphilis is still screened for and recently HIV 1 and 2 and hepatitis are often included.
Risk factors are mainly:
- intercourse with multiple partners
- sexual partners who have multiple partners
- lack of use of barrier methods during sexual relations
(condoms, foam, diaphragm) - frequent vaginitis/vaginal discharge
- atypical/abnormal pap smears
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