Principal Director, Gynaecology Oncologist at Fortis Hospital, Gurgaon
About Dr. Rama Joshi Gynaecologist
Dr. Rama Joshi has over 25 years of expertise. She is one of the India's most committed gynaecological cancer surgeons. Dr. Rama was the chief head of the gynaecological branch at Artemis Hospital in Gurgaon, B L Kapur Hospital, and Dharamshila Cancer Hospital in New Delhi, India, before joining Fortis Hospital Gurgaon. She was awarded six gold medals for academic achievement during her schooling, including the esteemed Pfizer Gold Medal in Post-Graduation.
Gynaecological Cancer
Gynaecologic cancer is any cancer that begins in a woman's reproductive system. These cancers occur in various sites in the pelvic area and are classified by type, symptom, treatment, and outlook. This is also called female reproductive system cancers.
Types of Gynaecologic Cancers
Cervical Cancer
Source: Cervix (lower portion of the uterus)
Usual Cause: Infection with Human Papillomavirus (HPV)
Signs: Abnormal vaginal bleeding, pelvic discomfort, pain during sex
Ovarian Cancer
Source: Ovaries
Usually Spotted Late as it presents with nonspecific symptoms
Symptoms: Bloating, abdominal pain, frequent urination, early satiety
Symptoms: Vaginal bleeding, discharge, mass or pain
Vulvar Cancer
Origin: Outer female genitalia
Less common gynecologic cancer
Symptoms: Itching, pain, bleeding, lump or sore
Fallopian Tube Cancer (rare)
Can be related to ovarian cancer
Symptoms: Pelvic pain, watery vaginal discharge, mass
Gynaecological Cancer Symptoms
All gynaecological cancers are located in a different area of the reproductive system and might have different symptoms. Many of the initial signs are subtle or mistaken for another cause, so awareness is a key.
Cervical Cancer
Abnormal vaginal bleeding
Unusual vaginal discharge
Pelvic pain or pain during intercourse
Ovarian Cancer
Bloating
Abdominal or pelvic pain
Feeling full quickly when eating
Frequent or urgent need to urinate
Unexplained weight loss or gain
Fatigue
Uterine (Endometrial) Cancer
Postmenopausal bleeding
Bleeding between periods
Pelvic pain or pressure
Unusual vaginal discharge
Vaginal Cancer
Abnormal vaginal bleeding
Pain during intercourse
A mass or lump in the vagina
Watery vaginal discharge
Painful or difficult urination
Vulvar Cancer
Persistent itching or burning
Pain or tenderness in the vulva
Changes in skin color or texture
Lump, wart-like growth, or open sore on the vulva
Bleeding not related to menstruation
Gynaecologic Cancer Causes
Gynecologic cancers occur in the reproductive organs and may result from the interaction of genetic, environmental, lifestyle, and hormonal factors. Although every form (cervical, ovarian, uterine, vaginal, vulvar and cancer of the fallopian tube) has its own individual risks, there are several causes that are most often found in all or most of these types:
Human Papillomavirus (HPV) Infection
Principal cause of cervical, vaginal, and vulvar cancers
Most frequently associated HPV types 16 and 18 with cancer
Frequently sexually transmitted
Preventable by HPV vaccine
Age
Risk with age, particularly over age 50
Most gynaecologic cancers happen in postmenopausal women
Family History and Genetic Mutations
BRCA1/BRCA2 mutation has increased risk of ovarian and breast cancer
Lynch syndrome has elevated risk of uterine and ovarian cancers
Ovarian, breast, or colon cancer in the family is a red flag
Hormonal Factors
Estrogen dominance (in the absence of progesterone) has increased risk of uterine cancer
Early menarche or late menopause = more years estrogen exposure
Hormone replacement therapy (HRT), particularly estrogen-only, can increase risk
Obesity
Gives higher estrogen stores in fat, increasing risk of endometrial (uterine) cancer
Also increases risk of ovarian and cervical cancers
Smoking
Increases risk of cervical, vulvar, and vaginal cancer
Also decreases the immune system to fight off HPV infection
Reproductive History
Never having been pregnant increases risk of ovarian and endometrial cancers
Infertility treatment and delayed or no childbearing may increase risk slightly
Weakened Immune System
Women with HIV or immunosuppression are at increased risk of developing HPV-related cancers
Previous Radiation Therapy
Pelvic radiation has the potential to increase secondary gynecologic cancer risk
Poor Diet and Lack of Exercise
Linked to obesity and chronic inflammation, furthering cancer risk
Gynaecologic Cancer Treatment
Treatment for gynecologic cancers is based on the type of cancer, its stage, your overall health, and personal preference (e.g. trying to preserve fertility). Most treatment combines one or more of surgery, chemotherapy, radiation, targeted therapy, and/or immunotherapy.
Surgery
Usually the first treatment, particularly if cancer is confined.
Hysterectomy: Uterus removal (routine in uterine and cervical cancer)
Oophorectomy: Removal of one or both ovaries (for ovarian or fallopian tube cancer)
Salpingectomy: Removal of the fallopian tubes
Lymphadenectomy: Removal of lymph nodes to test for spread
Debulking surgery: Removes as much cancer as possible (particularly in ovarian cancer)
Vulvectomy: Removal of part or all of the vulva
Chemotherapy
Uses medication to destroy cancer cells or prevent them from multiplying
Usually used for advanced or recurrent cancers
Common medications: Cisplatin, Carboplatin, Paclitaxel
Radiation Therapy
High-energy rays to kill cancer cells
Either external beam or brachytherapy (internal radiation)
Common for cervical, vaginal, vulvar, and endometrial cancer
Targeted Therapy
Targets specific proteins or genes in cancer cells
Commonly used for ovarian cancer
Examples: Bevacizumab (Avastin), PARP inhibitors such as Olaparib
Immunotherapy
Activates the immune system to attack cancer
Used for advanced or recurrent cancers, particularly those with PD-L1 expression or high MSI
Example: Pembrolizumab (Keytruda)
Hormone Therapy
Blocks hormones such as estrogen that feed certain cancers
Cancer of the uterus, which is most frequently endometrial cancer, starts in the lining of the uterus (endometrium). It usually occurs in women who are past menopause but may occur in younger women, particularly those with hormonal imbalances. Although the true cause is not always certain, the following are established causes and risk factors:
Estrogen Imbalance
Obesity
Age
Diabetes and Insulin Resistance
Polycystic Ovary Syndrome (PCOS)
Hormone Therapy
Family History and Genetics
Endometrial Hyperplasia
Nulliparity (Never Having Been Pregnant)
Radiation Exposure
Treatment of Uterine Cancer
Surgery (Primary Treatment)
The majority of women with uterine cancer will have surgery as the initial treatment.
Types of Surgery:
Total Hysterectomy: Hysterectomy with removal of the uterus (most common type)
Bilateral Salpingo-Oophorectomy (BSO): Removal of ovaries and both fallopian tubes
Lymph Node Dissection: To ensure there is no cancer spread
Minimally invasive (laparoscopic or robotic) surgery may be utilized in the early stages
Radiation Therapy
Used post-surgery to reduce the chance of coming back or as an alternative to surgery in women who are not fit for an operation.
Types:
External Beam Radiation Therapy (EBRT): Aims at cancer from the outside of the body
Brachytherapy (Internal Radiation): Radioactive materials are put inside the vagina or the uterus
Hormone Therapy
Used predominantly for early cancer in women who desire to preserve fertility or in advanced/recurrent cancers.
Chemotherapy
Utilized for advanced, aggressive, or recurrent endometrial cancers, particularly high-grade or non-endometrioid ones such as serous carcinoma.
Targeted Therapy
Utilized for tumors with unique mutations or genetic makeup.
Immunotherapy
Utilized for recurrent or advanced endometrial cancers with MSI-H (microsatellite instability-high) or mismatch repair deficiency (dMMR).
Cervical Cancer Causes
Cervical cancer starts in the cervix cells, which is the lower portion of the uterus and attaches to the vagina. It develops gradually, often beginning with precancerous lesions known as cervical dysplasia.
Primary Cause: Human Papillomavirus (HPV) infection
HPV types that have high risks, particularly HPV types 16 and 18, cause approximately 99% of cervical cancer.
Spread by sexual contact
Most HPV infections resolve by themselves, but long-term infection with a high-risk type causes cancer
Other Causes
Multiple Sexual Partners / Early Sexual Activity
Weak Immune System
Smoking
Long-Term Use of Oral Contraceptives
Multiple Full-Term Pregnancies
Lack of Regular Cervical Screening (Pap Test / HPV Test)
Low Socioeconomic Status
Exposure to DES (Diethylstilbestrol)
Cervical Cancer Treatment
Surgery
Frequently the first treatment for early cervical cancer (Stage 0 to I)
Conization: Removal of cone-shaped abnormal cervical tissue (for very early cancers or precancerous changes)
Trachelectomy: Cervix removal (sparing uterus for childbearing) – applied to early-stage cancers
Total Hysterectomy: Uterus and cervix removal
Radical Hysterectomy: Uterus, cervix, lower vagina, and surrounding tissues removal
Pelvic Lymphadenectomy: Removal of lymph nodes to look for spread
Radiation Therapy
Used alone or combined with chemotherapy (particularly for Stages II to IV or when surgery is not feasible)
Types:
External Beam Radiation Therapy (EBRT) – beams are directed at the pelvis externally
Brachytherapy – radioactive implant inside or close to the cervix
Chemotherapy
Used with radiation (chemoradiation) or alone in recurrent or advanced cases.
Targeted Therapy
Used in recurrent or advanced cervical cancer.
Immunotherapy
Used in recurrent/metastatic cervical cancer with specific biomarkers (e.g., PD-L1)
Ovarian Cancer Causes
Ovarian cancer starts in the ovaries, fallopian tubes, or peritoneum and usually is detected later when symptoms are nonspecific. Even though the cause is uncertain, there are some genetic, hormonal, environmental, and reproductive factors that raise the risk substantially.
Genetic Mutations (Hereditary Factors)
Age
Reproductive History
Hormone Replacement Therapy (HRT)
Obesity
Endometriosis
Talcum Powder Use
Smoking
Personal History of Breast Cancer
Fertility Treatments
Ovarian Cancer Treatment
Surgery (Initial Treatment)
The majority of ovarian cancer is managed with surgery as the initial treatment, particularly in the early stages or when tumors are very large and need to be extracted.
Total Hysterectomy: Removal of uterus
Bilateral Salpingo-Oophorectomy (BSO): Ovaries and fallopian tubes removal
Omentectomy: Abdominal fatty tissue removal (site of most common spread)
Debulking Surgery: Resection of as much cancer as can be seen (vitally important in advanced cases)
Fertility-sparing surgery: Can be done in early cases (Stage I), removing only a single ovary and tube.
Chemotherapy
Generally reserved after operation, but occasionally before (neoadjuvant chemo) if the tumor is bulky or extent of spread is great.
Targeted Therapy
With chemo or after chemo in advanced or recurrent disease.
Hormone Therapy
Reserved for low-grade serous ovarian cancer or hormone-sensitive tumors
Immunotherapy
Remains to be studied in clinical trials, but immune checkpoint inhibitors (such as pembrolizumab) can be utilized for:
MSI-high tumors
PD-L1 positive tumors
Types of Ovarian Cancer
Ovarian cancer is not a condition but a collection of varied tumors derived from distinct cell types in the ovary. They are categorized mainly according to the cell of origin.
Epithelial Ovarian Cancer (90% of ovarian cancer cases)
Derived from the lining (epithelial) cells of the ovary, fallopian tube, or peritoneum.
High-Grade Serous Carcinoma (HGSC): Most frequent and severe type; associated with BRCA mutations
Low-Grade Serous Carcinoma (LGSC): Slow growing, in young women
Endometrioid Carcinoma: Frequently associated with endometriosis; improved prognosis if detected early
Clear Cell Carcinoma: Uncommon, more resistant to chemo; also associated with endometriosis
Mucinous Carcinoma: May mimic GI tumors; requires careful differentiation
Germ Cell Tumors (5–10% of them)
Arise from the cells that form eggs. More prevalent in adolescents and younger women.
Dysgerminoma: Most frequent germ cell tumor; very curable
Yolk Sac Tumor (Endodermal Sinus Tumor): Fast-growing; seen in children/young adults
Teratoma: May be benign (dermoid cyst) or malignant
Choriocarcinoma: Rare and highly aggressive; may cause very elevated hCG
Sex Cord-Stromal Tumors (<5% of cases)
Derived from connective tissue that supports the ovary and secretes hormones.
Granulosa Cell Tumor: Secretes estrogen; can lead to premature puberty or irregular bleeding
Sertoli-Leydig Cell Tumor: Secretes androgens; may lead to virilization (face hair, deep voice)
Thecoma, Fibroma: Benign in most cases; thecoma can secrete estrogen
Vulvar Cancer Causes
Vulvar cancer involves the outer female genitalia, such as the labia, clitoris, and vaginal opening. It is an uncommon gynecologic cancer, but awareness of early signs of risk factors will assist in prevention and early diagnosis.
Primary Cause: Infection of Human Papillomavirus (HPV)
High-risk HPV types (particularly HPV 16) occur in a majority of vulvar squamous cell carcinoma.
Spread by sexual contact
Persistent infection can cause vulvar intraepithelial neoplasia (VIN), a precancerous condition
Other Causes
Age (50+ years)
Smoking
Vulvar Intraepithelial Neoplasia (VIN)
Weakened Immune System
Lichen Sclerosus
Personal History of Cervical or Vaginal Cancer
Persistent Itching or Irritation
Vulvar Cancer Treatment
Surgery (Main Treatment)
Surgery is the treatment of choice for the majority of vulvar cancers.
Wide Local Excision: Tumor removal with a border of healthy tissue
Radical Local Excision: Wider and deeper excision than usual wide local excision
Vulvectomy: Removing the vulva partially or entirely (for larger or invasive tumors)
Sentinel Lymph Node Biopsy: Tests whether cancer has spread to lymph nodes (less invasive)
Inguinal Lymphadenectomy: Groin node removal if cancer has spread
Radiation Therapy
Reserved for:
The tumor is large
Lymph nodes are positive for cancer
Surgery is not an option due to health issues
Chemotherapy
Reserved for advanced, recurred, or inoperable scenarios
Often used with radiation (known as chemoradiation)
Immune checkpoint inhibitors (such as pembrolizumab) can be applied for tumors with high PD-L1, MSI-H, or HPV-associated markers
Clinical trials can provide other more focused treatments
Vaginal Cancer Causes
Vaginal cancer is a less common form of gynecologic cancer that starts in the lining of the vagina. Although the exact cause is not always understood, some major risk factors have been identified.
Human Papillomavirus (HPV) Infection
Age
Vaginal Intraepithelial Neoplasia (VaIN)
Diethylstilbestrol (DES) Exposure
Smoking
History of Cervical or Vulvar Cancer
Weakened Immune System
Chronic Vaginal Irritation
Vaginal Cancer Treatment
Surgery
Mostly utilized for vaginal cancer in its early stages or for recurring tumors.
Wide local excision: Small, localized tumor
Partial or total vaginectomy: For the upper or lower vaginal tumors
Pelvic exenteration: Rare, for extensive or recurring cancer (vagina, uterus, bladder, rectum, etc.)
Radiation Therapy
First-line treatment for the majority of vaginal cancers, particularly Stage II–IV or if surgery is not an option.
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