Screening, Prevention, and Diagnosis of Gynecologic Malignancies
Three cancers, three different answers
Cervical cancer is the only gynecologic malignancy with a proven population screening test. Average-risk screening starts at 21 (or 25 under ACS 2020 guidance) and continues to 65 only if adequate prior negative results exist; typical exit criteria are three consecutive negative cytology tests or two consecutive negative co-tests within the prior 10 years, with the most recent test within 3–5 years. After total hysterectomy with cervix removal for benign disease, vaginal cytology is not indicated. Primary HPV testing is increasingly preferred; HPV 16/18 genotyping sends a patient to colposcopy even when cytology is normal. Ovarian cancer has no effective screening test: the USPSTF recommends against CA-125 and transvaginal ultrasound in average-risk women, and large randomized trials showed no mortality benefit plus real harm from surgery triggered by false positives. High-risk women (BRCA1/2, Lynch syndrome) are managed with risk-reducing salpingo-oophorectomy, not annual ultrasound. Endometrial cancer also has no screening test; the levers are prompt evaluation of postmenopausal bleeding and recognition of Lynch syndrome.
Traps
Ordering CA-125 as a “screen”; applying screening logic to a symptomatic patient (that is diagnostic workup); forgetting that ASC-US with negative HPV returns to routine screening rather than colposcopy; assuming HPV vaccination changes the age to start or stop screening.
Worked example
A 45-year-old has ASC-US cytology and a negative HPV test. Her CIN3+ risk is low, so repeat co-testing in 3 years is correct - not colposcopy. Had the HPV test been positive, colposcopy would be indicated; had she been HPV-16 positive with normal cytology, colposcopy would also be indicated.