Eduovisual
Female Reproductive & Breast
Cervical cancer: workup and management overview
— Cervical cancer is the 4th most common cancer in women worldwide; in the US, ~14,000 new cases/year with declining incidence due to screening
— >99% are caused by persistent high-risk HPV infection (HPV 16 and 18 account for ~70%)
— Two dominant histologies: squamous cell carcinoma (~75%) arising at the transformation zone, and adenocarcinoma (~25%) arising from endocervical glands
— Peak incidence age 35–44, but a second peak occurs in women >65 who fell out of screening
— Early coitarche, multiple sexual partners, high-parity, long-term OCP use (>5 yr), tobacco use, immunosuppression (HIV, transplant), in-utero DES exposure (clear cell adenocarcinoma), low socioeconomic status with under-screening
— HIV-positive women have markedly accelerated progression — annual screening required
— Any postcoital bleeding, intermenstrual bleeding, or new malodorous/watery vaginal discharge in a sexually active woman
— Postmenopausal bleeding with a visible cervical lesion (rule out endometrial cancer simultaneously)
— Pelvic/back pain, leg edema, hematuria, or hydronephrosis suggests locally advanced disease
— Abnormal screening (Pap/HPV) result in a woman who never returned for colposcopy — classic Step 3 care-transition trap
Board pearl: A visible cervical lesion is biopsied directly — do not "just repeat the Pap." A normal Pap does not rule out cancer if a lesion is seen; the false-negative rate of cytology for frank cancer is high because necrotic/inflammatory cells obscure dysplasia.
Step 3 management: When a patient presents with postcoital bleeding, your first ambulatory step is speculum exam with directed biopsy of any visible lesion, not cytology alone. Coordinate same-visit gyn-onc referral if biopsy confirms invasion.
— Asymptomatic — detected only through screening
— May have abnormal Pap/HPV co-test; this is the screening-detected pathway and the most common Step 3 vignette setup
— No bleeding, no pain, no discharge — emphasizes why screening is critical
— Postcoital bleeding is the hallmark — ask directly: "Do you bleed after intercourse?"
— Intermenstrual or irregular bleeding, heavier menses
— Watery, blood-tinged, or malodorous discharge from tumor necrosis
— Often still asymptomatic; lesion found on routine pelvic exam
— Pelvic or lumbosacral pain radiating to posterior thigh — suggests sidewall/sciatic involvement
— Unilateral leg edema from external iliac lymphatic/venous obstruction — classic triad with back pain + hydronephrosis = pelvic sidewall fixation
— Hematuria (bladder invasion) or hematochezia/rectal pressure (rectal invasion)
— Obstructive uropathy with rising creatinine — uremia is the most common cause of death in untreated cervical cancer
— Bone pain, supraclavicular adenopathy, dyspnea from pulmonary mets, hepatic involvement
— Screening history: date and result of last Pap/HPV; any abnormal results never followed up
— Sexual history, HPV vaccination status, parity, contraception
— Tobacco use, HIV status, immunosuppressants, prior transplant
— DES exposure in pregnancy of patient's mother (rare but classic)
Key distinction: Postcoital bleeding in a young woman = think cervical pathology (cancer, polyp, cervicitis, ectropion). Postmenopausal bleeding = think endometrial cancer first, but always perform speculum exam to inspect cervix; missing a synchronous cervical lesion is a tested error.
Board pearl: Unilateral leg swelling + back pain + hydronephrosis in a woman with abnormal bleeding is stage IIIB cervical cancer until proven otherwise — do not chase DVT alone.
— Cachexia, pallor (chronic anemia from bleeding), supraclavicular and inguinal lymphadenopathy
— Lower extremity edema — especially unilateral, suggesting ipsilateral pelvic lymphatic obstruction
— Costovertebral angle tenderness or palpable hydronephrotic kidney
— Hepatomegaly, ascites in advanced disease
— Visualize the entire cervix and transformation zone
— Early lesions: erythematous, friable patch; may bleed with contact ("contact bleeding")
— Exophytic cauliflower-like mass — classic SCC appearance
— Endophytic "barrel cervix" — adenocarcinoma growing within the endocervical canal, deceptively normal-appearing ectocervix
— Ulcerative, necrotic lesion with foul discharge — advanced
— Note: friable lesion bleeds with the speculum — biopsy directly, do not defer
— Assess cervical size, mobility, and extension to vaginal fornices (stage IIA)
— Rectovaginal exam is mandatory to evaluate parametrial involvement (stage IIB) and pelvic sidewall fixation (stage IIIB)
— Palpate for rectal mucosal involvement (stage IVA)
— IA: microscopic, ≤5 mm depth
— IB: visible/larger, confined to cervix
— II: beyond cervix but not to pelvic sidewall or lower 1/3 vagina (IIA vagina, IIB parametria)
— III: lower 1/3 vagina (IIIA), sidewall/hydronephrosis (IIIB), pelvic/para-aortic nodes (IIIC)
— IV: bladder/rectum (IVA) or distant (IVB)
Step 3 management: Hydronephrosis or nonfunctioning kidney alone upstages disease to IIIB regardless of tumor size — this is a frequently tested staging rule and changes treatment from surgery to chemoradiation.
Board pearl: Cervical cancer staging incorporates imaging and pathology (FIGO 2018), unlike the older purely clinical system — but the rectovaginal exam remains essential and is the historical board favorite.
— Per 2020 ACS / current USPSTF guidance: ages 21–29 cytology every 3 yr; ages 30–65 primary HPV testing every 5 yr (preferred) or co-testing every 5 yr or cytology every 3 yr
— Screening stops at age 65 if adequate prior negative screening and no high-grade history
— Stop screening after total hysterectomy for benign disease with no CIN2+ history
— HIV+ or immunosuppressed: begin within 1 yr of sexual activity, screen annually until 3 negatives, then every 3 yr
— ASC-US + HPV negative → routine surveillance
— ASC-US + HPV positive, LSIL, HSIL, ASC-H, AGC → colposcopy with biopsy
— Visible lesion → biopsy immediately, bypass cytology
— CBC (anemia from chronic blood loss), CMP (creatinine for hydronephrosis), LFTs, urinalysis
— HIV testing — mandatory because it alters management and prognosis
— Pregnancy test in reproductive-age women — alters workup imaging and treatment timing
— Type and screen if anemic or surgical candidate
— SCC antigen tumor marker not routinely used; CEA optional in adenocarcinoma
— Punch biopsy of visible lesion in clinic — no anesthesia required
— Colposcopy with directed biopsy + endocervical curettage (ECC) if no visible lesion but abnormal cytology
— Cone biopsy (cold knife or LEEP) if biopsy shows microinvasion, discrepancy between cytology and biopsy, positive ECC, or to define depth of invasion for fertility-sparing planning
Step 3 management: A pregnant patient with abnormal cytology — colposcopy is safe, but ECC is contraindicated in pregnancy. Defer treatment of CIN until postpartum unless invasive cancer is found.
Board pearl: HPV self-sampling is now FDA-approved for under-screened populations — a Step 3 health-systems angle on closing screening gaps.
— Imaging findings now formally incorporated; this changed the older clinical-only system
— Pelvic MRI with contrast — best for local tumor size, parametrial invasion, vaginal extension, bladder/rectal involvement; preferred for treatment planning
— PET/CT (whole body) — best for nodal and distant metastatic disease; standard for stage IB3 and above
— CT abdomen/pelvis with contrast — alternative if PET unavailable; assesses hydronephrosis, lymphadenopathy
— Chest imaging (CXR or CT chest) for pulmonary mets
— Cystoscopy if bladder invasion suspected (gross hematuria, anterior tumor, bulky disease)
— Sigmoidoscopy/proctoscopy if posterior extension or rectal symptoms
— EUA (exam under anesthesia) when office exam is limited by pain or body habitus
— Sentinel lymph node mapping with indocyanine green increasingly used in early-stage disease
— Para-aortic lymph node dissection sometimes performed before chemoradiation in locally advanced disease to tailor radiation fields
— Rising creatinine or flank pain → renal US first to confirm hydronephrosis quickly → upstages to IIIB
— Bone pain → bone scan or directed MRI
— Neurologic symptoms → MRI brain (rare metastatic site)
— Histologic subtype (SCC vs adenocarcinoma vs small cell)
— Depth of stromal invasion, lymphovascular space invasion (LVSI), horizontal spread
— Small cell neuroendocrine cervical carcinoma — rare, highly aggressive, treated like small cell lung cancer with platinum/etoposide
Key distinction: MRI = local extent; PET/CT = nodal/distant disease. On the exam, if the stem asks about parametrial invasion → MRI; if asking about metastatic workup → PET/CT.
Board pearl: Hydronephrosis on imaging — even without sidewall extension — defines stage IIIB and commits to chemoradiation rather than radical hysterectomy.
— CIN/preinvasive: ablation or excision (LEEP, cone)
— Stage IA1, no LVSI: simple/extrafascial hysterectomy; cone biopsy with negative margins if fertility desired
— Stage IA1 with LVSI or IA2: modified radical hysterectomy + pelvic lymphadenectomy, or radical trachelectomy if fertility-sparing
— Stage IB1–IB2 (≤4 cm): radical hysterectomy + pelvic lymphadenectomy OR definitive chemoradiation; equivalent outcomes
— Stage IB3–IVA: definitive concurrent chemoradiation with cisplatin + external beam RT + brachytherapy
— Stage IVB / recurrent: systemic therapy ± palliative RT
— Younger patients often favored for surgery (preserve ovarian/vaginal function; ovarian transposition possible)
— Avoid combining radical surgery + adjuvant RT when possible — doubles morbidity (lymphedema, fistula, stenosis)
— If high-risk features anticipated (large tumor, LVSI, deep stromal invasion), upfront chemoradiation often preferred
— Sedlis criteria (intermediate risk: tumor size, LVSI, depth) → adjuvant pelvic RT
— Peters criteria (high risk: positive margins, positive nodes, parametrial involvement) → adjuvant chemoradiation (cisplatin-based)
— Stage IA1–IB1 (≤2 cm), squamous or usual adenocarcinoma, no LVSI, negative nodes
— Options: cone biopsy (IA1) or radical trachelectomy with cerclage (IA2–IB1)
Step 3 management: Locally advanced cervical cancer (IB3–IVA) — order concurrent cisplatin chemoradiation + brachytherapy as a package; brachytherapy is non-negotiable and omission worsens survival.
Board pearl: LANDMARK 2024 update (KEYNOTE-A18): adding pembrolizumab to concurrent chemoradiation improves PFS in stage III–IVA disease — emerging standard.
— Cisplatin 40 mg/m² IV weekly during external beam RT (5–6 cycles), then brachytherapy boost
— Cisplatin acts as a radiosensitizer; weekly dosing is the standard
— Carboplatin substitutes if cisplatin contraindicated (renal dysfunction, neuropathy, hearing loss)
— Monitor CBC, BMP, magnesium weekly; cisplatin nephrotoxicity and electrolyte wasting (Mg, K) are classic
— Cisplatin weekly × 6 + pelvic RT, similar regimen
— Cisplatin (or carboplatin) + paclitaxel + bevacizumab + pembrolizumab if PD-L1 positive (CPS ≥1) — current standard
— Bevacizumab improves OS but carries risk of fistula, bowel perforation, hypertension, thromboembolism, proteinuria
— Patients with prior pelvic RT and bulky pelvic disease are highest fistula risk on bevacizumab — counsel carefully
— Tisotumab vedotin (tissue factor–targeted antibody-drug conjugate) — approved for recurrent/metastatic after platinum
— Pembrolizumab monotherapy for PD-L1+ or MSI-H/dMMR tumors
— Topotecan, gemcitabine, vinorelbine for further lines
— Antiemetics: 5-HT3 + dexamethasone + NK1 antagonist for cisplatin (highly emetogenic)
— Aggressive IV hydration with cisplatin to prevent nephrotoxicity
— Mg and K repletion routinely
— G-CSF if neutropenic complications develop
Step 3 management: Before each cisplatin dose, verify creatinine clearance ≥60 mL/min, Mg, K, audiometry baseline, and absence of grade ≥2 neuropathy. Hold or substitute carboplatin if criteria not met.
Key distinction: Bevacizumab + prior pelvic RT = high fistula risk — vesicovaginal or rectovaginal fistulas can be devastating; weigh against modest survival benefit and counsel patient.
— Diagnostic and therapeutic for CIN2/3, AIS, and stage IA1
— Cold knife cone preferred for adenocarcinoma in situ (cleaner margin assessment)
— Complications: bleeding, cervical stenosis, incompetent cervix in future pregnancy (preterm birth risk)
— Removes uterus and cervix without parametrial tissue
— Appropriate for AIS, stage IA1 without LVSI in non-fertility-sparing patient
— Removes uterus, cervix, parametria, upper 1/3 vagina, pelvic lymphadenectomy
— Ovaries can be preserved in premenopausal women (especially SCC; less commonly in adenocarcinoma)
— Open/abdominal approach is now standard after LACC trial (2018) showed inferior survival with minimally invasive radical hysterectomy
— Complications: bladder dysfunction, ureteral injury, lymphocele, lymphedema, sexual dysfunction
— Fertility-sparing for IA2–IB1 (<2 cm); removes cervix + parametria, places cerclage, preserves uterine corpus
— Pregnancy outcomes: ~50–70% live birth, high preterm rate; requires cesarean delivery
— Salvage for centrally recurrent disease after RT without distant mets
— Anterior (bladder), posterior (rectum), or total; major morbidity but potentially curative
— External beam RT (EBRT): 45–50 Gy to pelvis ± para-aortic nodes
— Brachytherapy: intracavitary boost to tumor (point A 80–90 Gy total) — essential, not optional in definitive RT
— Image-guided brachytherapy improves outcomes
— Late effects: vaginal stenosis, radiation cystitis/proctitis, sacral insufficiency fractures, ovarian failure
CCS pearl: When ordering radical hysterectomy in CCS, also schedule preop type and crossmatch, bowel prep (selective), DVT prophylaxis, ureteral stents (case-by-case), and counsel on ovarian preservation/transposition before surgery.
Board pearl: Open radical hysterectomy beats laparoscopic/robotic — a high-yield trial-driven shift.
— Often present at higher stage due to under-screening (screening stops at 65 only if criteria met)
— Comorbidities increase surgical and chemoradiation toxicity
— Geriatric assessment (functional status, frailty, cognition, social support) should guide treatment intensity
— Brachytherapy more challenging due to vaginal stenosis/atrophy; vaginal dilation prep helps
— Standard concurrent chemoradiation is feasible in fit elderly; weekly cisplatin dose-reduced or replaced with carboplatin/RT alone in frail patients
— Cisplatin requires CrCl ≥60 mL/min; nephrotoxicity is dose-limiting
— Hydronephrosis from tumor — percutaneous nephrostomy or ureteral stenting prior to cisplatin to recover renal function
— Substitute carboplatin (AUC dosed) when GFR 30–60, or omit chemo and use RT alone if very poor renal function
— Adjust supportive medications (gabapentin, opioids) for renal function
— Cisplatin minimally affected; paclitaxel undergoes hepatic metabolism — reduce dose if bilirubin elevated or AST/ALT >2.5× ULN
— Bevacizumab generally safe but monitor for hepatic decompensation
— Liver metastases or hepatic dysfunction worsen prognosis and may shift toward palliative goals
— Pelvic RT irradiates substantial marrow → cytopenias common during concurrent therapy
— Hold cisplatin if ANC <1500 or platelets <100,000; use G-CSF and transfusion support
— Prior chemo for other malignancy reduces marrow tolerance
Step 3 management: Patient with newly diagnosed locally advanced cervical cancer has Cr 2.5 from bilateral hydronephrosis — first action is bilateral percutaneous nephrostomy or ureteral stents to recover renal function, then proceed with cisplatin-based chemoradiation when CrCl recovers.
Key distinction: Don't withhold curative-intent therapy from elderly patients based on age alone — use functional status and comorbidity burden instead.
— Most common gynecologic malignancy in pregnancy (~1 in 2,000 pregnancies)
— Biopsy of visible lesion is safe; ECC is contraindicated in pregnancy
— Cone biopsy reserved for cases where invasion must be defined; second trimester safest
— Management depends on stage and gestational age:
— Stage IA1, early pregnancy: can defer treatment to postpartum, vaginal delivery acceptable
— Stages IA2–IB1, <22–25 wk: discuss pregnancy termination + definitive treatment vs delayed treatment
— Stages IA2–IB1, >22–25 wk: consider neoadjuvant chemo (cisplatin-based, 2nd/3rd trimester), then cesarean + radical hysterectomy at fetal maturity (~34 wk)
— Locally advanced disease: same approach, definitive therapy after delivery; chemoradiation contraindicated during pregnancy
— Delivery route: cesarean delivery is preferred for known invasive cervical cancer; vaginal delivery risks hemorrhage and tumor implantation at episiotomy
— Cervical cancer is an AIDS-defining illness
— Higher incidence, faster progression, earlier age of onset
— Annual screening (Pap or co-test) starting within 1 year of sexual activity; never extend intervals beyond 3 yr
— Optimize ART; CD4 recovery improves outcomes but does not eliminate HPV persistence
— Treatment of invasive disease per stage; tolerability often worse, dose adjustments may be needed
— 9-valent HPV vaccine routinely at age 11–12 (range 9–26); shared decision-making for 27–45
— Vaccination does not change screening intervals
— Vaccination after treatment of CIN may reduce recurrence risk
Board pearl: A pregnant woman diagnosed with cervical cancer requires multidisciplinary counseling (gyn-onc, MFM, neonatology, ethics) about treatment delay vs immediate intervention — informed consent and patient autonomy are central, especially around pregnancy continuation.
Step 3 management: HIV+ woman with normal Pap at age 25 — next Pap in 1 year, not 3.
— Vaginal hemorrhage — can be massive from friable tumor; control with vaginal packing, tranexamic acid, emergent radiation, embolization
— Obstructive uropathy and uremia — leading cause of death in untreated disease; manage with nephrostomies or stents
— Fistulae — vesicovaginal (urine leak) or rectovaginal (stool leak), from tumor invasion or treatment
— Lower extremity DVT/PE — Trousseau-like hypercoagulability; pelvic mass also causes mechanical compression
— Para-aortic and supraclavicular adenopathy — left supraclavicular (Virchow) node indicates distant mets
— Bladder dysfunction — atonic bladder from parasympathetic nerve disruption; may require intermittent self-catheterization for weeks–months
— Ureteral injury or stricture — intraoperative or delayed
— Lymphedema of lower extremities and vulva after pelvic lymphadenectomy
— Lymphocele — may require drainage if symptomatic or infected
— Sexual dysfunction (vaginal shortening, dyspareunia)
— Premature ovarian failure if ovaries removed/irradiated
— Acute: cystitis, proctitis, diarrhea, vaginal mucositis, dermatitis, cytopenias
— Late: vaginal stenosis, radiation proctitis/cystitis with bleeding, fistulae, sacral insufficiency fractures, secondary malignancy, ovarian failure
— Vaginal dilation and topical estrogen reduce stenosis
— Cisplatin: nephrotoxicity, ototoxicity, peripheral neuropathy, electrolyte wasting (Mg, K), severe emesis
— Bevacizumab: hypertension, proteinuria, bowel perforation, fistula, thrombosis, impaired wound healing
— Pembrolizumab: immune-mediated adverse events (thyroiditis, pneumonitis, colitis, hepatitis, hypophysitis)
CCS pearl: Patient on bevacizumab develops new feculent vaginal discharge — order CT with rectal contrast or exam under anesthesia to evaluate rectovaginal fistula; hold bevacizumab and involve surgery.
Board pearl: New unilateral leg edema during treatment — always evaluate for DVT (Doppler) alongside lymphedema and tumor progression.
— Any biopsy-proven invasive cervical cancer — refer same week
— Suspicious gross cervical lesion even before biopsy result
— AIS, microinvasion on cone, persistent high-grade dysplasia
— Cervical mass in pregnancy
— Heavy vaginal bleeding with hemodynamic instability or symptomatic anemia → admit, transfuse, pack, urgent RT
— Acute renal failure from obstructive uropathy → admit for percutaneous nephrostomy/stents
— Sepsis from pyonephrosis or tumor superinfection → IV antibiotics, source control
— Bowel obstruction or perforation → surgical consult
— DVT/PE with hemodynamic compromise
— Neutropenic fever during chemo
— Severe electrolyte derangement (cisplatin-induced)
— Radiation oncology — for definitive RT/brachytherapy planning
— Medical oncology — for systemic therapy in metastatic/recurrent disease
— Urology — for nephrostomy, stenting, fistula
— Interventional radiology — embolization for hemorrhage, biopsies, drains
— Palliative care — early integration improves QoL and outcomes
— Reproductive endocrinology — fertility preservation before treatment
— Genetic counseling — Lynch-associated tumors are rare in cervix but consider in adenocarcinoma
— Recommended for all newly diagnosed invasive cases to align surgery/RT/chemo plan
CCS pearl: Patient presents with hypotension, tachycardia, and active vaginal hemorrhage from known cervical cancer — order 2 large-bore IVs, type and crossmatch, IV TXA, vaginal packing, gyn-onc and radiation oncology STAT, and admit to ICU if pressors needed. Emergent radiation hemostasis (single fraction) or IR embolization stops bleeding.
Step 3 management: Early palliative care referral at diagnosis of stage IVB disease — not at end of life. This is an evidence-based, board-favored intervention that improves both quality of life and survival.
— Smooth, pedunculated, often endocervical; bleeds with contact
— Usually benign — excise in office, send to pathology to exclude malignancy
— Common in perimenopausal women
— Mucopurulent discharge, friable cervix, contact bleeding
— Causes: Chlamydia trachomatis, Neisseria gonorrhoeae, HSV, trichomoniasis, mycoplasma
— Test with NAAT; treat empirically with ceftriaxone + doxycycline for high suspicion
— Repeat exam after treatment; persistent friability warrants biopsy
— Columnar epithelium visible on ectocervix — normal variant especially in pregnancy or with OCP use
— May cause postcoital bleeding; reassurance unless atypical features
— Postmenopausal bleeding is the classic presentation
— Endometrial biopsy distinguishes; imaging helps stage
— Treatment differs (hysterectomy ± adjuvant therapy based on grade/depth)
— Rare; usually SCC of upper posterior vagina
— DES-exposed daughters → clear cell adenocarcinoma of vagina/cervix
— Firm, smooth mass; usually asymptomatic but can prolapse and bleed
— Imaging distinguishes from carcinoma; biopsy any ulcerated area
— Bluish nodules on cervix, cyclical bleeding
— Biopsy if unclear
— Cervical mass with positive β-hCG, vaginal bleeding
— TVUS for diagnosis; methotrexate or surgical management
Key distinction: Friability + contact bleeding is shared by cervicitis, ectropion, polyp, and cancer — biopsy any persistent, atypical-appearing lesion even if STIs are positive. Treating cervicitis and ignoring an underlying cancer is a classic missed diagnosis scenario.
Board pearl: Postmenopausal bleeding always requires endometrial sampling, but never skip the speculum exam — synchronous cervical and endometrial pathology occurs.
— UTI, bladder cancer, urethral caruncle — present as hematuria, may be mistaken for vaginal bleeding
— Distinguish with urinalysis, urine culture, cystoscopy; tampon test to localize
— Hemorrhoids, rectal cancer, anal fissure — may be confused with vaginal source
— Digital rectal exam and anoscopy/colonoscopy clarify
— Rectovaginal fistula from advanced cervical cancer presents as stool per vagina
— Anticoagulants, von Willebrand disease, thrombocytopenia → menorrhagia or intermenstrual bleeding
— Check CBC, PT/PTT, vWF if family history; resolves with correction but does not exclude structural cause
— Sexual assault, foreign body, recent instrumentation
— Document carefully; mandatory considerations for assault (Chunk 17)
— Threatened/incomplete abortion, ectopic, placenta previa, abruption
— Always check β-hCG in reproductive-age women with bleeding before further workup
— Postmenopausal estrogen deficiency → thin, friable vaginal/cervical mucosa with bleeding
— Treat with topical estrogen; rules out cancer first
— Granulomatous lesions can mimic carcinoma
— Biopsy with AFB and special stains
— Rare; biopsy distinguishes
— Treat per primary malignancy
Key distinction: A patient with a "vaginal bleeding" complaint may actually have rectal or urinary bleeding — confirm source on exam (speculum + DRE) before labeling as gynecologic.
Board pearl: Always check β-hCG first in any reproductive-age woman with abnormal bleeding — drives the differential and protects from teratogen exposure during workup.
— Most recurrences occur within 2 years; 80–90% within 3 years
— Follow-up schedule:
— Every 3–6 months for years 1–2
— Every 6–12 months for years 3–5
— Annually thereafter
— Each visit: symptom review, pelvic exam (speculum + bimanual + rectovaginal), assessment of treatment toxicity
— Cervical/vaginal cytology annually for the first few years (low yield but standard)
— Imaging (CT/PET) only if symptomatic or exam suspicious — not routine surveillance
— Vaginal dilators + topical estrogen to prevent post-RT vaginal stenosis (start 2–4 wk after RT)
— Lubricants for dyspareunia
— Pelvic floor physical therapy for incontinence/dysfunction
— Lymphedema therapy referral after pelvic lymphadenectomy
— Hormone replacement therapy in premenopausal women with surgical/radiation menopause — generally safe in cervical cancer (most are squamous; not hormone-driven)
— Bisphosphonates / calcium / vitamin D for bone health if iatrogenic menopause
— Antidepressants and sexual health counseling — high prevalence of depression/sexual dysfunction
— Smoking cessation — synergistic with HPV in carcinogenesis; counsel at every visit
— Safer sex practices; HPV vaccination for unvaccinated partners or patients under 45
— Maintain weight, exercise, mental health support
— Survivorship care plan handoff to PCP after 5 years
— Address insurance, employment, fertility documentation
— Patient navigators and community resources improve adherence in under-resourced populations
Step 3 management: First post-treatment visit at 3 months — pelvic exam, symptom screen, address treatment toxicities (bladder, bowel, sexual). No routine imaging unless symptomatic.
Board pearl: HRT is acceptable in premenopausal cervical cancer survivors with surgical menopause — quality of life and bone protection outweigh theoretical risk in this non-hormone-driven cancer.
— New pelvic pain, leg edema, weight loss, bleeding, persistent cough, or bone pain → workup for recurrence with imaging
— Hydronephrosis recurrence → suspect central pelvic recurrence
— Persistent vaginal discharge or new fistula symptoms → exam under anesthesia
— Post–radical hysterectomy: bladder retraining, timed voiding, post-void residuals; intermittent catheterization if atonic
— Post-RT cystitis/proctitis: hydration, anti-inflammatories, hyperbaric oxygen for refractory cases
— Dietary modification for radiation enteritis (low fiber, low fat)
— Vaginal stenosis: dilator therapy starting 2–4 wk post-RT, 3×/wk indefinitely
— Topical estrogen creams/tablets unless contraindicated
— Couples counseling; address body image and intimacy concerns
— Early referral to certified lymphedema therapist
— Compression garments, manual lymphatic drainage, skin care to prevent cellulitis
— Early antibiotics for cellulitis (common trigger for worsening lymphedema)
— Screen for depression and anxiety (PHQ-9, GAD-7) at each visit
— Support groups, oncology social work
— Address financial toxicity and return-to-work issues
— DXA scan baseline at iatrogenic menopause; repeat per osteoporosis guidelines
— Calcium 1200 mg/day, vitamin D 800–1000 IU/day; bisphosphonates if osteopenia/osteoporosis
— Sacral insufficiency fractures common after pelvic RT — present as low back pain; MRI diagnoses
— Iatrogenic menopause accelerates CV risk — manage BP, lipids, glucose aggressively
— Routine USPSTF screening for other cancers, especially breast and colon
Step 3 management: Survivor presents 18 months post-RT with new low back pain and no neurologic deficit — order pelvic MRI to evaluate for sacral insufficiency fracture vs recurrence; both are stage-3 favorites.
Board pearl: Vaginal dilator therapy is the single most important intervention for preserving sexual function after pelvic RT — start early.
— Fertility preservation discussion is mandatory before any sterilizing therapy in reproductive-age women — failure to offer is both an ethical and medicolegal failure
— Document discussion of surgery vs chemoradiation, expected outcomes, sexual/bladder/bowel side effects, lymphedema risk, secondary malignancy from RT
— Special consent considerations for radical hysterectomy include ovarian preservation and intraoperative decisions
— Patient autonomy regarding pregnancy continuation vs immediate treatment must be respected after thorough counseling
— Involve MFM, neonatology, ethics committee for complex cases
— Document shared decision-making in detail
— Cervical cancer is a disease of healthcare access — disproportionately affects under-screened, uninsured, immigrant, and rural populations
— Step 3 systems-based questions test knowledge of patient navigators, mobile screening, self-sampling, federally qualified health centers
— Sexual assault history — offer trauma-informed care, SANE exam if acute, mandatory reporting for minors and impaired adults per state law
— Adolescents with abnormal Paps — confidentiality of sexual/reproductive care; HPV vaccine consent rules vary by state
— Lost-to-follow-up after abnormal cytology is a major safety event — track abnormal results, document contact attempts, use registry/recall systems
— Closed-loop communication between PCP, gyn, gyn-onc, radiation, and medical oncology
— Medication reconciliation across services especially during chemoradiation
— Early goals-of-care conversations
— Hospice referral when curative options exhausted; symptom control prioritized
— DNR/POLST discussions before crisis events
— Quality metrics: timeliness of biopsy after abnormal screen, time to treatment, brachytherapy delivery rate, completion of recommended cycles
Step 3 management: A 22-year-old with HSIL never returned after her Pap — documented contact attempts, certified letter, and outreach by clinic staff are standard of care; failure to track represents a system safety failure, not just patient nonadherence.
Board pearl: Brachytherapy omission in locally advanced disease is a known quality-of-care gap and reduces survival — verify it is delivered.
— HPV 16 and 18 cause ~70% of cervical cancers; E6 inactivates p53, E7 inactivates Rb
— 9-valent vaccine covers HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
— Squamous cell carcinoma (~75%) — transformation zone, more common with HPV 16
— Adenocarcinoma (~25%) — endocervical, more common with HPV 18, harder to detect on cytology, rising incidence
— Clear cell adenocarcinoma — DES exposure in utero
— Small cell neuroendocrine — rare, aggressive, treat like SCLC
— Hydronephrosis = stage IIIB regardless of tumor size
— Lower 1/3 vagina = IIIA
— Pelvic or para-aortic nodes = IIIC (new in 2018)
— Bladder/rectum mucosal invasion = IVA (biopsy required, bullous edema doesn't count)
— IA1, no LVSI → cone or simple hysterectomy
— IB1–IB2 → radical hysterectomy OR chemoradiation
— IB3–IVA → definitive chemoradiation + brachytherapy
— IVB or recurrent → systemic therapy ± palliation
— LACC (2018): open > minimally invasive radical hysterectomy
— KEYNOTE-A18: pembrolizumab + chemoradiation improves PFS in stage III–IVA
— KEYNOTE-826: pembrolizumab added to chemo + bevacizumab for metastatic/recurrent PD-L1+
— Start at age 25 (ACS) or 21 (USPSTF/ACOG older) — know both, current trend toward 25 with primary HPV
— Stop at 65 with adequate prior screening
— HIV+: annual until 3 negatives, then every 3 yr; no upper age cutoff
— Routine at 11–12 (range 9–26); shared decision-making 27–45
— 2-dose series if started <15, 3-dose if ≥15 or immunocompromised
— Does not change screening recommendations
Board pearl: A "barrel-shaped cervix" with a normal-appearing ectocervix in a woman with abnormal bleeding suggests endocervical adenocarcinoma — image with MRI; cytology is often negative.
— 38 yo with postcoital bleeding × 6 months, friable cervical lesion on speculum exam
— Next step: punch biopsy of the lesion (NOT repeat Pap, NOT colposcopy first, NOT empiric antibiotics)
— Tests recognition that a visible lesion is biopsied directly
— 52 yo with cervical SCC, exam shows 3-cm cervical mass, no parametrial extension; CT shows right hydronephrosis
— Stage: IIIB → treatment is concurrent chemoradiation with brachytherapy, not radical hysterectomy
— 28 yo nulliparous with stage IA2 SCC, desires future fertility, no LVSI
— Answer: radical trachelectomy with pelvic lymphadenectomy
— Pregnant patient with cervical mass on routine prenatal exam → punch biopsy (not ECC, not cone in 1st trimester unless invasion suspected)
— Confirmed stage IB1 at 28 weeks → neoadjuvant chemo → cesarean + radical hysterectomy at fetal maturity
— Radical hysterectomy reveals positive parametria and 2 positive nodes → adjuvant cisplatin-based chemoradiation (Peters criteria)
— 47 yo with biopsy-proven stage IVB SCC, PD-L1 CPS 5 → cisplatin + paclitaxel + bevacizumab + pembrolizumab
— 32 yo with negative co-test → next screen in 5 years
— HIV+ 28 yo with normal Pap → next Pap in 1 year
— 67 yo with 3 prior negative co-tests, no high-grade history → stop screening
— Advanced disease; order MRI pelvis + PET/CT for staging; expect IIIB/IIIC
— 2 years post-chemoradiation, new low back pain → MRI to evaluate sacral insufficiency fracture vs recurrence
— Vaccinated 35 yo asking about screening → continue routine screening per age-based guidance
Board pearl: Stems that mention hydronephrosis, unilateral leg edema, or back pain are screaming stage III — abandon surgical answers and pick chemoradiation.
Cervical cancer is an HPV-driven malignancy whose outcome hinges on screening, early biopsy of any visible cervical lesion, FIGO 2018 stage-directed therapy (cone/simple hysterectomy for microinvasion, radical hysterectomy for early IB, and concurrent cisplatin-based chemoradiation with brachytherapy ± immunotherapy for locally advanced/metastatic disease), and lifelong survivorship care addressing sexual, urinary, lymphatic, and psychosocial sequelae.
Board pearl: When in doubt, the Step 3 answer for advanced cervical cancer is "concurrent cisplatin-based chemoradiation with brachytherapy" — and you should never pick minimally invasive radical hysterectomy.