A 53-year-old woman comes to the emergency department due to heavy vaginal bleeding. The bleeding started yesterday as dark brown vaginal spotting and has increased to now soaking a thick menstrual pad every 2 hours. Menarche was at age 14. Menopause was at age 45 and the patient has had no prior episodes of vaginal bleeding since then. She smoked half a pack of cigarettes daily for 20 years; she does not use alcohol or illicit drugs. The patient's mother died of breast cancer at age 77. Blood pressure is 110/70 mm Hg and pulse is 94/min. BMI is 37 kg/m2. The abdomen is obese, soft, and nontender, with no rebound or guarding. Pelvic examination shows dark red blood in the posterior vaginal vault and a 3-cm friable mass on the ectocervix and extending laterally. The lesion is actively bleeding. Hemoglobin is 10.2 g/dL. Pelvic ultrasonography reveals a thin endometrial stripe and no adnexal masses. Which of the following is a risk factor for this patient's condition?
Risk factors for cervical cancer |
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HPV = human papillomavirus. |
This patient has heavy vaginal bleeding and a laterally extending, friable cervical mass that is concerning for advanced-stage cervical cancer. Cervical cancer is caused by persistent infection with high-risk human papilloma virus types 16 and 18. Tobacco use is another major risk factor for squamous cell cervical cancer and, with human papilloma virus infection, exerts oncogenic effects on the cervix through impaired immunity. Additional risk factors include early onset of sexual activity, multiple sexual partners, and immunosuppression (eg, HIV infection, chronic glucocorticoid use). After the diagnosis of invasive cervical carcinoma is confirmed by direct biopsy, treatment is with excision, radiation, or chemotherapy, depending on disease extent.
(Choices A, F, and H) Although endometrial cancer can present with postmenopausal bleeding, a lesion on the ectocervix is consistent with a cervical, rather than an endometrial, malignancy. Endometrial cancer is excluded when a thin endometrium is viewed on ultrasound. Chronic anovulation and obesity increase the risk of endometrial cancer due to unopposed estrogen stimulation of the endometrium. Progesterone (eg, oral contraceptives, progestin intrauterine device) stimulates differentiation of the endometrial cells and prevents endometrial hyperplasia/cancer.
(Choices B, C, D, and E) Ovarian cancer typically presents with an adnexal mass, and advanced disease can cause ascites. Endometriosis and family history are risk factors. The risk of ovarian cancer is decreased by delayed menarche and early menopause.
Educational objective:
Advanced cervical cancer may present as vaginal bleeding with a cervical lesion. Smoking is a risk factor for squamous cell cervical carcinoma.