More women are surviving gynecological cancer with advancements in screening, diagnosis, and treatment. Survivorship care of gynecological cancer includes surveillance for recurrence of disease, monitoring for late effects of treatment, reducing the risk and early detection of other cancer, and assessment of psychosocial function. Even if the surveillance of gynecological cancer survivors has some common features, non-invasive and invasive breast, cervical, endometrial, and ovarian cancer will require an individualized therapeutic approach. Many survivors of gynecologic cancer will have long lasting effects on bone and sexual heath, so these areas should be addressed on a regular basis. In addition, it is important to use every encounter as an opportunity to assess the risk of other cancer and provide appropriate early detection. Survivorship care will also incorporate strategies to decrease the risk of other cancer through lifestyle modifications. Many female cancer survivors will have lifelong issues related to distress, body image, finance, and social support. Assessment of psychosocial issues and referral to appropriate services should be performed at every patient encounter.

While many urologic cancer can occur in both sexes, bladder cancer has the most unique sex-specific differences. Despite lower incidence of bladder cancer in females, these patients experience a worse prognosis compared to their male counterparts. Importantly, to decrease delays in care, bladder cancer should always be considered in the differential of those with hematuria. The hematuria evaluation involves imaging studies and direct visualization of the bladder with a camera, known as cystoscopy. Bladder cancer can be divided into two categories of disease: non-muscle invasive (NMIBC) and muscle invasive bladder cancer (MIBC). NMIBC may be treated with endoscopic resection and intravesical therapies, with ongoing need for cystoscopic surveillance. MIBC often requires removal of the bladder (cystectomy) and urinary diversion with or without systemic chemotherapy or immunotherapy. Historically, removal of the uterus, fallopian tubes, ovaries, and anterior vagina have occurred in conjunction with cystectomy for MIBC. Recent research and expert opinion suggest that removal of all gynecological organs is unlikely to be necessary in many cases. In addition to common surgical complications and quality of life disruptions of cystectomy, gynecologic-specific complications include vaginal closure dehiscence, prolapse, dyspareunia, iatrogenic menopause, and vaginal fistula.

Though both preventable and curable, cervical cancer remains a leading cause of cancer-related deaths globally. It is generally understood that the overwhelming majority of cervical cancer cases are caused by persistent infection with high-risk human papillomavirus infection. In addition to other well-studied risk factors, it is well-established in the literature that there is an increased risk of progression from preinvasive disease to invasive cancer in women with immunosuppression, such as those living with human immunodeficiency virus (HIV) and those with cancer. In this chapter, we seek to summarize recommendations surrounding cervical cancer screening and treatment for women with who are immunosuppressed following cancer therapy. We review the use of cervical cytology and HPV testing and discuss their use in both patients of average and increased risk. We also review the American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines for treatment of preinvasive disease in immunocompromised patients.

Lung cancer has emerged as a distinct disease in women, and women have unique risk factors as compared to men. Women are more likely to be diagnosed at a young age with adenocarcinoma, lack a significant smoking history and carry driver mutations. Current screening guidelines center around tobacco use, so health care disparities related to gender may impact those women who never smoked and/or prone to lung cancer from distinct etiologies. Molecular and immune markers are important in the workup for cancer, and new treatments with targeted and immune-mediated therapies are available. Women diagnosed with lung cancer have improved survival rates compared to men even while accounting for stage of diagnosis, age, smoking history and treatment modality. Lung cancer survivorship issues can contribute to significant symptom burden, and these can include cancer-related fatigue, reproductive issues, sexual health and sleep disruption. The impact of lung cancer and its’ therapies can affect quality of life especially when treatment-related complications are persistent.

Masses of the ovary, fallopian tube, or surrounding tissues are common and found in up to 35% of premenopausal patients and 17% of postmenopausal patients. They are often diagnosed incidentally on physical examination or at the time of pelvic imaging. The differential diagnosis is broad and includes both benign and malignant lesions, as well as gynecologic and non-gynecologic lesions. The patient’s age, family history, physical exam, imaging findings, and serum marker levels can aid with narrowing the differential. Risk factors for ovarian cancer include age, family history of ovarian cancer or genetic predisposition for ovarian cancer, nulliparity, early menarche, late menopause, and endometriosis. Management aims include identifying need for emergent surgery, identifying malignancy, managing symptoms, and preserving fertility when appropriate. Management options for pelvic masses include expectant management, surveillance, and surgical management. While minimally invasive surgery is often the preferred surgical approach for removal of an adnexal mass, open surgery may be required for larger masses or those concerning for malignancy. Ovarian cancer is the second most common gynecologic malignancy after uterine carcinoma and is the deadliest gynecologic cancer in the United States. Approximately 95% of ovarian cancer arise from the epithelial cells and include high grade serous, low grade serous, endometrioid, clear cell, and mucinous carcinoma. Most patients have advanced staged disease at the time of ovarian cancer diagnosis. While surgery alone can cure most patients with early-stage disease, most patients present with advanced stage disease and will require a combination of both surgery and chemotherapy. The standard chemotherapy regimen includes a combination of platinum- and taxane-based chemotherapy. Five-year overall survival rates are 89% for stage I, 71% for stage II, 41% for stage III, and 20% for stage IV disease.

Positive serum β-human chorionic gonadotropin (β-hCG) testing in reproductive-age women generally indicates a pregnancy and to a lesser extent gestational trophoblastic disease (GTD) or a germ cell tumor (GCT). Other non-pregnant or false-positive causes of serum β-hCG testing include pituitary hormone production in perimenopausal or postmenopausal women, heterophilic antibody interference, chronic renal disease, familial β-hCG, and exogenous hCG administration for assisted reproductive technology. Non-gynecologic cancer can be associated with positive β-hCG results. We review the general physiology of the β-hCG molecule and typical approaches to β-hCG testing. We present an algorithm to help guide clinicians in evaluating the non-pregnant or false-positive causes of positive β-hCG test results.

Cancer treatments can induce temporary or permanent menopause and lead to persistent menopausal symptoms. In reproductive age women, cancer treatment may impair fertility but evaluating fertility and managing contraception can be complex. Managing menopausal symptoms and contraceptive decisions after cancer treatment can be challenging for women and their care providers. In this chapter, we present concepts for managing these consultations and some specific advice for women in particular situations.

Vulvar melanoma is a rare malignant tumor of the female genital tract that affects mostly women in the 5th−8th decade of life. A histopathological evaluation and immunohistochemical analysis are paramount to confirm the diagnosis. Treatment requires a multidisciplinary approach. Secondary to a high metastatic potential as well as late diagnosis due to non-specific clinical signs, the prognosis is typically poor. Close monitoring, patient education regarding self-skin examination and screening are necessary for all atypical lesions and to identify local recurrences.

A small but important fraction of cancer are primarily due to a hereditary cancer predisposition, and their diagnosis has significant clinical implications for both index cases and their families. Germline BRCA1BRCA/2 pathogenic variants (PVs) can lead to the Hereditary Breast and Ovarian Cancer (HBOC) Syndrome and identification of both germline and somatic BRCA1/BRCA2 PVs have important treatment implications. In addition, endometrial cancer is closely associated with inherited PVs in the mismatch repair (MMR) genes which leads to Lynch syndrome. Both HBOC and Lynch syndrome affect around 1:300 people, most of whom are undiagnosed. Genetic panel testing is crucial to identifying PV carriers, before a sentinel cancer, who can then be offered prophylactic interventions such as risk reducing salpingo-oophorectomy (RRSO). Within this chapter we discuss the most common hereditary cancer syndromes associated with gynecological cancer. These include HBOC, Lynch syndrome, the moderate penetrant genes including RAD51C, RAD51D, BRIP1, PALB2, and ATM as well as rarer hereditary cancer syndromes including Cowden syndrome (PTEN), DICER1, Rhabdoid Tumor Predisposition syndrome (SMARCB1, SMARCA4) and Peutz-Jeghers syndrome (STK11).

Breast cancer is the second most common malignancy in women worldwide. Due to improvements in screening, diagnosis, endocrine therapy and novel targeted agents, survival continues to increase. The initial workup should include thorough imaging of the breast and nodal basins, pathologic review, receptor status analysis and systemic staging as necessary. This information is fundamental to determine the best options for surgery, systemic therapy and radiation therapy and in addition, the most appropriate sequence of multimodal therapy. Care of patients with germline mutations should include genetic counseling and consideration of prophylactic mastectomy and salpingo-oophorectomy. Recent advances in immunotherapy, targeted agents and antibody drug conjugates improve survival and quality of life for metastatic breast cancer patients while limiting toxicity. Surgical techniques have evolved to allow more patients to undergo breast conservation and to limit morbidities from axillary node dissections. New genomic predictive assays allow us to select high risk patients who will truly benefit from chemotherapy and radiation therapy. Modern radiation approaches can limit toxicities by using hypofractionation, partial breast irradiation, 3D conformal planning and proton therapy. The optimal treatment of breast cancer patients requires a multidisciplinary approach tailored to the individual patient in order to maximize clinical outcome and minimize toxicities.

Human papillomavirus (HPV) is a leading cause of cancer and cancer-related death in women, overwhelmingly attributed to rates of cervical cancer in low and middle-income countries. However, in the U.S., HPV-related oropharyngeal cancer (OPC) has surpassed cervical cancer as the most common HPV-related cancer, although it is much more common (5-fold) in men than women. Similar to other head and neck cancer, HPV-related OPCs typically require complex multidisciplinary treatments often with major lifelong sequelae. However, HPV-related OPCs have much better cancer cure rates and lower second primary malignancy rates than tobacco-related head and neck cancer. Unique patterns of second primary malignancies, related to HPV exposures, are often a concern for female patients. This chapter will focus on HPV-related OPC, its associations with other malignancies in women, and prevention / screening recommendations and potentials for women with HPV-related OPC.

Approximately 10% of women diagnosed with cancer are of reproductive age. As survival rates improve, there is an increased focus on the complex issues surrounding cancer survivorship, particularly for younger women of reproductive age. Among young women diagnosed with cancer, concerns regarding future fertility are secondary only to concerns regarding survival. Guidelines from the American Society of Clinical Oncology (ASCO) and American Society for Reproductive Medicine (ASRM) state that healthcare providers should discuss the risk of infertility and fertility preservation options with all reproductive age patients diagnosed with cancer. This chapter reviews the proposed mechanisms of chemotherapy induced ovarian toxicity and how to assess baseline ovarian reserve. Fertility preservation options are discussed, including medical and conservative surgical management for select patients with gynecologic malignancies, oocyte and embryo cryopreservation, ovarian tissue cryopreservation and ovarian suppression. Data regarding the safety of ovarian stimulation and subsequent pregnancy are included.

Obstetrician-gynecologists are frequently consulted during an episode of abnormal uterine bleeding (AUB) to stop bleeding acutely and to prevent further bleeding during cancer treatment. Women with hematologic malignancies, such as acute myelogenous leukemia (AML), are the most frequently affected and new onset heavy menstrual bleeding may be the chief complaint leading to their diagnosis. Cancer and cancer treatments including chemotherapy, total body irradiation, and conditioning regimens for bone marrow or stem cell transplant can induce thrombocytopenia and lead to AUB. Main treatment options include oral contraceptive pills (OCPs), gonadotropin-releasing hormone (GnRH) agonists, and progestin-only hormone therapy. Algorithms are available to guide treatment and medical management is first line, especially in patients who have not completed childbearing. The risk of venous thromboembolism and need for contraception are special considerations when choosing a treatment for AUB in this patient population.