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.

The incidence of cancer during gestation has risen due to multiple factors such as advanced maternal age and improvement in cancer treatment, which has resulted in longer life span and a rising number of survivors who will then become pregnant. Whether a woman is diagnosed with cancer during pregnancy or becomes pregnant after surviving the disease, navigating treatment for both the mother and the fetus can seem daunting for patients as well as their care providers, as there is a higher risk of morbidity for these patients. This chapter aims to describe safe diagnostic and therapeutic options during pregnancy and includes special considerations regarding survivors’ treatment. Breast cancer, lymphoma, leukemia and cervical cancer are the focus of the chapter and obstetric management of patients with these malignancies is addressed, including antenatal care, delivery considerations and breastfeeding.

Premature ovarian insufficiency (POI) is a heterogeneous diagnosis caused by a multitude of factors including genetic, autoimmune, iatrogenic, social, and environmental. It is defined as loss of ovarian function prior to 40 years of age with subsequent secondary amenorrhea for at least 4−6 months in conjunction with elevated follicle stimulating hormone levels on two different measurements. Prompt recognition of symptoms should encourage thorough history-taking and work-up, as some causes of POI are associated with conditions requiring additional screening or medical management. Early initiation of hormone replacement therapy is necessary to prevent long-term sequelae from chronic hypoestrogenism such as cardiovascular events, poor bone health, and cognitive dysfunction. Extensive counseling with regards to future fertility and family building options is necessary as the diagnosis of POI can be psychologically devastating to many women.

Cervical cancer is the most common gynecologic malignancy worldwide and the third most common in the United States. While incidence and mortality rates have decreased significantly with improved access to screening and prevention methods in the United States, cervical cancer remains a significant cause of cancer morbidity and mortality in resource-limited countries. Human papillomavirus (HPV) infection is the cause of almost all cervical cancer and is associated with 99.7% of cervical cancer. Additional risk factors associated with HPV include early onset of sexual activity, multiple sexual partners, history of sexually transmitted infections, increased parity, and immunosuppression. Non-HPV-related risk factors include cigarette smoking, oral contraceptive use, and low socioeconomic status. Squamous cell carcinoma is the most common histologic subtype of cervical cancer, comprising around 70% of cases, and adenocarcinoma is the second most common histologic subtype, comprising approximately 25% of cases. Cervical cancer is staged clinically, and stage is the most important prognostic factor. Early-stage disease can generally be treated surgically with a hysterectomy. Fertility-sparing surgical options include cold knife conization and radical trachelectomy in select cases. Adjuvant therapy with chemotherapy, radiation, or chemoradiation may be required for early-stage disease with specific risk factors. Advanced-stage disease is primarily treated with chemoradiation. Using FIGO 2018 staging, five-year survival rates were 92−97% for stage IA tumors and 76−92% for stage IB tumors. Lymph node involvement is associated with worse prognosis with five-year survival rates near 40−60%. Routine screening with cervical cytology is recommended starting in young adulthood to identify and treat females with high-grade dysplasia. Routine HPV vaccination is recommended to protect against development of cervical cancer from persistent high-risk HPV infection.

It can be painful to witness the toll of cervical cancer on women offered next-to-no treatment options. Persons with cervixes who acquire the disease in places like Africa or Southeast Asia often experience a brutal life trajectory. In the absence of highly trained professionals, sophisticated medical facilities, and expensive surgical or radiation equipment, most cervical cancer patients in lower-income countries are sent home to die. These deaths can be protracted and lonely, with little access to palliative care. What’s more, the stigma of the disease – associated with “dirty” female reproductive organs and the smell of advanced cancer – can lead to social banishment in a sufferer’s final days. In higher-income countries, greater availability of treatment is still no guarantee of equity. Low-income patients in the United States are often cut off from insurance once cancer goes into remission, excluding them from critical follow-up. Pockets of inequity, the rural–urban divide, and inconsistent access to care mean women from affluent countries die inexcusably from a preventable cancer. The inhumane circumstances cervical cancer sufferers face worldwide remind us of this mission’s urgency.

Every year, more than 600,000 persons with cervixes end up with cervical cancer. Without treatment, these people will die. And yet, treatment for cervical cancer remains is scarce enough in lower-income countries to typically make a cervical cancer diagnosis a terminal one. Women who can’t afford to travel for their treatment are left to die painful, lonely deaths, stigmatized, and with next-to-no palliative care. In higher-income countries, surgery, radiation, chemotherapy, as well as immunotherapy can prolong or even save lives. But these treatments can be arduous and even torturous, with life-altering consequences, such as loss of fertility and physical disfigurement, along with chronic or debilitating health conditions and radical lifestyle changes. In affluent regions, treatment is often seen as a last-ditch option, while marginalized women around the globe consider it a luxury. Cervical cancer prevention is the most cost-effective, sustainable, and humane approach toward eliminating the disease. But until treatment can be offered equitably alongside prevention, thousands more will suffer and die.

Many benign and malignant conditions are treated with fertility-threatening medical or surgical therapies. Fertility preservation is a recourse critical to discuss prior to initiation of these therapies. This chapter describes contemporary and future fertility preservation approaches while also exploring barriers in access to their use as well as key decision-making strategies helpful for clinicians caring for patients with a range of medical conditions.

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Provides an overview of the categories of cancer treatment modalities consisting of chemotherapy, stem cell transplant, hormone, immunotherapy, radiation, targeted cell therapy

Cancer during pregnancy is rare, affecting approximately 1 in 1 000 pregnancies. Although rare, most obstetricians will at times be responsible for women who have a history of cancer, or present with symptoms or signs of possible malignancy during pregnancy, or even encounter a new diagnosis during a current pregnancy. Pregnancy itself does not predispose to cancer, but there may be delays in diagnosis due to symptoms being falsely attributed to physiological symptoms related to pregnancy.

Uterine leiomyosarcomas are rare diseases but represent the commonest subtype of uterine sarcomas. For patients with early-stage localized disease, it is well-known that surgery is the most important part of treatment. However, approximately 40% of patients will present recurrent disease with distant metastasis, and for these patients the question arises as to whether they should have secondary cytoreductive surgery or systemic therapy alone. Decision making needs to take various factors into consideration, as only carefully selected patients will benefit from surgery. Patients for whom surgery is most likely to be beneficial are those with small-volume metastatic disease and late recurrences. In contrast, patients with rapidly progressive disease, or those for whom surgery will not achieve complete macroscopic removal, are unlikely to benefit from surgery, which should be avoided.