GC112 Abnormal Vaginal Bleeding Gynaecological Cancer
Abnormal vaginal bleeding in the context of gynaecological cancer refers to irregular, postmenopausal, or otherwise unexplained uterine or vaginal bleeding that may signal an underlying malignancy of the endometrium, cervix, ovary, vagina, or vulva, warranting urgent investigation.
Abnormal Vaginal Bleeding & Gynaecological Cancer
This lecture bridges two critical domains: the clinical approach to abnormal vaginal bleeding (AVB) and the three major gynaecological cancers (cervical, endometrial, ovarian). The core insight is that abnormal vaginal bleeding is overwhelmingly benign in origin, but the clinician's primary job is to rule out malignancy — especially in older women and those with risk factors. The lecture systematically moves from differential diagnosis → history → examination → investigations → cancer-specific teaching (staging, spread, treatment, prognosis).
Learning Objectives (from GC 112): [1]
- Know the common causes of abnormal vaginal bleeding
- Know how to make a diagnosis — from history, examination, investigation
- Know how female cancers spread
- Know the general principles of treatment of common gynaecological cancers
Exam relevance: This topic is tested almost every year in the Fourth Summative (SAQ, MCQ, and minicases). Past papers from 2018, 2019, 2020, 2021, and 2024 all feature questions on AVB investigations, differential diagnoses, and gynaecological cancer management [3][4][5][6][7].
Part 1: Causes of Abnormal Vaginal Bleeding
Cancer is NOT the commonest cause → there are many many more benign causes [2]
The key mental model is anatomical classification — start from below and work upwards:
| Anatomical Site | Benign Causes | Malignant Causes |
|---|---|---|
| Vulva/Vagina | Atrophic vaginitis, lacerations/trauma | Vulval cancer, vaginal cancer |
| Cervix | Cervical erosion (ectropion), cervical polyp | Cervical cancer |
| Uterus (Endometrium/Myometrium) | Fibroids, endometrial polyps, endometrial hyperplasia, dysfunctional uterine bleeding (DUB)/anovulation | Endometrial cancer, uterine sarcoma |
| Pregnancy-related | Miscarriage, ectopic pregnancy, gestational trophoblastic disease | Choriocarcinoma |
| Ovary | Functional cysts | Oestrogen-secreting tumours (granulosa cell) |
Common Causes listed on GC 112 slide: Fibroid, endometrial polyps, pregnancy-related, hyperplasia, dysfunctional uterine bleeding, anovulation, cervical erosion, cervical polyp, atrophic vaginitis, lacerations — these can be benign or malignant and can arise from any part of the genital tract [1]
Important Distinction
The FIGO PALM-COEIN classification (Polyp, Adenomyosis, Leiomyoma, Malignancy — Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified) applies specifically to abnormal uterine bleeding in non-gravid reproductive-age women. This lecture's scope is broader — it covers per-vaginal bleeding from ANY anatomical source and at ANY age, including post-menopausal. Don't conflate the two in exams [2].
- Anovulation/DUB: The most common cause of endometrial bleeding is irregular ovulation causing irregular periods [2]. Without ovulation, there is no progesterone to stabilize the endometrium, leading to erratic shedding.
- Fibroids: Submucosal fibroids distort the endometrial cavity and increase surface area, causing heavy menstrual bleeding (HMB).
- Endometrial polyps: Focal endometrial overgrowths that cause intermenstrual or post-menopausal bleeding.
- Cervical ectropion (erosion): Columnar epithelium extends onto ectocervix; fragile, bleeds on contact. Common with OCP use, pregnancy.
- Atrophic vaginitis: Post-menopausal oestrogen deficiency → thin, fragile vaginal mucosa → bleeding with minimal trauma.
Part 2: Clinical Approach — History
The history is structured around age/reproductive status, bleeding pattern, provoking factors, associated symptoms, and key past histories.
Ask where the patient is in her reproductive life: [1]
- Pre-menarche? → Think trauma, foreign body, precocious puberty, rare tumours (sarcoma botryoides)
- Pregnant? → Must exclude pregnancy-related causes (miscarriage, ectopic, molar pregnancy)
- Peri-menopausal? → Anovulatory cycles common; but must exclude endometrial pathology if > 40
- Post-menopausal? → Must exclude endometrial cancer; also consider atrophic vaginitis, cervical cancer
Key questions: [1]
- Amount? — Quantify: number of pads/tampons, flooding, clots, haemodynamic symptoms
- Regular or irregular bleeding? — Regular heavy = structural cause (fibroid); irregular = anovulation or pathology
- Intermenstrual bleeding (IMB)? — Bleeding between periods → think polyps, cervical pathology, endometrial cancer
- Postcoital bleeding (PCB)? — Bleeding after intercourse → cervical ectropion, cervical polyp, cervical cancer
Contraceptive history — Can she be pregnant? Is she on hormones? [1] Cervical smear history [1] Obstetric history [1] Drug history — Anticoagulation? HRT? [1] Family history — FHx of Ca ovary / breast / colon etc? [1]
Why each matters:
- Contraceptives: OCPs can cause breakthrough bleeding; missing pills → pregnancy risk
- Cervical smear: No regular screening → higher risk of undetected cervical dysplasia/cancer
- Anticoagulants: Warfarin, DOACs can exacerbate or cause vaginal bleeding
- HRT: Unopposed oestrogen → endometrial hyperplasia → cancer
- Family history: Lynch syndrome (hereditary nonpolyposis colorectal cancer / HNPCC) confers 15–60% lifetime risk of endometrial cancer [1]
Part 3: Clinical Approach — Physical Examination
Pallor (anaemia from chronic blood loss), bleeding tendency (petechiae, bruising), constitutional signs (weight loss, cachexia suggesting malignancy) [1]
Speculum examination: Can you see an abnormality? Lesion on vulva / vagina / cervix [1] Bimanual: Uterine size, adnexal masses [1] Rectal examination — assesses parametrial involvement in cervical cancer [1]
Exam Tip
In past paper SAQs, "aspects of physical examination to focus on" typically expects: (1) General examination for anaemia/pallor, (2) Abdominal examination for masses, (3) Pelvic/speculum examination [3]. Always mention all three in your answer.
Part 4: Investigations
This table synthesizes the MCQ theme from the 2021 Fourth Summative [6]:
| Clinical Scenario | Most Appropriate First-Line Investigation | Why |
|---|---|---|
| Young woman, irregular cycles, acne, BMI 33, never sexually active | Serum FSH, LH and oestradiol (or pelvic USS) | Likely PCOS; hormonal profile needed. Cannot do pelvic exam/TVS if not sexually active |
| 44F, intermenstrual bleeding, normal smear 1 year ago | Endometrial aspiration (Pipelle) | Age > 40 + IMB → must exclude endometrial pathology |
| 54F, PMB, breast cancer on tamoxifen | Endometrial aspiration (or TVS → then biopsy) | Tamoxifen is oestrogenic on endometrium → high risk for endometrial cancer/hyperplasia |
| 44F, heavy PV bleeding, 4cm cervical mass with contact bleeding, smoker | Cervical biopsy | Visible cervical mass → biopsy for tissue diagnosis, NOT smear |
| 30F, secondary amenorrhoea post-chemo, hot flushes | Serum FSH, LH and oestradiol | Premature ovarian insufficiency from chemo; FSH will be elevated |
Part 5: Cervical Cancer
- 7th most common female cancer in Hong Kong (2020 HK Cancer Registry data) [1]
- Incidence has been declining with screening programs
Human papillomavirus (HPV) — the necessary cause; especially types 16 and 18 [1] Early sex, multiple partners — increased HPV exposure [1] Smoking — impairs local cervical immunity [1] Lower socio-economic class — reduced access to screening [1] OC pills — possibly via cervical ectropion increasing HPV access to transformation zone [1] Immunosuppression — HIV, transplant patients; impaired HPV clearance [1]
Age: Median 55 [1] Bleeding pattern: Postcoital bleeding — the hallmark symptom [1] Associated symptoms: [1]
- Early disease — not much (asymptomatic; picked up on screening)
- Late disease — back pain / leg oedema (pelvic sidewall involvement, lymphatic obstruction)
Contraceptive/Sexual history: Sexually active (or had been), ? OC pills [1] Cervical smear history: ? No regular screening [1] Obstetric history: Parous [1] Family history: Probably not related (cervical cancer is NOT a hereditary cancer) [1]
Growth on cervix: exophytic (cauliflower), endophytic (infiltrative, barrel shape), ulceration [1]
For diagnosis: Take a biopsy [1] For management planning: [1]
- Blood tests: CBP, RFT, LFT
- Tumour markers (SCC antigen for squamous cell carcinoma)
- Imaging: CT / MRI / PET-CT to assess renal tract, extent of spread, lymph node involvement
Why RFT? Cervical cancer commonly causes ureteric obstruction → hydronephrosis → renal impairment. This is staging-relevant (Stage IIIB).
Cervical cancer uses Clinical / Pathology / Imaging staging [1]
This is important — cervical cancer staging is NOT purely surgical (unlike endometrial cancer). Imaging and clinical examination contribute.
| Stage | Extent | 5-Year Survival |
|---|---|---|
| I | Cervix only | 90% |
| II | Upper vagina or parametrium | 75% |
| III | Lower vagina, pelvic sidewall, pelvic/para-aortic LN | 55% |
| IV | Bladder/rectum mucosa or distant metastasis | 15% |
Detailed substaging (high yield for written exams):
| Substage | Key Feature |
|---|---|
| IA | Microscopic only, depth < 5 mm |
| IA1 | Stromal invasion < 3 mm |
| IA2 | Stromal invasion ≥ 3 mm and < 5 mm |
| IB | Clinically visible or measured invasion ≥ 5 mm |
| IB1 | ≥ 5 mm depth, < 2 cm greatest dimension |
| IB2 | ≥ 2 cm and < 4 cm |
| IB3 | ≥ 4 cm |
| IIA | Upper 2/3 vagina, no parametrial involvement |
| IIB | Parametrial involvement |
| IIIA | Lower 1/3 vagina |
| IIIB | Pelvic sidewall or hydronephrosis/non-functioning kidney |
| IIIC | Pelvic (IIIC1) or para-aortic (IIIC2) lymph node involvement |
| IVA | Bladder/rectum mucosa involvement |
| IVB | Distant metastases |
Key 2018 Update
IIIC is new in the 2018 FIGO staging: lymph node metastasis now upstages to Stage III regardless of tumour size/local extent. Notation uses "r" for imaging and "p" for pathology to indicate how lymph node status was determined [1].
Treatment modalities: Surgery, Radiotherapy, Chemotherapy, Targeted therapy / immunotherapy [1]
| Stage | Primary Treatment | Notes |
|---|---|---|
| IA1 (< 3 mm) | Cone biopsy / simple hysterectomy | Very early; fertility-sparing option with cone |
| IA2–IB (early) | Wertheim's hysterectomy (radical hysterectomy + pelvic lymphadenectomy) | Removes uterus, upper vagina, parametria, pelvic LN. Route: abdominal |
| Early disease (if surgery not suitable) | Radiotherapy | Alternative to surgery |
| Stage IIB or above (late) | Chemoradiation (concurrent cisplatin-based chemo + radiotherapy) | Standard of care for locally advanced disease |
| Recurrence | Targeted therapy — Bevacizumab (anti-VEGF) in combination with chemo | Also: immunotherapy (pembrolizumab) for PD-L1+ tumours |
Advantages of surgery over radiotherapy: preserves ovarian function, avoids long-term morbidities of radiotherapy [1]
Why preserve ovaries? In pre-menopausal women, ovaries can be preserved during radical hysterectomy because cervical cancer rarely metastasizes to ovaries. This avoids surgical menopause.
Long-term RT morbidities include: vaginal stenosis, radiation cystitis, radiation proctitis, lymphoedema, premature ovarian failure (if ovaries irradiated), secondary malignancies.
Stage, lymph node metastasis, histology [1]
- Stage is the most important prognostic factor
- Lymph node positivity dramatically worsens prognosis
- Histology: squamous cell carcinoma (most common, ~70–80%) vs. adenocarcinoma (worse prognosis stage-for-stage)
Part 6: Endometrial Cancer (Cancer Corpus Uteri)
- 4th most common female cancer in Hong Kong (2020 HK Cancer Registry) — and rising [1]
- Predominantly a disease of post-menopausal women
- Most common gynaecological cancer in developed countries
The unifying mechanism is unopposed oestrogen exposure on the endometrium:
Risk factor table from GC 112: [1]
| Category | Risk Factors |
|---|---|
| Age | Predominantly post-menopausal |
| Excessive endogenous oestrogens | Early menarche, late menopause, nulliparity, obesity, PCOS, oestrogen-secreting tumours (ovarian granulosa cell tumours), endometrial hyperplasia |
| Exogenous oestrogen | Unopposed oestrogen therapy, tamoxifen therapy |
| Miscellaneous | Family history of breast/ovarian/colorectal cancer, Lynch syndrome (lifetime risk 15–60%), diabetes mellitus, hypertension |
Why each matters — first principles:
- Obesity: Adipose tissue contains aromatase → converts androgens to oestrone → chronic oestrogen exposure. Also: higher BMI → lower SHBG → more free oestrogen.
- Nulliparity/late menopause/early menarche: More lifetime ovulatory cycles → more cumulative oestrogen exposure without the protective effect of progesterone in pregnancy.
- PCOS: Chronic anovulation → no progesterone to oppose oestrogen.
- Tamoxifen: Anti-oestrogenic on breast tissue but pro-oestrogenic on endometrium → endometrial hyperplasia/cancer. This is a classic exam question!
- Lynch syndrome (HNPCC): Germline mutation in DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2). Lifetime endometrial cancer risk 15–60%. Also associated with colorectal cancer.
- Unopposed oestrogen HRT: Without progestogen, oestrogen stimulates endometrial proliferation.
CFB (OG04) also lists these risk factors: Obesity, PCOS, Lynch syndrome, FHx of gynae/GI malignancy, unopposed oestrogen therapy, tamoxifen, persistent/long-standing AUB, no response to medical treatment [8]
2020 Minicase — Classic Endometrial Cancer Vignette
The 2020 minicase gives a 55F with: early menarche (10 years), nulliparous, BMI 36, diabetes, taking unopposed oestrogen, FHx endometrial + breast cancer. The answer is endometrial cancer — this is the "sinister cause" they want you to identify. Investigation: endometrial aspiration (Pipelle) and/or hysteroscopy with biopsy [5].
Abnormal bleeding presentations: [1]
- Change in menstrual pattern
- Prolonged bleeding
- Intermenstrual bleeding
- Irregular bleeding
- Post-menopausal bleeding
Key clinical pearl: Unlike cervical cancer (which is asymptomatic early), endometrial cancer presents early with bleeding — this is why prognosis is generally better.
"Corpus cancer — symptomatic at early stage (abnormal bleeding)" [1]
Age over 40 — careful!! Need endometrial sampling (endometrial aspirate with samplers e.g. Pipelle) [1]
Post-menopausal bleeding — Transvaginal USS (endometrial thickness ≥ 5 mm) [1]
Gold standard — hysteroscopy and biopsy [1]
Investigation algorithm:
- PMB → TVS first → if endometrial thickness ≥ 5 mm → endometrial sampling (Pipelle or hysteroscopy + biopsy)
- Pre-menopausal > 40 with abnormal bleeding → direct endometrial sampling (Pipelle)
- Hysteroscopy = gold standard → allows direct visualization + targeted biopsy
Spread pattern (from GC 112 slide 41, diagram) [1]:
- Direct extension: Through myometrium → serosa → adnexae
- Downward: To cervix, vagina
- Lymphatic: To pelvic → para-aortic lymph nodes
- Transperitoneal: Across peritoneal cavity (peritoneal deposits)
- Haematogenous: Lungs (late)
Endometrial cancer is SURGICALLY staged [1] — this contrasts with cervical cancer (clinical/imaging staging).
| Stage | Extent | 5-Year Survival |
|---|---|---|
| I | Uterus only | 90% |
| II | Cervix (cervical stromal invasion) | 75% |
| III | Outside uterus (serosa, adnexae, vagina, LN) | 45% |
| IV | Bladder/rectum or distant metastasis | 10% |
Detailed substaging:
| Substage | Feature |
|---|---|
| IA | No or < half myometrial invasion |
| IB | ≥ half myometrial invasion |
| II | Cervical stromal invasion |
| IIIA | Invades serosa/adnexae |
| IIIB | Vaginal/parametrial involvement |
| IIIC1 | Positive pelvic LN |
| IIIC2 | Positive para-aortic LN ± pelvic LN |
| IVA | Bladder/bowel mucosa invasion |
| IVB | Distant metastases (incl. intra-abdominal, inguinal LN) |
Why myometrial invasion depth matters: The deeper the invasion, the higher the risk of lymph node metastasis. Stage IA (< 50% myometrial invasion) has excellent prognosis; Stage IB (≥ 50%) has significantly higher LN metastasis risk.
Primary surgery: TH BSO ± lymphadenectomy (abdominal / laparoscopic) [1]
- TH = Total Hysterectomy, BSO = Bilateral Salpingo-Oophorectomy
Early disease (confined to uterus) — can do laparoscopic hysterectomy [1]
Adjuvant treatment: [1]
- If LN positive → post-op chemo ± RT
- If high-risk group, even if LN negative → can consider brachytherapy ± chemotherapy
- If LN not done → give external RT if high risk
What defines "high risk"? Grade 3 histology, deep myometrial invasion, lymphovascular space invasion (LVSI), serous/clear cell histology, older age.
Why BSO? The ovaries are removed because: (1) they are a potential site of metastasis, (2) they produce oestrogen which fuels the cancer, (3) ovarian cancer must be excluded (Lynch syndrome patients at risk of both).
| Feature | Cervical Cancer | Endometrial Cancer |
|---|---|---|
| Screening | Yes (Pap smear/HPV) | No established screening program |
| Early symptoms | Asymptomatic at early stage — need screening | Symptomatic at early stage (abnormal bleeding) |
| Key symptom | Postcoital bleeding | Post-menopausal bleeding / irregular bleeding |
| Cause | HPV infection | Unopposed oestrogen |
| Staging | Clinical/Pathological/Imaging | Surgical |
| Primary treatment (early) | Radical hysterectomy (Wertheim's) or RT | TH BSO ± lymphadenectomy |
| Primary treatment (late) | Chemoradiation | Chemotherapy ± RT |
| Hereditary? | No (infectious aetiology) | Yes (Lynch syndrome) |
| Prevention | HPV vaccination, cervical screening | Weight management, progestogen in HRT |
| Prognosis (if treated early) | Good | Good |
Summary from GC 112: [1]
- "Cervical cancer — asymptomatic at early stage — need screening"
- "Corpus cancer — symptomatic at early stage (abnormal bleeding)"
- "If treated early, both have good prognosis"
While the lecture focuses on cervical and endometrial cancer, ovarian cancer is listed as one of the "common gynaecological cancers" on slide 17 [1]. Key points:
- 6th most common female cancer in HK (2020) [1]
- Usually presents late (no early symptoms, no screening test)
- Symptoms: abdominal distension, bloating, early satiety, pelvic/abdominal pain
- Tumour marker: CA-125 (non-specific)
- Staging: Surgical (FIGO)
- Treatment: Debulking surgery + platinum-based chemotherapy
- Hereditary risk: BRCA1/BRCA2 mutations → high-grade serous carcinoma [9]
This integrates with the 2021 SAQ [10] and pathology AOS [9]:
| Application | Genetic Test | Cancer |
|---|---|---|
| Genetic susceptibility / hereditary cancer | BRCA1/BRCA2 germline mutation testing | Ovarian (high-grade serous), breast |
| Genetic susceptibility / hereditary cancer | MMR gene testing (MLH1, MSH2, MSH6, PMS2) / microsatellite instability | Endometrial cancer (Lynch syndrome) |
| Diagnosis | Somatic FOXL2 mutation | Adult granulosa cell tumour of ovary |
| Treatment selection | BRCA testing (for PARP inhibitor eligibility) | Ovarian cancer |
| Immunotherapy eligibility | PD-L1 testing, MSI/dMMR status | Cervical and endometrial cancer |
Genetic Counselling Required
BRCA1/BRCA2 germline mutation testing requires genetic counselling and patient consent because it reveals information about inherited cancer predisposition affecting the patient and family members. Somatic mutation tests (FOXL2, DICER1) do NOT require genetic counselling because they only test tumour tissue, not germline [9].
From GC 112 slides [1]:
| Rank | Cancer |
|---|---|
| 1 | Breast |
| 2 | Colorectal |
| 3 | Lung |
| 4 | Corpus uteri (endometrial) |
| 5 | Thyroid |
| 6 | Ovary & peritoneum |
| 7 | Cervix |
| 8 | Non-Hodgkin lymphoma |
| 9 | Stomach |
| 10 | Non-melanoma skin |
Exam relevance: You may be asked to rank gynae cancers. Remember: Corpus > Ovary > Cervix in incidence in HK.
Likely Exam Questions
Q1: A 55-year-old post-menopausal woman presents with vaginal bleeding for 2 months. She is obese (BMI 34), nulliparous, and has a family history of colorectal cancer.
- (a) What is the most important diagnosis to exclude? Endometrial cancer
- (b) List 3 risk factors in this patient. Obesity, nulliparity, post-menopausal status, family history of colorectal cancer (? Lynch syndrome)
- (c) Name 2 investigations. Transvaginal ultrasound (endometrial thickness), endometrial aspiration (Pipelle) / hysteroscopy and biopsy
Q2: A 44-year-old woman has irregular intermenstrual bleeding. Last smear 1 year ago was normal. What is the most appropriate first-line investigation?
Q3: Name the FIGO staging for cervical cancer confined to the cervix with 4 mm stromal invasion.
- Stage IA2 (stromal invasion ≥ 3 mm and < 5 mm) [1]
Q4: List the treatment for Stage IB1 cervical cancer.
- Radical hysterectomy (Wertheim's) with pelvic lymphadenectomy OR radiotherapy if surgery not suitable [1]
Q5: What is the advantage of surgery over radiotherapy in early cervical cancer?
- Preserves ovarian function and avoids long-term morbidities of radiotherapy [1]
Q6: A 44-year-old smoker has a 4cm cervical mass with contact bleeding. What is the most appropriate investigation?
| Trap | Correct Answer |
|---|---|
| Cervical smear for visible cervical mass | Wrong — need biopsy |
| Tamoxifen is anti-oestrogenic on endometrium | Wrong — tamoxifen is PRO-oestrogenic on endometrium |
| Endometrial cancer is clinically staged | Wrong — it is SURGICALLY staged |
| Cervical cancer is surgically staged | Wrong — it uses clinical/pathological/imaging staging |
| Lynch syndrome only causes colorectal cancer | Wrong — also endometrial (15–60% lifetime risk), ovarian |
| Endometrial thickness < 5 mm excludes cancer in PMB | Largely reassuring but does not 100% exclude (can still occur rarely in type 2 cancers) |
High Yield Summary
Abnormal vaginal bleeding has many benign causes (DUB, fibroids, polyps, cervical ectropion, atrophic vaginitis) but the clinical priority is to exclude malignancy — especially in women > 40 or post-menopausal.
Key investigations: Cervical biopsy (for visible lesions, NOT smear), Pipelle endometrial sampling (age > 40), TVS (PMB — threshold ≥ 5 mm), hysteroscopy + biopsy (gold standard for endometrial pathology).
Cervical cancer: HPV-driven, presents with postcoital bleeding, staged clinically/imaging. Early → surgery (Wertheim's); Late → chemoradiation. Asymptomatic early → need screening. Prognostic factors: stage, LN, histology.
Endometrial cancer: Oestrogen-driven, presents with PMB/abnormal bleeding (symptomatic early). Staged surgically. Treatment: TH BSO ± lymphadenectomy ± adjuvant chemo/RT. Risk factors: obesity, nulliparity, PCOS, tamoxifen, Lynch syndrome.
Both have good prognosis if treated early.
Corpus > Ovary > Cervix in incidence in Hong Kong (2020).
Active Recall - Abnormal Vaginal Bleeding & Gynaecological Cancer
[1] Lecture slides: GC 112. Abnormal vaginal bleeding Gynaecological cancer.pdf [2] Lecture slides: Block C - Abnormal vaginal bleeding_ gynaecological cancer.pdf [3] Past papers: 2018 Fourth Summative SAQ.pdf (Question 11) [4] Past papers: 2019 Fourth Summative SAQ.pdf (Question 1) [5] Past papers: 2020 Fourth Summative Minicases.pdf (Case 3) [6] Past papers: 2021 Fourth Summative Assessment MCQ.pdf (Questions 14–18) [7] Past papers: 2024 Fourth Summative MCQ.pdf (Question 13) [8] Lecture slides: CFB (OG04) Menstrual Disorders.pdf (p22) [9] AOS material: AOS - Pathology.pdf (Molecular genetic testing in Gynaecological cancers) [10] Past papers: 2021 Fourth Summative SAQ.pdf (Question 2)
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