Most women don’t grow up thinking about gynecologic cancer. The symptoms aren’t always dramatic, and by the time something feels obviously wrong, it can already be advanced.
Dr. Keely Ulmer is a gynecologic oncologist at the Cancer Care Institute at Monument Health in Rapid City, and she grew up on the Pine Ridge Reservation. She went to Black Hills State on a basketball scholarship, thought she’d be a pharmacist, ended up loading cattle at a sale barn, and a phone call from a captain at the Indian Health Service sent her to medical school instead. Fellowship trained at the University of Iowa, former chief resident, and now she’s back home taking care of the exact communities she came from.
She describes the path as a series of open doors. “When I saw open doors, I took them,” she said. “If this door swings open for me, it’s probably the right choice.”
The Four Cancers You Should Know About
Gynecologic cancers cover uterine (also called endometrial), ovarian, cervical, and vulvar. Each shows up differently.
Ovarian cancer tends to hit women in their sixties and seventies, and there’s no reliable screening tool for it. No blood test, no ultrasound that catches it early enough. Most patients don’t have obvious symptoms until it’s advanced. What to watch for: persistent bloating, unexplained abdominal weight gain, a belly that seems to be growing without a clear reason, or ongoing pelvic pain. Not occasional discomfort. Something that won’t let up.
Endometrial cancer is the most common gynecologic cancer right now, and it has one very clear signal. Postmenopausal bleeding. If you’ve gone through menopause and you’re bleeding again, or you’re approaching menopause and your periods have turned heavy and irregular, that needs a workup. “Our saying for that is, it’s endometrial cancer until proven otherwise,” Dr. Ulmer said. Get a transvaginal ultrasound and a biopsy. Don’t wait.
Vulvar cancer often starts with unrelenting itching or pain, or a lesion that wasn’t there before and is starting to hurt. It affects older women more often, and certain autoimmune conditions raise the risk. When it’s caught early, surgery is frequently all you need.
Cervical cancer is the one Dr. Ulmer talks about with the most urgency, and it’s the only one on this list that’s both screenable and largely preventable. Pap smears work. Self-swab HPV testing works. Warning signs include bleeding after sex, spotting between periods, or irregular bleeding that’s new. The most common patient story she hears: “I haven’t had a Pap smear since my last pregnancy.” Life gets busy, years pass, and screening falls off the list.
The One Cancer We Can Actually Prevent
Cervical cancer, vulvar cancer, vaginal cancer, and head and neck cancers, which are growing fast among young men, are largely driven by HPV. There’s a vaccine for it, and it works best between ages nine and twelve, when the immune system builds the strongest, longest-lasting response.
Dr. Ulmer hears the hesitancy. Parents worry the HPV vaccine signals something about their kid’s behavior. Her response is to reframe the whole thing. “HPV is ubiquitous. It’s like a cold sore,” she said. “How many people do you know that get a cold sore? Almost everybody. So almost everybody’s also going to have HPV.” The vaccine doesn’t change that exposure risk. It changes what your body does when it encounters the virus.
Australia committed to widespread HPV vaccination and they’re on track to effectively eliminate cervical cancer in their population within a few years. We don’t have many examples of a vaccine wiping out a cancer entirely. This is one of them.
When Access Is the Problem
American Indian women have twice the incidence of cervical cancer and four times the mortality rate compared to the general population. They’re diagnosed younger and at later stages. The funding gap is part of why. “If you take a Medicare patient and put their healthcare spending as one dollar, IHS gets about zero point four,” Dr. Ulmer said. That shortfall creates staffing problems, high turnover, limited specialty care, and a referral system that breaks down under the pressure of it all.
Part of her work here involves the Walking Forward program, a more than twenty-year-old NIH-funded initiative started by radiation oncologist Dr. Peter Wright. It focuses on screenable cancers and pairs screening with patient navigation. “It’s not just about the screen,” Dr. Ulmer said. “It’s about the follow-up to the screen and helping patients navigate that process.” Dr. Ulmer is expanding it into cervical cancer care and working to establish a subspecialty clinic closer to reservation communities.
The goal, as she put it, is to “meet patients where they’re at instead of the other way around.”
If You’re Sitting With a Scary Diagnosis
Dr. Ulmer’s message to any woman waiting on results or already sitting with a diagnosis: treatment has come a long way. Even advanced-stage ovarian cancer responds to chemotherapy in eighty to ninety percent of patients. Endometrial and vulvar cancers, caught early, are often handled with surgery alone. Targeted therapies based on a tumor’s specific genetic profile have opened up options that didn’t exist a decade ago.
“It’s a new chapter,” she said. “It’s not the end of the book.”
Don’t put off the Pap smear. Don’t dismiss the bleeding. Don’t decide the bloating is probably nothing. Women are good at pushing through discomfort, and that instinct can work against you here. These cancers are most treatable when they’re found early, and that starts with making the call.
