Endometrial cancer is the most commonly occurring cancer of the female reproductive system.
It is the fourth most common cancer that affects women, after breast cancer, lung cancer and cancer of the colon and rectum. Unfortunately many of the early symptoms can often be missed, causing a late diagnosis and a delay in treatment. The treatment of all cancers has a much greater chance of success if it is started as early as possible.
The following information provides an overview of endometrial (womb) cancer, symptoms to look out for and possible treatments. You will also find links to research funded by Wellbeing of Women, expert interviews, other women’s stories and common myths.
In 2007 in the UK, 7,536 new cases of endometrial cancer were diagnosed. It is more common in women who have been through the menopause, and most cases (93%) were diagnosed in women aged over 50.
Cancer begins with a change in the structure of the DNA that's present in all cells. DNA provides the cells with instructions, including when to grow and reproduce. A change in the DNA’s structure is known as a mutation and it can alter the instructions that control cell growth. This means that the cells continue growing instead of stopping when they should. If the cells reproduce uncontrollably they produce a lump of tissue called a tumour.
The uterus, also known as the womb, is where the baby is carried during pregnancy. Cancer of the uterus usually begins in the cells lining the womb. This lining is called the endometrium. The cells that make up the endometrium are regularly discarded during a woman’s monthly period, then replaced by new cells. Uterine cancers are therefore often referred to as endometrial cancer.
Type 1 endometrial cancer is a slow-growing cancer, thought to be linked to the female hormone oestrogen. This is the most common type, accounting for about 80% of cases.
Type 2 endometrial cancer is a more aggressive, faster-growing form of cancer that does not appear to have any connection to oestrogen and accounts for about 10% of cases.
As well as types 1 and 2 endometrial cancer, there are several rarer types of cancers of the uterus. For more information about these see Cancer Research UK www.cancerresearchuk.org
As with most types of cancer, the outlook depends largely on how far the cancer has advanced by the time it is diagnosed and the age at diagnosis. Eighty-five per cent of women diagnosed with early-stage type 1 endometrial cancer will be alive five years after diagnosis (the five-year survival rate).
Unusual vaginal bleeding
The main symptom of endometrial cancer is unusual bleeding from the vagina. Bleeding may be light with a water discharge and may get heavier over time. Most women who are diagnosed with endometrial cancer have been through the menopause. Any vaginal bleeding after menopause is considered to be unusual.
Unusual vaginal bleeding may also present as:
· periods that are heavier than usual
· bleeding in between normal periods
In advanced endometrial cancer additional symptoms may include:
· pain in the lower abdomen, back, legs or pelvis
· unexplained weight loss
If you have post-menopausal vaginal bleeding, or notice a change in the normal pattern of your period, visit your GP.
Only one in 10 cases of unusual vaginal bleeding after the menopause are caused by endometrial cancer, so it's unlikely that your symptoms will be caused by this condition.
However it is important to get the cause of your symptoms investigated because it may be the result of a number of other potentially serious health conditions, such as polyps or fibroids (non-cancerous growths that can develop inside the uterus). Other forms of gynaecological cancer can also cause unusual vaginal bleeding, particularly cervical cancer.
CAUSES AND RISK FACTORS
Risk factors for endometrial cancer
It is not known exactly what causes endometrial cancer, but a number of important risk factors have been identified.
The risk increases with age - most cases of endometrial cancer develop in women who are over the age of 50.
Developing endometrial cancer is linked to the exposure of the body to oestrogen. Oestrogen is the hormone that stimulates the release of eggs from your ovaries and causes the cells of the womb lining (endometrium) to divide.
Progesterone prepares the lining of your uterus to receive the egg from the ovaries.
Oestrogen and progesterone are usually balanced with each other. If the balance is affected, the level of oestrogen in the body can increase - called unopposed oestrogen.
After the menopause, the body stops producing progesterone. However, there are still small amounts of oestrogen being produced. This unopposed oestrogen causes the cells of the endometrium to divide, and this can increase the risk of endometrial cancer.
Hormone replacement therapy (HRT)
Because of the link between increased levels of unopposed oestrogen and endometrial cancer, oestrogen-only hormone replacement therapy (HRT) should only be given to women who have had their womb surgically removed (hysterectomy).
In all other cases, both oestrogen and progesterone (combination HRT) must be used in HRT in order to reduce the risk of endometrial cancer.
Being overweight or obese is a major risk factor. Obesity increases the level of oestrogen in your body while also reducing the protective effects of progesterone.
In the UK, people with a BMI of 25 to 30 are overweight, and those with an index above 30 are obese. One way to assess whether your weight is healthy is to calculate your body mass index (BMI). This is your weight in kilograms divided by your height in metres squared.
Women who are overweight are three times more likely to develop endometrial cancer compared with women who are a healthy weight. Women who are very obese (with a BMI of more than 40) are six times more likely to develop endometrial cancer compared with women who are a healthy weight.
Women who have diabetes are twice as likely to develop endometrial cancer as women without the condition. Diabetes causes an increase in the amount of insulin in your body, which in turn can raise your oestrogen level.
Women who have not had children are at a higher risk of endometrial cancer. Hormonal changes during pregnancy may have a protective effect on the womb (increased progesterone and decreased oestrogen).
Tamoxifen is a hormone treatment for breast cancer and can confer an increased risk of developing endometrial cancer. This risk is outweighed by the benefits that tamoxifen provides in preventing breast cancer.
Polycystic ovarian syndrome (PCOS)
Women with PCOS are at a higher risk. Women with PCOS have multiple cysts in the ovary, and this can cause symptoms such as irregular or light periods, or no periods at all, problems getting pregnant, weight gain, acne and excessive hair growth (hirsutism).
This is when the lining of the womb becomes thicker. Women with the condition may be at increased risk of developing endometrial cancer.
If you have unusual vaginal bleeding, your GP is likely to carry out a physical examination of your vagina.
Your GP will ask about your symptoms and your general health.
If no obvious cause can be found you may be referred for a transvaginal ultrasound (TVU).
TVU is a type of ultrasound scan that is placed directly into the vagina to obtain a detailed picture of the inside of the uterus. The TVU checks whether there are any changes to the thickness of the lining of your uterus.
If the results of the TVU do detect changes in the thickness of the lining of the uterus, you will usually have a biopsy. A small sample of cells is taken from the lining of the womb (the endometrium). The sample is then checked at a laboratory for the presence of cancerous cells.
The biopsy can be carried out in a number of ways.
Aspiration biopsy: a small flexible tube is inserted into your vagina and up into your womb. This then sucks up a small sample of cells.
Hysteroscopy: A thin type of telescope called a hysteroscope is inserted through your vagina and into your womb. The doctor is then able to look at the lining of the womb and take a sample from it.
For most women, the tests can be done at the outpatient clinic, but some may need to be admitted for a general anaesthetic.
If you are diagnosed with endometrial cancer, you may have further tests that can help to determine the stage of the cancer. This will allow the doctors to work out how large the cancer is, whether or not it has spread and the best treatment options for you.
These further tests may include a chest X-ray, blood tests and various types of scans (CT, MRI).
When deciding what treatment is best for you, your doctors will consider the stage of your cancer, your general health and whether fertility is a matter of concern.
The main treatments for endometrial cancer are:
o Hysterectomy- surgery to remove the reproductive organs including the womb, ovaries and cervix.
o Lymphadenectomy - may be done in addition to a hysterectomy. It is the removal of all or part of the lymph nodes which are part of the infection fighting and fluid drainage system in the body. By removing the nodes and testing them, doctors can determine if the cancer has begun to spread to different areas of the body.
· radiotherapy – this sometimes follows surgery to try to kill any possible remaining cancer cells
You may have one of these treatments, or a combination. This will depend mainly on the stage of your cancer.
Younger women who haven't already reached the menopause may not want to have their womb removed if they wish to have children. In this case, under very specific circumstances, it may be possible to treat the cancer using hormone therapy.
Healthy weight, diet and exercise
Maintaining a healthy weight is the most effective way to prevent endometrial cancer. The best way to avoid becoming overweight or obese is to eat healthily and exercise regularly.
If you haven't exercised before, or haven't done it for some time, see your GP for a health check-up before you start a new exercise programme.
Some research has suggested that a diet high in soya may possibly help to prevent endometrial cancer. Soya contains isoflavens, which may help to protect the lining of the womb. Foods that are high in soya include soya beans and tofu. However, further research into this area has been recommended.
Research has shown that long-term use of combination oral contraception (the contraceptive pill that contains both oestrogen and a synthetic version of progesterone) can lower the risk of endometrial cancer.
Other types of contraception such as contraceptive implants and the intrauterine system (IUS) work by releasing progestogen (a synthetic version of progesterone). These may also reduce the risk of endometrial cancer.
Carleen was only 36 when she was diagnosed with endometrial cancer and had just got married. However the physical symptoms had started 18 months before.
Carleen had always had irregular periods – sometimes so irregular that they were two or three years apart. Then Carleen began to have irregular bleeding, particularly after sex, and despite reassurance from her GP she knew that this wasn’t right for her body and did in fact have a pattern unlike her previous irregular periods. She says "GPs are good at what they do, but they don’t know your body like you do".
She moved to a different area of the UK. Her new GP was concerned by the symptoms and referred Carleen to the local hospital for further tests.
The appointment came through a couple of weeks later. Whilst the procedure was carried out a swab from inside the neck of the womb was taken, as he did so a large amount of blood came out and the Dr had concerns. Even though the follow up appointment had been set for three months later, Carleen received a phone call on the following Monday calling her back in. The test had revealed cancerous cells inside her womb. Fortunately this was a very early stage of the disease (Stage 1b) and was still in the lining of the womb rather than the surrounding muscle.
Carleen was told that she would have to have a hysterectomy and this was scheduled in quite quickly. The operation she underwent also removed her ovaries. Carleen did question why they would be removed as she had just got married and had yet to start a family. In retrospect she wishes that she had challenged that one decision – if she had kept the ovaries, she might have been able to try for IVF and surrogacy, but in the shock of the moment of finding out she had cancer she did not question the advice.
Carleen is now 7 years on and has just qualified as a Midwife. Her advice to other women is "Listen to your body, don’t be put off if you really think something is wrong, ask as many questions as you need to and don’t be afraid to get a second opinion".
If you would like to tell us your story so we can help and inform other women; there is more information available HERE
This interview was recorded in March, 2010.
Hello, we are joined today by Sean Kehoe; gynaecological oncologist, who is here to talk about endometrial cancer, a disease that affects more than 6, 500 women in the UK each year.
Could you start by giving us an overview of endometrial cancer?
Well endometrial cancer is essentially a cancer that affects the womb, mainly the lining of the womb. It is a disease infact which is increasing year on year. It used to be that ovarian cancer was the main gynaecological cancer that we dealt with, but with time now we can see that endometrial cancer is actually probably going to take over, over the next few years; dealing with probably 6,500 to 7000 cases in the UK is what we anticipate. This is occurring for a variety of reasons, probably because women are living longer, not dying from other diseases and in particular probably women surviving longer from breast cancer which has an association with endometrial cancer.
Could you tell us what the signs and symptoms of the cancer are?
Yes, most women who develop endometrial cancer are after the menopause, therefore one of the big known symptoms is that of post-menopausal bleeding. A woman who develops bleeding after the menopause should seek advice from a doctor for a rapid referral to have that bleeding investigated. Not all women are post-menopausal though, and there are a group of women in the younger age group who can develop endometrial cancer. For women over the age of 40 it would mainly be that they were developing abnormal bleeding, not necessarily related to the onset of the menopause, and those women also require investigation.
Is it more prevalent in older women?
As I stated, it is indeed. It is a disease primarily of women after the menopause; 75-80% of women developing womb cancer will be in that age group.
Do we know what causes endometrial cancer?
We know a lot about the associated risks of developing endometrial cancer. The main association with endometrial cancer is that of the hormone oestrogen, whereby it seems to drive the lining of the womb to become very thickened and also increases the risk of developing malignancy.
I understand the risk is getting much higher for women who have not had children. Could you explain why that is?
It is interesting, it is a thing which we see both not just for endometrial cancer but also for ovarian cancer. Whilst the hypothesis regarding this is known for ovarian cancer, nobody has actually undertaken any research to explain why that association does exist, so we don’t have an explanation at the moment.
Could you explain the link between the hormone oestrogen and endometrial cancer?
Yes, the oestrogen hormone itself is a driving force, if you like, on the growth of the lining of the womb. This means that by exposing the lining of the womb to oestrogen, you will get increase and rapid growth of the cells there. When you have the rapid growth of cells the chances of cancer occurring is increased; and that is just a simple way of putting it. It is probably more complex that that, but that association or that link is one of the strongest ones regarding endometrial cancer development.
Do weight and lifestyle play a role?
They will to a certain extent. The weight factor is probably the major one here, women who are over weight carry in their bodies more hormone of the oestrogen type, compared to those who are slim. That seems to be part of the linkage between increased weight and the risk of endometrial cancer, so overweight is not to be recommended.
Does having PCOS increase the risk of this type of cancer?
It does indeed. Women who have PCOS, there are a certain group of them that will go on to develop endometrial cancer. Again it is recognised as an individual entity not just weight related, but obviously the weight factor is involved there as well.
Can I ask if endometriosis has any link with endometrial cancer?
Not that we know of. There are some associated links with endometriosis and some types of ovarian cancer, but not necessarily with endometrial cancer.
Is there a screening programme for endometrial cancer?
There isn’t at the moment any screening programme and I’m not aware of any planned screening programme. We tend to screen all women with post-menopausal bleeding, but that is not true screening that is just investigating them I suppose, rather than screening them and in those women who do have post-menopausal bleeding about 10% or thereabouts will have an endometrial cancer. Regarding population screening for asymptomatic women, one does not exist.
What kind of research is taking place to find out more about this disease?
There has not been an awful lot of focus on endometrial cancer in the terms of laboratory based research. Part of the reason for this is the vast majority of endometrial cancer patients will fortunately have disease confined to the womb and the success of surgery or surgery radiotherapy is quite high and therefore one often finds the focus of monies into research often goes into more sinister or life threatening conditions than endometrial cancer. What we have done is we have undertaken, and I appreciate there are other clinical trials ongoing, looking at the management of patients with endometrial cancer, particularly relating to the removal of the lymph glands in those patients. The largest type of study ever undertaken in the world was actually done in the UK. That revealed in that study that there was no benefit in a select group of patients in removing the pelvic lymph glands, I thought it was quite an important study in its own right.
Can I ask about contraceptives, do they protect or increase the risk of endometrial cancer?
Well we know that the combined pill infact reduces the risk of endometrial cancer, anywhere up to 30% even when it is used for a short period of time, it has quite a major protective affect against endometrial cancer and interestingly against ovarian cancer as well. Other hormones that protect will be the mirena coil for example, that has progesterone which acts against oestrogen, but it is known as well that it may well be a very good protective treatment if you like, against the development of endometrial cancer.
Can I ask if endometrial cancer is a hereditary disease?
In the vast majority of women who develop this, it is not a hereditary condition. There is one very rare condition called HNPCC or Lynch type II syndrome where there is hereditary associations and in that condition the risk is mainly bowel cancer, there is a recognised increased risk of endometrial cancer in women in that family.
Thank you very much for joining us today.
To find out about our research follow these links:
Page last updated January 2013