Endometrial cancer

Endometrial cancer is a type of uterine cancer that begins in the layer of cells forming the lining (endometrium) of the uterus. A study on epidemiology of endometrial cancer quoted that it is the most frequently diagnosed gynaecologic malignancy. According to wrcf.org, endometrial cancer is the sixth most commonly occurring cancer in women.

Though Endometrial cancer is common, it can usually be cured because in most cases its gets detected in an early stage. Symptoms like abnormal vaginal bleeding and pelvic pain give a clear hint to look for abnormalities. A visit to the doctor can lead to diagnostic tests that give precise results.

Explore more about endometrial cancer symptoms, causes, prevention, screening, staging, treatment, statistics, survival rates and researches.

What is endometrial cancer?

Endometrial cancer is the abnormal growth of malignant cells in the inner lining of the uterus. Because the endometrium is a part of the uterus, endometrial cancers are also referred as uterine cancer. Around 92 per cent of uterine cancers are found in the endometrium.

Recent statistics of endometrial cancer cases reveal a sharp surge in the number of occurrences mostly because of the increased incidence of obesity, which is a major risk factor for this disease.

Types of endometrial cancer

Endometrial cancers are classified into two types –

Estrogen dependent (Type I)
Estrogen independent (Type II)

About 85% of endometrial cancers belong to type I. As the name suggests, these cancer cases are a result of an imbalance in the levels of estrogen. It is more common in obese women and is typically preceded by complex atypical hyperplasia. Also, this type is usually confined to the uterus with minimal invasion.

The estrogen-independent endometrial cancer is most likely to occur in thin, older patients with an atrophic endometrium. It is rare but patients commonly have early metastasis. Approximately half of all endometrial cancer relapses are reported in patients with type II tumours.

The endometrium

The endometrium is the inner epithelial layer lining the uterus in which the implantation takes place. It is a hollow, muscular organ that sits in a woman’s pelvis. The endometrium has two layers – basal layer (inner layer) and functional layer (outer layer).

This outer functional layer experiences morphologic and functional changes throughout the monthly cycle. The endometrium is also closely associated with the cyclic release of sexual hormones.

Function of endometrium layer

After puberty, every month the ovaries release an egg that travels into the uterus and has the potential to be fertilized. During the weeks prior to menses, the endometrium thickens to provide a place for a fertilized oocyte to grow and develop.

The functional layer of the endometrium undergoes proliferation and differentiation to prepare for this process. If the egg is not fertilized then the functional layer of the endometrial lining is shed and the unneeded blood supply is passed through the birth canal.

In absence of this periodic cycle, that means, before puberty or after menopause, the endometrium maintains a constant morphology and thickness.

Endometrial cancer is often diagnosed in the early stages because of early symptoms. The following enlists the common endometrial cancer symptoms; however, these symptoms might vary or there may not be any prominent initial symptom at all.

Pelvic pain
Constipation
Abnormal vaginal bleeding.
Abnormal Vaginal discharge.
Bleeding between periods.
Pain or cramps in the lower abdomen.
Problems during pregnancy
Premature contractions
Spontaneous abortion.

The exact cause of endometrial cancer for every case is not yet certain. That means, doctors cannot pinpoint the exact causative factor responsible for endometrial cancer in a particular patient.

Till now all that’s known is – mutations in the DNA of cells in the endometrium causes endometrial cancer. Now, there are several possible factors that can trigger these changes. Some of the common factors are enlisted below –

Hormonal Changes – The ovaries generate two main female hormones — estrogen and progesterone. An increase in the amount of estrogen, but not the level of progesterone, can increase the risk of endometrial cancer.

This imbalance in the hormonal levels can be caused by irregular ovulation process, Polycystic ovary syndrome, obesity and diabetes. Taking hormonal medicines containing estrogen but not progesterone also increases the risk of endometrial cancer.

Prolonged menstruation – Early puberty or late menopause increases the risk of Endometrial Cancer. Frequent menarche that means a cycle of less than 28 days can also increase the risk of this cancer.

In other words, women who endure more menstrual cycles in their lifetime have an increased risk of endometrial cancer. Those with early periods starting before 12 years and going through menopause after 50 years are at high risk.

Infertility – Infertility is a rising concern among modern couples. But for women, it is also a major risk factor affecting the chances of uterine cancer. Also, women who have never been pregnant in their lifetime are at an increased risk.

Irregular menstrual cycles and infertility also may be related to imbalances in estrogen and progesterone levels, and this hormone imbalance may increase the risk for Endometrial Cancer.

Increased Age – Older women are at an increased risk of developing Endometrial Cancer than younger ones. Especially the ones who have undergone menopause, shall be more alert for any symptoms.

Most cases of endometrial cancer are reported in post-menopausal women.

Obesity – Obesity is the culprit for most modern diseases including cancer. Excess body fat alters the body’s balance of hormones which is an established risk factor for endometrial cancer.

Obese people having a BMI more than 30 are three times more likely to develop Endometrial cancer. Fat tissue can further convert other types of hormones like androgens into estrogen.

Tamoxifen – Tamoxifen is a hormone therapy drug used in the treatment of breast cancer. It acts as an anti-estrogen in breast tissue, but increases estrogen level in the uterus. This can result in hormonal imbalance thereby increasing the risk of endometrial cancer.

If the doctor prescribes this medicine, then please discuss the possible side-effects. Though it’s a risk factor for endometrial cancer, the benefits of tamoxifen outweigh the small risk of endometrial cancer.

Inherited colon Cancer syndrome – Hereditary nonpolyposis Colorectal Cancer increases the risk of endometrial cancer. HNPCC occurs because of a gene mutation passed from parents to children.

If a family member has been diagnosed with inherited colon cancer syndrome, then please discuss the risk with a doctor. Ask your doctor about the cancer screening tests that you shall take.

Endometrial hyperplasia – Endometrial hyperplasia occurs when a build-up of cells or glandular structures results in thickening of the endometrium. Hyperplasia is not cancer, but it may increase the risk of developing cancer of the endometrium.

This condition most often occurs in women after menopause and may be caused by an imbalance of excess estrogen. Women with obesity issues, medical conditions or family history are at an increased risk of Endometrial hyperplasia and thus endometrial cancer.

Family History – About 10% of cancer cases are linked to inheritance and about 5% of uterine cancers are linked to hereditary factors. Having a first-degree relative (mother, sister or daughter) having a history of endometrial cancer can increase the risk.

Familial history of other cancer types like colon, ovarian or breast cancer may also put you at a higher risk of developing Endometrial Cancer. Knowing your genetics and family history help in making aware decisions about screenings and preventions.

These conditions increase the probability of getting endometrial cancer and are termed as a ‘risk factors’. Though none of these risk factors are a guaranteed contributor of cancer, but it is better to keep the chances low.

Please consult your doctor and go for regular screenings if you ticked any of these risk factors.

Though most causatives of Uterine Cancer are natural and cannot be controlled yet a few precautionary measures help lower the risk. Having good health in general and leading a healthy lifestyle are definitely sure shot ways to shield the risk.

Here are a few things that all women should adapt despite being in risk or not –

Maintain weight: As already stated, obesity is a big risk factor for endometrial cancer. Eating a healthy diet, exercising regularly and maintaining a healthy weight help reduce Endometrial cancer risk.

Birth control: Birth control pills that combine estrogen and progesterone can lower the risk of endometrial cancer. Using a progestin-secreting intrauterine device (IUD) may also reduce the risk of endometrial cancer. But again, discuss the risks and benefits of using birth control with your doctor.

Awareness: Awareness plays a big role in the prevention of endometrial cancer. Being aware of the family history, the symptoms and possible risk factors helps in making important decisions on cancer screenings and diagnosis.

Diabetes management: Diabetes is an underlying causative of many types of cancers including endometrial cancer. Proper management of diabetes and keeping the blood sugar levels under control may help reduce the risk of uterine cancer.

All cancerous growths are categorized into different stages based on their spread and severity. In medical terminology, cancer is categorized as T, N, M – T stands for tumor, N denotes node and M is for metastases.

The tumor is further staged from 0 to IV wherein the severity goes on increasing in ascending order. Nodes are numbered as 1,2 and 3. Metastases is indicated by 1 or 0, where in 0 means negative and 1 means that cancer has metastasized.

The staging of uterine cancer is elaborated below:

Stage I – T1, N0, M0 – At this stage, cancer cells are found only in the endometrium. The most common symptom at this stage is unusual bleeding. Doctors might suggest surgery or progestin therapy for treatment.

Stage IA – Cancer cells are found only in the endometrium and may have spread less than halfway into the underlying muscles.
Stage IB – Cancer cells are still in the endometrium but they have more than halfway through the underlying muscle.

Stage II (T2, N0, M0) – At this stage, cancer cells are found in both the uterus and cervix but they have not spread outside of the uterus. It is also absent in lymph nodes or distant sites.

Bleeding, spotting and unusual discharge are the most common signs. The doctor might suggest a radical hysterectomy to remove the uterus and the upper part of the vagina. The doctor might also remove the fallopian tubes and ovaries. Along with surgery, radiation therapy or vaginal brachytherapy may also be used.

Stage III (T3, N0, M0)

Cancer has spread beyond the uterus, but not beyond the pelvis. Cancer cells are found in the ovaries, fallopian tubes, vagina and lymph nodes. But it has not affected the bladder or the rectum.

At this stage, the patient may complain of pelvic pain, bloating, pain during sex, changes in bowel and bladder habits and weight loss. Some might also feel the tumor in the belly.

The doctor might suggest total or radical hysterectomy, also known as pelvic washing in which the fallopian tubes and ovaries are removed. This is followed by radiation or chemotherapy.

Stage IIIA: Cancer has spread to the outer layer of the uterus or to the fallopian tubes, ovaries, and ligaments of the uterus.
Stage IIIB: Cancer has spread to the vagina or to the tissues around the uterus.
Stage IIIC: Cancer has spread to lymph nodes in the pelvis and/or around the aorta.

Stage IV (T4, any N, M0) or (any T, any N, M1)

Cancer has spread past the pelvic region and can affect the bladder, rectum and more distant parts of the body. The symptoms can be same as stage III. Some might also complain of pain in the bones or shortness of breath at this stage.

At this stage, doctor might or might not proceed with surgery. Radiation therapy is usually used to treat cancer at this stage. The doctor might also suggest Hormone therapy, targeted therapy, chemotherapy, and immunotherapy.

Stage IVA: The Cancer has spread to the inner lining of the rectum or bladder. It may or may not have spread to nearby lymph nodes but has not spread to distant sites.
Stage IVB: The Cancer has spread to distant lymph nodes, the upper abdomen, the omentum, or to organs away from the uterus. The Cancer can be of any size and it may or may not have spread to lymph nodes.

Stage	Survival Rate
0	90%
IA	88%
IB	75%
II	69%
IIIA	58%
IIIB	50%
IIIC	47%
IVA	17%
IVB	15%

Endometrial cancer is often diagnosed when the patient visits a gynaecologist complaining of bleeding or spotting or any other symptom mentioned above. If the gynaecologist suspect cancer then he or she may suggest the following

Medical history: Thedoctor would enquire about the medical history of the patient. Any history of cancer in the family is also noted. Knowing the medical history helps in assessing the risk factors, planning the treatment and prognosis.

Pelvic examination: The gynaecologist carefully observes the outer portion of the vulva(genitals). Then insert two fingers of one hand into the vagina while pressing the abdomen with other hand. This helps the doctor fell the uterus and ovaries to check for any tumour growth. The doctor might also insert a speculum that opens up the vagina and lets the doctor view the vagina and cervix.

Ultrasound: Transvaginal ultrasound is used to look at the thickness and texture of endometrium. It helps the doctor look into the uterus, ovaries, and fallopian tubes. An ultra sound is done by inserting the transducer into the vaginal opening. The transducer uses sound waves to create a video image of the uterus. The ultrasound helps the doctor look for any abnormalities in the uterine lining.

Hysteroscopy: A lens on a special lighted microscope is called a hysteroscope. The doctor inserts the hysteroscope into the uterus through the cervix. In this procedure the uterus is filled with saline water for a better view. This helps the doctor examine the inside of uterus and endometrium.

Biopsy: An endometrial biopsy is the most common test done to confirm cancer. A thin flexible tube is inserted into the uterus through the cervix to extract a sample of endometrial cell/ tissue from uterine line. These cells are observed under microscope for cancerous cells.

Dilatation and curettage: When enough information couldn’t be obtained by biopsy then dilatation and curettage is used. In this procedure, the cervix is widened (dilated) so that a curette (a spoon-shaped instrument with a sharp edge) can be inserted into the uterus to remove cells, tissues or growths from the endometrium.

The choice of treatment may vary depending on multiple factors like the stage of cancer, general health of the patient, age of patient and preference of the patient. The most commonly opted treatment for endometrial cancer is surgery to remove the uterus, fallopian tubes and ovaries.

Another option is radiation therapy with powerful energy. The doctor might also use chemotherapy, hormone therapy, targeted therapy or immunotherapy depending on several aspects.

Surgery: Depending on the spread of the malignant cells, surgery is conducted to remove the uterus, fallopian tubes and ovaries. This is known as hysterectomy. Hysterectomy causes menopause and infertility.

During the surgery, the doctor also looks around the uterus to check if the cancer has spread.

Radiation Therapy: Radiation therapy uses powerful energy beams, such as X-rays and protons, to kill Cancer cells. It reduces the risk of Cancer recurrence after surgery, and helps to shrink the tumour before surgery (down-staging the tumour) and make it easier to remove.
Radiation therapy includes:
- External Radiation
- Internal radiation (brachytherapy)
Chemotherapy:

Chemotherapy uses chemicals to kill Cancer cells. The doctor might prescribe one chemotherapy drug or a combination of two or more chemo drugs. Chemotherapy drugs are given by pills or intravenously.

Chemotherapy is often recommended after surgery to kill any remaining cancer cells. It can also be used before surgery with radiation therapy to shrink the size of the cancer.

But because chemotherapy can cause side effects, it is mostly used in advanced cancer stages.

Hormone therapy

Since, hormonal imbalance is a causative factor of endometrial cancer, medicines to control the hormones help in treatment and management. These medicines kill the cancer cells that rely on hormones to feed and grow. This is also an option for advanced stages only when the cancer cells have spread beyond the uterus.

Supportive (palliative) care:
Palliative care is specialized medical care that focuses on providing relief while undergoing aggressive treatments like surgery, chemotherapy or radiation therapy. It helps in controlling the side effects of other medications bringing relief and comfort to the cancer patient.

Endometrial cancer in most cases is curable. Because of the early symptoms, it is often detected early when the cancer is concentrated in one place. Doctors may conduct surgery to remove the cancer cells and then radiation or chemotherapy is given to kill any remaining cancer cells.

But in some cases, when the cancer does not show symptom, or the patient ignore the early symptoms, then more aggressive treatment options are opted for. However, in most cases, the survival and prognosis of endometrial cancer is good!

If you encounter any of the symptoms or tick any of the risk factors then consulting a doctor is the smartest move though the symptom might not necessarily indicate the presence of the fatal disease.

Being vigilant is always the key. Keep a track of your periods, check the flow, check for abnormal or untimely bleeding, bleeding after menopause or bleeding between periods. Also, check for vaginal discharge, discomfort, pelvic pain or any other abnormalities in the body.

Being vigilant and aware of the symptoms will help the patient take the right step without wasting any time. Visit a gynaecologist at the earliest and discuss your risk factors and symptoms in details.

If you are worried that it might be cancer, then ask the doctor to conduct an examination. Also, visit your doctor regularly and get your cancer screenings done from time to time.

Know more: Uterine Sarcoma

Endometrial cancer