Cancer is a genetic mutation of the way cells grow in the body. Changes in the DNA cause cells to over produce in an uncontrolled way creating a cell mass, commonly known as a tumour. If left untreated the cells continue to grow and the cancer can spread to other organs and systems in the body.
 

Endometrial cancer is also known as womb cancer or uterine cancer, and affects the womb and its lining. Endometrial cancer is the most common gynaecological cancer and now over 7000 women are diagnosed in the UK each year.

Endometrium is the term used for the lining of the womb. This lining is shed each month during menstruation (your period), after which, hormones produced in the ovaries cause a new layer of endometrial tissue (lining) to be developed. The hormone that causes this growth is known as oestrogen and a second hormone involved is progesterone, which causes the lining to stabilise. A lowering of hormone levels occurring each month causes the endometrium to break down and shed through the vagina in the process called a period.

Endometrial Cancer is a malignancy (an abnormal development) of cells within the lining of the womb. These cells then mutate causing a malignant tumour in the uterus.

Cancer Research UK figures show that survival rates tend to be good, the 5 year survival rate is around 85 percent for stage I (early stage). However, for stage 4 (late stage) the 5 year survival rate is 25 percent. This is why awareness of symptoms, prompt assessment and treatment are essential.

There are two main types of endometrial cancer:

Type 1: the majority of endometrial cancers are slow growing and are associated with oestrogen levels.

Type 2: 20 percent of cases are a more aggressive form of cancer that does not seem to be linked with oestrogen.

Symptoms

Like many other less serious minor gynaecological problems the main symptom of endometrial cancer is unusual vaginal bleeding.
However, it is very important that if you suffer any unusual vaginal bleeding to seek medical help immediately as it can sometimes be a sign of a serious health issue and must be investigated further.

Unusual vaginal bleeding can include:
 

• Bleeding after the menopause
• Heavier periods than normal
• Vaginal bleeding between periods
• Vaginal bleeding after intercourse (sex)

Other signs of endometrial cancer can include:

• Unexplained weight loss
• Pain in the lower abdomen, back, or pelvis
• Pain during sex
• Vaginal discharge

Causes and risk factors

What exactly causes endometrial cancer is still unclear but it is widely recognised that certain factors can contribute to its development. Most of the known risk factors are due to increased exposure to oestrogen which is unopposed (unchecked) by progestagens. Oestrogen causes the cells of the endometrium (lining of the womb) to divide, making the lining thicker.

Contributing factors:

• Total number of menstrual cycles- early menarche (start of periods) and late menopause can increase the risk, because of prolonged exposure to oestrogen in the normal menstrual cycle.  
• Post Menopause- the majority of endometrial cancers occur in women after the age of 50. After the menopause, progesterone is not produced by the body, but low levels of oestrogen are still produced and are unopposed, this can cause the cells in the endometrium to divide.  
• Obesity or being overweight- women who are overweight are three times more likely to develop endometrial cancer. This is because being overweight increases the level of unopposed oestrogen in the body.  
• Diabetes- women with diabetes are more likely to develop this cancer due to raised insulin levels which can raise levels of oestrogen.  
• Women who have never had children – this is thought to increase the risk because these women have not had the change in hormonal levels that occurs during pregnancy (increased progesterone and decreased levels of oestrogen).  
• PCOS (Polycystic Ovarian Syndrome)- statistics show that women with PCOS are slightly more likely to develop endometrial cancer than those without.  
• Family history- there is a rare condition which can run in families, which increases the risk of bowel and uterine cancer. It is called hereditary nonpolyposis colon cancer (HNPCC). If there is a family history of colon cancer or endometrial cancer and you have concerning symptoms, discuss this with your GP.  
• Endometrial hyperplasia- is a condition where the womb lining is thickened. Women with certain types of this condition may be at increased risk.  
• Breast or Ovarian cancer- some treatments for breast cancer and some types of ovarian cancer can cause an increased risk of endometrial cancer.

Diagnosis

After visiting the doctor with vaginal bleeding, it is likely that they will first carry out a vaginal examination and possibly other tests to rule out an infection.

The doctor may then recommend referral to the hospital to see a specialist. Often an internal ultra sound (trans-vaginal scan) is used to investigate the uterus and ovaries. If an abnormality in the lining of the womb is suspected, a biopsy will be carried out to confirm a diagnosis. A Biopsy involves taking a sample or piece of the womb to send off for tests.

There are a number of ways to do this, but the most usual is called a Hysteroscopy. This test uses a fine telescope called a hysteroscope, which is passed through the cervix to look into the womb and assess the lining. A biopsy can be taken at the same time. It is usually done as an outpatient appointment, so does not include a hospital stay.

Treatment

If endometrial cancer is diagnosed there are a number of treatments available.

The stage of the cancer and whether the menopause has already occurred will determine the appropriate treatment. But options include:

Hysterectomy- surgery to remove the reproductive organs including the womb, ovaries and cervix. This helps to ensure that any future cancer does not develop in the different parts of the reproductive system.

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- controlled doses of radiation. If there is a chance of recurrence, radiotherapy will be recommended in order to prevent the return of the cancer. It may also be used to slow the spread of the cancer if surgery was not possible.

Chemotherapy- is a drug given, over a specific course of time, it is designed to destroy cancerous cells. If a later stage of cancer is discovered it is likely that chemotherapy will be prescribed. It may also be prescribed, like radiotherapy to prevent a return of the cancer.

Hormone therapy- although hormone treatment cannot cure the disease, it can reduce the spread and slow the cancer down.

Prevention

Unlike cervical cancer there is no routine screening method.

There are certain things women can do that may help to lower the risk of endometrial cancer:

• Lifestyle- try to maintain a healthy weight through a balanced diet and exercise.
• Balanced diet- a lower fat, high-fibre diet, which includes wholegrains and at least five portions a day of fresh fruit and veg.
• Exercise- regular exercise. Please consult your GP before starting exercise if this is not a regular activity or you have not exercised for some time.
• Contraception- there are certain hormone based contraceptives that have been shown to reduce the risk of endometrial cancer with long term use. These include the combined pill, the implant and the IUS (Intrauterine system). These methods of contraception all have benefits and risks. A discussion with your GP will help decide what is suitable for you.
• Breastfeeding- reduces the risk of endometrial cancer.

Carleen's story-

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.

 

Endometrial Cancer: Text Version

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.

Hello Sean.

Hello.

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.

Thank you.

To find out about our research follow these links:
 

• Investigation of endometrial hyperplasia before and following treatment with Levonorgestrel-releasing intrauterine system (LNG-IUS)

• The role of lipid-type (fat-like) molecules in cancer of the womb