Endometrial Cancer

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Endometrial cancer is a type of cancer that begins in the lining of the uterus (endometrium). It is the most common gynaecological cancer in the UK, primarily affecting postmenopausal women.

Aetiology

Endometrial cancer arises from the endometrial lining of the uterus. It is often driven by excess oestrogen without the balancing effect of progesterone. There are two main types:

• Type 1: The most common form, often associated with excess oestrogen, obesity, and a history of polycystic ovary syndrome (PCOS). It generally has a better prognosis.
• Type 2: Less common and not linked to oestrogen. It tends to occur in older women and is often more aggressive.

Risk Factors

Several factors can increase the risk of developing endometrial cancer:

• Age: Most cases occur in women over 50, with risk increasing with age.
• Obesity: Excess body fat can lead to higher levels of oestrogen, increasing the risk.
• Hormone Replacement Therapy (HRT): Unopposed oestrogen therapy increases the risk; combined HRT (oestrogen and progesterone) is safer.
• Polycystic Ovary Syndrome (PCOS): Women with PCOS often have higher levels of oestrogen, contributing to increased risk.
• Nulliparity: Women who have never had children are at higher risk, possibly due to prolonged exposure to oestrogen.
• Early Menarche or Late Menopause: Prolonged exposure to oestrogen increases risk.
• Diabetes: Linked to a higher risk of endometrial cancer, possibly due to associated obesity and insulin resistance.
• Family History: A history of endometrial or colorectal cancer in close relatives, particularly with Lynch syndrome, increases risk.

Clinical Presentation

Endometrial cancer often presents with early symptoms, which allows for timely diagnosis and treatment. Common symptoms include:

• Postmenopausal Bleeding: The most common symptom. Any vaginal bleeding after menopause should be investigated.
• Intermenstrual Bleeding: Bleeding between periods in premenopausal women.
• Heavy Menstrual Bleeding: Particularly if there is a change in pattern for the patient.
• Abnormal Vaginal Discharge: Watery, bloody, or foul-smelling discharge.
• Pelvic Pain: Typically a later symptom, often associated with more advanced disease.
• Pain during Intercourse: Can also be a presenting symptom.

Investigations

If endometrial cancer is suspected, the following investigations are typically performed:

• Transvaginal Ultrasound (TVUS): First-line imaging to assess endometrial thickness. An endometrial thickness greater than 4mm in postmenopausal women may suggest malignancy.
• Endometrial Biopsy: A sample of the endometrial tissue is taken for histological examination, often done during an outpatient procedure.
• Hysteroscopy: Direct visualisation of the uterine cavity with a camera, allowing for targeted biopsies.
• CA125 Blood Test: Although not specific to endometrial cancer, CA125 levels may be elevated and can help assess for metastatic disease.
• MRI or CT Scan: Used to stage the cancer and assess for spread to other parts of the body if a diagnosis is confirmed.

Management

Treatment of endometrial cancer depends on the stage at diagnosis, the type of cancer, and the patient’s overall health:

Primary Care Management

As a Physician Associate, your role includes recognising the signs and symptoms of endometrial cancer and facilitating timely referral to secondary care. Educating patients on the importance of reporting any postmenopausal bleeding or abnormal bleeding patterns is also crucial.

Secondary Care Management

Treatment in secondary care typically involves a combination of the following:

• Surgery:
  • Total Hysterectomy with Bilateral Salpingo-Oophorectomy (THBSO): The removal of the uterus, fallopian tubes, and ovaries. This is the standard treatment for most cases of endometrial cancer.
  • Lymphadenectomy: Removal of lymph nodes to assess for cancer spread.
• Radiotherapy: May be used after surgery to reduce the risk of recurrence, or as the primary treatment in patients who are not surgical candidates.
• Chemotherapy: Often used in advanced or high-risk cases, particularly when the cancer has spread beyond the uterus.
• Hormone Therapy: Progesterone therapy may be used in certain cases, particularly for women with type 1 endometrial cancer or those who are not suitable for surgery.
• Follow-Up Care: Regular monitoring and follow-up are essential to detect any recurrence early.

When to Refer

Urgent referral to a gynaecologist or oncologist is warranted in the following situations:

• Any case of postmenopausal bleeding should be referred for further investigation.
• Persistent or unexplained intermenstrual bleeding, particularly in women over 40.
• Abnormal findings on transvaginal ultrasound or endometrial biopsy.
• Patients with a strong family history of endometrial or colorectal cancer, particularly those with known Lynch syndrome.

References

1. NHS (2024) Endometrial Cancer. Available at: https://www.nhs.uk/conditions/womb-cancer/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Endometrial Cancer: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng121 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Endometrial Cancer: Diagnosis and Management in Primary Care. Available at: https://www.bmj.com/content/350/bmj.h2045 (Accessed: 26 August 2024).
4. Target Ovarian Cancer (2024) Endometrial Cancer Information and Support. Available at: https://www.targetovariancancer.org.uk/endometrial-cancer (Accessed: 26 August 2024).

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