Endometrial Cancer

What Is Endometrial Cancer?

Endometrial cancer is a cancer that starts in the inner lining of the womb (uterus). This lining is called the endometrium. The pictures below show where the uterus is found and then a closer look at the uterus.

The uterus is a hollow organ, about the size and shape of a medium-sized pear. It has 2 main parts. The lower part, which extends into the vagina, is called the cervix. The upper part is the body of the uterus, also known as the corpus. The body of the uterus has 2 layers. The inner layer is called the endometrium.

During a woman's menstrual cycle this inner layer changes. In the early part of the cycle it gets thicker in case the woman becomes pregnant. If she does not become pregnant, the tissue is shed from the uterus and becomes the menstrual flow. This cycle repeats throughout a woman's life until change of life (menopause).

Types of cancers of the uterus and endometrium

Nearly all cancers of the uterus start in the endometrium. They are called endometrial carcinomas. Cancers can also start in the muscle layer of the uterus. These cancers belong to the group of cancers called sarcomas.

Carcinomas

Most carcinomas are cancers that start in the cells that form glands in the lining of the uterus. They are called adenocarcinomas. Among these there are 2 types. In the first and most common type, the cancer cells look a lot like normal cells. This is called endometrioid adenocarcinoma. This type can be less likely to spread, which makes it less dangerous. The other type of endometrial cancer is less common and more likely to grow and spread quickly.

Uterine sarcomas

Less common uterine cancers that do not come from glandular tissue of the endometrium are called uterine sarcomas. These can involve the endometrium. These types of cancer are not covered here because their treatment and outlook for survival are different from the most common cancers of the endometrium. If you would like to know more about this type of cancer you can get our document called Uterine Sarcoma.

Cervical cancers

Cancers of the cervix are different from cancers of the body of the uterus and are described in our document, Cervical Cancer.

What Causes Endometrial Cancer?

We do not yet know what causes most cases of endometrial cancer. But we do know that certain risk factors are linked to this disease. A risk factor is anything that changes a person's chance of getting a disease such as cancer. Different cancers have different risk factors. For example, being in strong sunlight without protection is a risk factor for skin cancer. Smoking is a risk factor for many cancers. But risk factors don't tell us everything. Someone can have several risk factors and still not get a disease. Also, not having any risk factors doesn't mean that you won't get the disease.

Risk factors for endometrial cancer

Hormone levels

A woman's hormone balance plays a part in most endometrial cancers. Many of the risk factors for endometrial cancer affect estrogen levels. Before change of life, the ovaries are the main source of the 2 main types of female hormones -- estrogen and progesterone. The balance between these hormones changes during a woman's menstrual cycle each month. A shift in the balance of these 2 hormones toward more estrogen increases a woman's risk for getting endometrial cancer.

After change of life, the ovaries stop making these hormones, but a small amount of estrogen is still made in fat tissue. Female hormones can also be taken as birth control pills to prevent pregnancy and as hormone therapy to treat symptoms of menopause.

Estrogen therapy: Using estrogen to treat symptoms of change of life is known as estrogen therapy or menopausal hormone therapy. Estrogen treatment can reduce hot flashes, improve vaginal dryness, and help prevent the weakening of the bones (osteoporosis) that can happen with menopause. But the use of estrogen alone increases a woman's risk of getting endometrial cancer. Studies show that giving progesterone-type drugs along with the estrogens helps lower this risk. But studies also show that giving this combination of the hormones increases a woman's chance of getting breast cancer and blood clots.

It is important to discuss the pros and cons of estrogen therapy with your doctor. If you choose to take it, you should use the lowest dose that is needed for the shortest period of time. You should also have follow-up exams for cancer at least every year. Let your doctor know right away if you have any vaginal bleeding or discharge that isn't normal.

Birth control pills: Using birth control pills lowers the risk of endometrial cancer. The risk is lowest in women who take the pill for a long time. And this protection continues for at least 10 years after a woman stops taking this form of birth control. But you need to look at all of the pros and cons when choosing a birth control method -- endometrial cancer risk is only one factor to think about. It's a good idea to talk to your doctor about the different methods of birth control to find the one that is best for you.

Total number of menstrual cycles (periods): Having more periods during a woman's lifetime raises her risk of endometrial cancer. Starting periods before age 12 or going through change of life late raises the risk. Starting periods early is less a risk factor for women with early change of life. Likewise, late change of life may not lead to a higher risk in women whose periods began later in their teens.

Pregnancy: During pregnancy, the hormonal balance shifts toward more progesterone. So having many pregnancies reduces endometrial cancer risk. Women who have not been pregnant have a higher risk.

Obesity (being very overweight): Most of a woman's estrogen is made by her ovaries, but fat tissue can change some other hormones into estrogens. Having more fat tissue can increase a woman's estrogen levels and, as a result, increase her endometrial cancer risk.

Tamoxifen: Tamoxifen is a drug that is used to treat women with breast cancer. It is also used to reduce the risk in women who are at a high risk of getting breast cancer. The drug acts like estrogen in the uterus. It can cause the uterine lining to grow and increase the risk of endometrial cancer in women who take this drug.

The risk of getting endometrial cancer in women taking tamoxifen is fairly small (about 1 in 500). It must be balanced against the value of this drug in treating breast cancer and reducing the chances of the woman getting cancer in the other breast. This is something women may want to talk about with their doctors. If you decide to take tamoxifen, you should have yearly pelvic exams. You should also be sure to tell your doctor if you have any endometrial cancer symptoms, such as discharge or bleeding that isn't normal.

Ovarian tumors: Certain ovarian tumors make estrogen. Women who have these tumors have higher than normal estrogen levels and lower levels of progesterone. The increase in estrogen compared to progesterone can increase a woman's chance of getting endometrial cancer.

Polycystic ovarian syndrome: Women with polycystic ovarian syndrome (PCOS) have hormone levels that are not normal, such as higher estrogen levels and lower levels of progesterone. The increase in estrogen compared to progesterone can increase a woman's chance of getting endometrial cancer.

Age

The risk of endometrial cancer goes up as a woman gets older.

A diet high in animal fat

A high-fat diet can increase the risk of several cancers, including endometrial cancer. Because fatty foods are also high-calorie foods, a high-fat diet can lead to obesity, which is an endometrial cancer risk factor. Some doctors think that fatty foods may also have a direct effect on estrogen levels, which can also increase risk.

Diabetes

Diabetes is more common in people who are overweight. This could be why diabetes is a risk factor for endometrial cancer. But some studies suggest that diabetes by itself could be a risk factor.

Family history

This cancer appears to run in some families who also tend to get a certain type of colon cancer. A small number of endometrial cancers may be due to this inherited factor. Women who have had several family members with colon cancer or endometrial cancer might think about having genetic counseling and testing. This kind of testing can help show if you (or members of your family) are at high risk. If you are, your doctor may suggest a hysterectomy once you are through having your children. Your doctor may also recommend endometrial sampling (biopsy) every year for women age 35 or older.

Breast or ovarian cancer

Women who have had breast cancer or ovarian cancer may have a higher risk of getting endometrial cancer. Some of the risk factors for breast and ovarian cancer also increase endometrial cancer risk.

Earlier pelvic radiation therapy

Radiation used to treat some other cancers can damage the DNA of cells. This could increase the risk of getting a second type of cancer, such as endometrial cancer.

Endometrial hyperplasia

Endometrial hyperplasia is an increased growth of the endometrium. The most common type has a very small risk of becoming cancer. It may go away on its own or after treatment with hormones. If the hyperplasia is called "atypical," it has a higher chance of becoming a cancer.

It is important to keep in mind that although these factors may increase a woman's risk for getting endometrial cancer, they do not always cause the disease. Many women with one or more of these risk factors never get endometrial cancer, and some women with endometrial cancer do not have any of these risk factors.

How Is Endometrial Cancer Found?

Most women are diagnosed because they have symptoms. Watching for any signs and symptoms of this cancer and telling your doctor about them right away allows the cancer to be found at an early stage. Finding it early improves the chances that it will be treated with success. But sometimes this cancer can reach an advanced stage before it causes any symptoms.

Early detection tests

Early detection refers to testing to find a disease such as cancer in people who do not have symptoms of that disease.

Women at average endometrial cancer risk

Women should talk to their doctors about getting regular pelvic exams, including Pap tests. Although the Pap test can find some female cancers early, most cases of endometrial cancer are not found by this test. But the Pap test is very good at finding early cancer of the cervix (the lower part of the uterus).

After menopause you should tell your doctor if you have any discharge or bleeding that is not normal. This could be a sign of endometrial cancer.

Women who have a higher risk of endometrial cancer

Women at high risk for this cancer should see their doctor whenever they have any vaginal bleeding that is not normal. This includes women who:

• are older
• had late menopause
• never had children
• are unable to get pregnant (infertile)
• are obese
• have diabetes
• have high blood pressure
• are using estrogen treatment
• are taking tamoxifen therapy

Women who have (or are at risk for) a certain type of colon cancer (hereditary nonpolyposis colon cancer, or HNPCC), should have yearly testing with an endometrial biopsy beginning at age 35. Another option would be for the woman to have a hysterectomy once she is finished having children.

Signs and symptoms of endometrial cancer

Unusual bleeding, spotting, or other discharge

If you have gone through change of life (menopause) it is very important to tell your doctor about any bleeding or spotting that is not normal. About 9 out of 10 women with endometrial cancer have some type of abnormal vaginal bleeding, but some have discharge that does not look like blood. Abnormal discharge also can be caused by something other than cancer.

Pelvic pain or a mass and weight loss

These symptoms usually happen in the later stages of the disease. Still, you should see the doctor right away because a delay in getting treatment can allow the cancer to get worse. This lowers the chance for successful treatment.

What will happen next?

History and physical exam

The doctor will ask about your symptoms, risk factors, and family medical history. The doctor will also do a physical and a pelvic exam.

Seeing a specialist

If the doctor thinks you might have endometrial cancer, you should see a gynecologist--a doctor with special training in finding and treating diseases of the female reproductive system.

Getting a sample of endometrial tissue

To find out whether the problem is endometrial hyperplasia or endometrial cancer, the doctor must remove some tissue so that it can be looked at under the microscope. Tissue can be taken out by doing an endometrial biopsy or by a D & C (this stands for dilation and curettage). These are described below.

Endometrial biopsy

This kind of biopsy can be done in a doctor's office. A very thin flexible tube is placed into the uterus through the cervix. Then suction is used to remove a small amount of endometrium. The suction usually takes less than a minute. The discomfort is much thing like menstrual cramps and can be helped by taking a drug like ibuprofen before the test.

Hysteroscopy

This is a way that doctors can look inside the uterus. The doctor puts a tiny telescope into the uterus through the cervix. The uterus is then filled with salt water (saline). This lets the doctor see and take a sample of anything that might be causing a problem, such as a cancer or a polyp. You stay awake for this, and the biopsy is done after the area is numbed with medicine.

Dilation and curettage (D & C)

If the biopsy sample doesn't get enough tissue, or if the doctor can't tell for sure whether it is cancer, a D & C must be done. To do this, the cervix is opened (dilated) and a special instrument is used to scrape tissue from inside the uterus. The test takes about an hour and you may need medicine to make you sleep (general anesthesia). D & C is most often done in an outpatient surgery area of a clinic or hospital. Most women have little pain after this procedure.

Testing the tissue

Tissue that has been removed is looked at under a microscope to see whether there are cancer cells in it. If cancer is found, the cells will be studied to learn more about the cancer. The lab report will give these details.

The lab will also assign a grade to the cancer. If most of the cancer cells look like normal tissue, it’s given a grade 1. If most of the cells look very different from normal cells, it's given a grade of 3. Grade 2 tumors fall somewhere in between. The grade is important because women with lower grade cancers are less likely to have advanced disease or to have the cancer come back after treatment.

Imaging tests for endometrial cancer

Ultrasound

Ultrasound is the use of sound waves to take pictures of the inside of the body. For this test, a probe is placed into the vagina. It gives off sound waves that echo off the tissue of the pelvic organs to create a picture on a video screen. This test can be used to see if there is a tumor. It could also show whether the tumor is growing into the outer muscle layer of the uterus. Salt water (saline) might be put into the uterus before the test to give a clearer picture.

Cystoscopy and proctoscopy

If a woman has signs that suggest the cancer may have spread, the doctor can use a lighted tube to look at the inside of the bladder or rectum. Small pieces of tissue can be removed to be looked at under a microscope.

CT scan

This is a special type of x-ray that creates detailed pictures of the inside of the body. CT scans are rarely used to find endometrial cancer. But they may be helpful if it looks as if the cancer has come back or has spread into the liver or other organs. CT scans can also be used to guide a biopsy needle into the area that could be cancer.

CT scans take longer than regular x-rays. You will need to lie still on a table while the scans are done. You may also have an IV (intravenous) line through which a contrast "dye" is injected. Some people are allergic to the dye and get hives or, rarely, problems like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a problem from any dye used for x-rays. You may also be asked to drink 1 to 2 pints of a liquid that helps outline the intestine so that it is not mistaken for tumors.

MRI scan (magnetic resonance imaging)

MRI scans use radio waves and strong magnets instead of x-rays. MRI scans are helpful in looking at the brain and spinal cord. They take longer than CT scans, and you may have to be placed inside a tube-like machine. This can be upsetting for some people. Sometimes newer "open MRI" machines are used. The machine makes thumping or buzzing noises that you may find disturbing. Many places will give you headphones with music to block this out. A contrast dye might be used, just as with CT scans.

PET scan (positron emission tomography)

In this test, a type of radioactive sugar is given to look for cancer cells. The cancer cells take in large amounts of the sugar. A special camera can then detect where it goes in the body. PET is sometimes useful in finding small collections of cancer cells. But PET is not often used for endometrial cancer.

Chest x-ray

This can show if the cancer has spread to the lungs. It may also be used to look for serious lung or heart problems.

IVP (intravenous pyelogram)

An IVP may be done if the doctor thinks the cancer might have spread to the urinary tract or nearby tissues. An IVP is an x-ray that outlines the urinary system. But CT scans are used more often than IVP.

Blood tests

Complete blood count (CBC)

This test measures the different cells in the blood, such as the red blood cells, white cells, and platelets. Many times women who have lost blood from the uterus will have low red blood cell counts. This is called anemia.

CA 125 blood test

CA 125 is a substance that many endometrial and ovarian cancers release into the bloodstream. Very high blood CA 125 levels are a sign that the cancer has likely spread beyond the uterus. If CA 125 levels are high before surgery, some doctors will track this number to find out how well the treatment is working. The levels will go down after surgery if treatment is killing the cancer cells. CA 125 levels may also be watched to see if the cancer has come back after treatment is done.

How Is Endometrial Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

After going over your test results, your doctor will recommend one or more treatment options. Don't feel rushed about making a decision. If there is anything you do not understand, ask to have it explained again. The choice of treatment mostly depends on the type of cancer and stage of the disease when it is found. Other factors that could play a part might include your age, your overall health, whether you plan to have children, and other personal matters. Be sure you understand all the risks and side effects of the different treatments before making a decision.

You may want to get a second opinion. This can give you more information and help you feel more certain about the treatment plan you choose. Some insurance companies say you must get a second opinion before they will pay for some treatments, but most of the time a second opinion is not needed for routine cancer treatments.

There are 4 basic types of treatment for women with endometrial cancer: surgery, radiation therapy, hormone therapy, and chemotherapy (chemo). Surgery is the main treatment for most women with endometrial cancer. But sometimes one or more of these treatments is combined.

Surgery

Hysterectomy

The main treatment for endometrial cancer is an operation to remove the uterus and cervix. This is called a hysterectomy. Most often, the ovaries and fallopian tubes are also removed. If both ovaries are removed, you will go into menopause (change of life) if you have not done so already.

To decide what stage the cancer is in, lymph nodes in the pelvis and around the aorta will also need to be removed (see below). This can be done at the same time as the hysterectomy or as a separate procedure.

Lymph node surgery

Lymph node removal: When lymph nodes are taken out it is called "lymph node dissection." In this operation, lymph nodes from the pelvis and the area around the main artery that carries blood from the heart (the aorta) are removed. They are looked at to see if they contain cancer cells. This can be done at the same time as the hysterectomy or with a laparoscope (explained below).

Laparoscopic lymph node sampling: When only a few of the lymph nodes are removed, it is called "lymph node sampling." Thin tubes are put into the belly (abdomen) through very small incisions. Small tools can be controlled through the tubes and the doctor can take out some lymph nodes. Studies are going on to find out whether this method is as good as removing all the lymph nodes to treat endometrial cancer.

Pelvic washings

To do a pelvic washing, the surgeon "washes" the abdominal and pelvic areas with salt water (saline) and then sends the fluid to the lab to see if it contains cancer cells.

Other tests that may be used for staging

Omentectomy: The omentum is a layer of fatty tissue that covers the abdominal contents like an apron. Cancer sometimes spreads to this tissue. When this tissue is removed, it is called an omentectomy. Sometimes the omentum is removed during a hysterectomy to see if cancer has spread there.

Peritoneal biopsies: The tissue lining the pelvis and abdomen is called the peritoneum. Peritoneal biopsies remove small pieces of this lining to check for cancer cells.

Tumor debulking

If cancer has spread throughout the abdomen, the surgeon may try to remove as much of the tumor as possible. This is called debulking. Debulking a cancer can help other treatments work better. Tumor debulking is helpful for other types of cancer, but it isn't clear yet if it will help women with endometrial cancer live longer.

Recovery after surgery

For an abdominal hysterectomy, the hospital stay is usually 3 to 7 days. Complete recovery takes about 4 to 6 weeks.

Side effects

A woman cannot become pregnant after a hysterectomy. If change of life had not happened before surgery, removing the ovaries will cause it to happen. Problems from surgery are rare but could include too much bleeding, wound infection, and damage to the urinary or intestinal systems.

Radiation therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation). Or it can come from radioactive materials placed near the tumor. This is called brachytherapy. In some cases, both types of radiation treatment are used.

How much of the pelvis needs to have radiation treatment depends on how far the cancer has spread.

Brachytherapy

In cases where only the upper third of the vagina needs to be treated after surgery, radioactive pellets or seeds can be put into place for a short time. They are put in through the vagina. With brachytherapy there is little effect on nearby structures, such as the bladder or rectum.

This treatment is given in the radiation suite of the hospital or care center. About 4 to 6 weeks after surgery, the doctor puts the pellets of radioactive material into the vagina. More than one treatment may be needed. The number of treatments depends on the strength of the dose. For endometrial cancer, high dose radiation is often given weekly or even daily for at least 3 doses.

External radiation

This method of giving radiation is like a regular x-ray but it takes longer. It is most often given 5 times a week, for 4 to 6 weeks. While treatment itself takes less than a half-hour, the daily trips may hard to manage.

Side effects of radiation therapy

• tiredness (fatigue)
• upset stomach
• loose bowels (diarrhea)
• nausea and vomiting
• skin changes like redness and soreness
• problems passing urine
• the vagina may become dry, or shorter, or more narrow (this is called vaginal stenosis), causing pain during sex
• early menopause
• weakened bones in the pelvis

Radiation can also lead to low blood counts, causing low red blood cells and low white blood cells. The blood counts usually return to normal after radiation is stopped.

If you are having side effects from radiation, talk to your doctor. There are things you can do to get relief from these problems or to prevent them from happening.

Chemotherapy

Chemotherapy (often called "chemo") is the use of cancer-fighting drugs to kill cancer cells. Usually these drugs are given into a vein or by mouth. Once the drugs enter the bloodstream they spread throughout the body. Chemo is useful in treating cancer that has spread. One or more drugs may be used.

While these drugs kill cancer cells, they can also damage some normal cells. This can cause side effects. Which side effects happen will depend on the type of drugs given, the amount or dose, how often treatment is done, and how long treatment lasts. Common side effects are:

• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores
• vaginal sores
• a higher chance of infection (from low white blood cell counts)
• bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
• shortness of breath or tiredness (from low red blood cell counts)

Most side effects go away after treatment ends. If you have problems with side effects, talk with your doctor or nurse, as there are often ways to help.

Hormone therapy

Hormone therapy is the use of hormones or hormone-blocking drugs to fight cancer. Below are some of the types of hormone therapy that might be used.

Progestins: Progesterone-like drugs can be used to slow the growth of cancer cells. The drugs are usually taken as pills or injections.

Tamoxifen: Tamoxifen is a drug often used to treat breast cancer. It may also be used to treat advanced endometrial cancer or endometrial cancer that has returned (recurrent endometrial cancer).

GNRH (Gonadotropin-releasing hormone): These drugs switch off the estrogen made by the ovaries in women who have not gone through change of life. The drugs are injected every 1 to 3 months.

Aromatase inhibitors: After the ovaries are removed (or if they are not working), estrogen is still made in fat tissue. This becomes the body's main source of estrogen. Drugs called aromatase inhibitors can stop this estrogen from being formed and lower estrogen levels even further. These drugs are still being studied, and their role in endometrial cancer treatment is not clear.

Endometrial cancer survival by stage

The 5-year relative survival rate is the percentage of patients who have not died from endometrial cancer at least 5 years after the cancer is found. Those who die of other causes are not counted. Of course, patients might live more than 5 years after diagnosis.

When all cases of endometrial cancer are looked at together, the 5-year relative survival rate is about 88%. Most of these cancers are found at an early stage, which has a 5-year survival rate of over 95%. But the outlook (prognosis) for any one woman depends on the stage of her cancer as well as several other factors.

These numbers give you an overall picture, but keep in mind that every woman's situation is unique and the statistics can't predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your personal chances of a cure, or how long you might survive your cancer. They know your situation best.