Cancer, uterine (uterus)

Cancers of the uterus (womb) usually begin in the cells that make up the lining of the uterus (called the endometrium).

Cancers of the uterus are often called endometrial cancer because this term helps to distinguish them from other cancers that can affect the female reproductive system, such as cervical cancer or ovarian cancer.

The uterus and the endometrium

The uterus, commonly known as the womb, is the part of the female reproductive system where the baby is carried during pregnancy.

The uterus is lined by a layer of cells called the endometrium. The cells that make up the endometrium are regularly discarded during a woman's monthly period, then replaced by new cells.

Types of endometrial cancer

There are two main types of endometrial cancer:

  • Type 1 endometrial cancer is a slow-growing cancer, thought to be linked to the female hormone oestrogen.
  • Type 2 endometrial cancer is a more aggressive, faster-growing form of cancer that does not appear to have any connection to oestrogen.

Type 1 endometrial cancer is the most common type, accounting for an estimated 80% of cases. Type 2 accounts for around 10% of cases.

As well as types 1 and 2 endometrial cancer, there are several rarer types of cancers of the uterus.

How common is endometrial cancer?

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.

On average 390 new cases of endometrial cancer are diagnosed annually. Endometrial cancer is more common in women who have been through the menopause, and most cases of endometrial cancer (93%) were diagnosed in women aged over 50.

Obesity is a major risk factor for endometrial cancer. The number of cases of endometrial cancer is 10 times higher in Europe and north America than in the developing world. This can be explained by the corresponding high rates of obesity in Europe and north America.

Outlook

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).

Endometrial cancer can be treated by surgically removing the womb (hysterectomy). Radiotherapy and chemotherapy are also sometimes used after surgery to reduce the risk of the cancer returning.


Womb
The uterus (or womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

How cancer begins

The body is made up of millions of different cells. Cancer happens when some of the cells multiply in an abnormal way. When cancer affects organs and solid tissues, it causes a growth called a tumour to form. Cancer can occur in any part of the body where the cells multiply abnormally.

How cancer spreads

Left untreated, cancer can quickly grow and spread from the uterus into other tissues in the pelvis or to other parts of the body. This usually happens through the lymphatic system.

The lymphatic system is a series of glands that are spread throughout the body and linked together in a similar way to the blood circulation system. If you have a cold or flu, the glands that come up in the neck are the lymph glands (also called lymph nodes). The lymph glands produce many of the cells that are needed by your immune system.

Once the cancer reaches your lymphatic system, it can spread to any other part of your body, including your bones, blood and organs.

Risk factors for endometrial cancer

It is not known exactly what causes endometrial cancer, but a number of important risk factors have been identified. They are:

Age

The risk of developing endometrial cancer increases with age. Most cases of endometrial cancer develop in women who are over the age of 50.

Oestrogen

The risk of developing endometrial cancer is linked to the exposure of the body to oestrogen. Oestrogen is one of the hormones that regulates the reproductive system in women.

  • Oestrogen stimulates the release of eggs from your ovaries and causes the cells of the womb lining (endometrium) to divide.
  • Progesterone gets the lining of your uterus (the endometrium) ready to receive the egg from the ovaries.

The levels of oestrogen and progesterone in your body are usually balanced with each other. If oestrogen isn't kept in balance by progesterone, the level in the body can increase, this is 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

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. People with a BMI of 25 to 30 are overweight, and those with an index above 30 are obese.

Being overweight or obese is a major risk factor for endometrial cancer, as this increases the level of oestrogen in your body while also reducing the protective effects of progesterone.

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.

Diabetes

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.

Reproductive history

Women who have not had children are at a higher risk of endometrial cancer. This may be because the hormonal changes that occur during pregnancy have a protective effect on the womb (increased levels of progesterone and decreased levels of oestrogen). It may also be because hormonal changes associated with some forms of infertility (for example polycystic ovary syndrome) are associated with a failure of ovulation, causing a decrease in the level of progesterone and thus an increase in the level of unopposed oestrogen.

Tamoxifen

Women who are treated with tamoxifen (a hormone treatment for breast cancer) can be at an increased risk of developing endometrial cancer. However, this risk is outweighed by the benefits that tamoxifen provides in preventing breast cancer.

Polycystic ovarian syndrome (PCOS)

Women with polycystic ovarian syndrome (PCOS) are at a higher risk of developing endometrial cancer. 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).

Endometrial hyperplasia

Endometrial hyperplasia is when the lining of the womb becomes thicker. Women with the condition may be at increased risk of developing endometrial cancer.

 

HRT
Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those that the body no longer produces.
Hysterectomy
A hysterectomy is surgery to remove the uterus (womb), cervix and sometimes the fallopian tubes and ovaries.
Ovary
Ovaries are the pair of reproductive organs that produce eggs and sex hormones in females.
Womb
The uterus (also known as the womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

How cancer begins

The body is made up of millions of different cells. Cancer happens when some of the cells multiply in an abnormal way. When cancer affects organs and solid tissues, it causes a growth called a tumour to form. Cancer can occur in any part of the body where the cells multiply abnormally.

How cancer spreads

Left untreated, cancer can quickly grow and spread from the uterus into other tissues in the pelvis or to other parts of the body. This usually happens through the lymphatic system.

The lymphatic system is a series of glands that are spread throughout the body and linked together in a similar way to the blood circulation system. If you have a cold or flu, the glands that come up in the neck are the lymph glands (also called lymph nodes). The lymph glands produce many of the cells that are needed by your immune system.

Once the cancer reaches your lymphatic system, it can spread to any other part of your body, including your bones, blood and organs.

Risk factors for endometrial cancer

It is not known exactly what causes endometrial cancer, but a number of important risk factors have been identified. They are:

Age

The risk of developing endometrial cancer increases with age. Most cases of endometrial cancer develop in women who are over the age of 50.

Oestrogen

The risk of developing endometrial cancer is linked to the exposure of the body to oestrogen. Oestrogen is one of the hormones that regulates the reproductive system in women.

  • Oestrogen stimulates the release of eggs from your ovaries and causes the cells of the womb lining (endometrium) to divide.
  • Progesterone gets the lining of your uterus (the endometrium) ready to receive the egg from the ovaries.

The levels of oestrogen and progesterone in your body are usually balanced with each other. If oestrogen isn't kept in balance by progesterone, the level in the body can increase, this is 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

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. People with a BMI of 25 to 30 are overweight, and those with an index above 30 are obese.

Being overweight or obese is a major risk factor for endometrial cancer, as this increases the level of oestrogen in your body while also reducing the protective effects of progesterone.

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.

Diabetes

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.

Reproductive history

Women who have not had children are at a higher risk of endometrial cancer. This may be because the hormonal changes that occur during pregnancy have a protective effect on the womb (increased levels of progesterone and decreased levels of oestrogen). It may also be because hormonal changes associated with some forms of infertility (for example polycystic ovary syndrome) are associated with a failure of ovulation, causing a decrease in the level of progesterone and thus an increase in the level of unopposed oestrogen.

Tamoxifen

Women who are treated with tamoxifen (a hormone treatment for breast cancer) can be at an increased risk of developing endometrial cancer. However, this risk is outweighed by the benefits that tamoxifen provides in preventing breast cancer.

Polycystic ovarian syndrome (PCOS)

Women with polycystic ovarian syndrome (PCOS) are at a higher risk of developing endometrial cancer. 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).

Endometrial hyperplasia

Endometrial hyperplasia is when the lining of the womb becomes thicker. Women with the condition may be at increased risk of developing endometrial cancer.

 

HRT
Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those that the body no longer produces.
Hysterectomy
A hysterectomy is surgery to remove the uterus (womb), cervix and sometimes the fallopian tubes and ovaries.
Ovary
Ovaries are the pair of reproductive organs that produce eggs and sex hormones in females.
Womb
The uterus (also known as the womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

If you have unusual vaginal bleeding, it is likely that your GP will carry out a physical examination of your vagina.

Your GP will ask about your symptoms, when they happen and how often. They'll also ask about your general health.

Transvaginal ultrasound (TVU)

If no obvious cause can be found for your symptoms, you may be referred for a transvaginal ultrasound (TVU).

TVU is a type of ultrasound scan that uses a small scanner, in the form of a probe. This is placed directly into the vagina to obtain a detailed picture of the inside of the uterus. The probe can feel a little uncomfortable, but shouldn't be painful.

The TVU checks whether there are any changes to the thickness of the lining of your uterus that could be caused by the presence of cancerous cells.

Biopsy

If the results of the TVU do detect changes in the thickness of the lining of the uterus, you will usually have a biopsy to confirm the diagnosis.

In 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: this allows the doctor to look at the inside of the womb using a thin type of telescope called a hysteroscope. This is inserted through your vagina and into your womb. It enables the doctor 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 find the tests painful and need to be admitted for a general anaesthetic.

 

Tests if you're diagnosed with endometrial cancer

If you're diagnosed with endometrial cancer, you may have further tests that can help to determine the stage of the cancer. Staging the cancer 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:

  • Chest X-ray
  • MRI
  • CT
  • Blood tests

 

Glossary

Anaesthetic
Anaesthetic is a drug used either to numb a part of the body (local) or to put a patient to sleep (general) during surgery.
Biopsy
A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.
Magnetic resonance imaging
MRI stands for magnetic resonance imaging. It is the use of magnets and radio waves to take detailed pictures of the inside of the body.
X-ray
An X-ray is a painless way of producing pictures of the inside of the body using radiation.

Stages of endometrial cancer

Health professionals use a staging system to describe how far endometrial cancer has advanced. These stages are:

  • Stage one: the cancer is still contained inside the uterus.
  • Stage two: the cancer has spread to the neck of the womb (the cervix).
  • Stage three: the cancer has spread outside the womb into nearby tissues in the pelvis or the lymph nodes.
  • Stage four: the cancer has spread to the bladder or bowel, or to other parts of the body (metastasis) such as the liver or lungs.

 

Treatment overview

The main treatment for endometrial cancer is to remove the uterus (hysterectomy). This is sometimes followed by radiotherapy to try to kill any possible remaining cancer cells, depending on the stage and grade of the cancer. Chemotherapy may also be used.

Treatment for women who haven't been through the menopause

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.

Treating advanced cancer

Only a small minority of endometrial cancer is diagnosed at a later stage when it has spread to other parts beyond the uterus. This requires a different course of treatment, usually depending more on chemotherapy. Advanced cancer may not be curable, but the treatment aims to achieve a remission, where the cancer shrinks, making you feel normal and able to enjoy life to the full.

Even if there's no chance of a cure, surgery may be carried out to remove as much of the cancer as possible. Radiotherapy, chemotherapy or hormone therapy can reduce symptoms such as pain by shrinking the cancer or slowing its growth. This can help you feel better.

Surgery

Surgery for stage one endometrial cancer

If you have stage one cancer, you'll probably have a hysterectomy. This involves the removal of both ovaries and the fallopian tubes (bilateral salpingo-oophorectomy, or BSO) and the uterus (called a hysterectomy).

The surgeon may also take samples from the lymph nodes in the pelvis and abdomen, and other nearby tissue. These will be sent to the laboratory to see whether the cancer has spread.

You'll probably be ready to go home three to five days after your operation, or less if the surgery is done by keyhole techniques. But it can take many weeks to recover fully. After your operation, you'll be encouraged to start moving about as soon as possible. This is very important, and even if you have to stay in bed you'll need to keep doing regular leg movements to help your circulation and prevent blood clots. You'll be shown exercises by the nurses or physiotherapist to help prevent complications.

When you go home, you'll need to exercise gently to build up your strength and fitness. Discuss with your doctor or physiotherapist which types of exercise would be suitable for you.

Surgery for stage two or three endometrial cancer

If you have stage two or three endometrial cancer and the cancer has spread to the cervix or nearby lymph nodes in the pelvis, you may have a radical hysterectomy. This involves the additional removal of the cervix and the top of your vagina, as well as the removal of the pelvic lymph nodes. You may also need back up radiotherapy treatment after surgery.

Surgery for advanced cancer (stage four)

If you have advanced womb cancer, you may have surgery to remove as much of the cancer as possible. This is called debulking surgery. This won't cure the cancer, but it may ease some of the symptoms. Your doctor will discuss whether debulking surgery is suitable for you.

Radiotherapy

A course of radiotherapy will be recommended if your treatment team thinks there's a significant risk that the cancer could return in the pelvis. Radiotherapy may also be used to slow the spread of cancer when a surgical cure is not possible.

There are two types of radiotherapy that are used to treat endometrial cancer:

  • Internal radiotherapy (also known as brachytherapy), where a plastic tube is inserted inside the uterus and radiation treatment is passed down the tube into the uterus.
  • External radiotherapy, where a machine is used to deliver pulses of radiation to your pelvis.

A course of external radiotherapy is usually given to you as an outpatient, for five days a week with a break at the weekend. The treatment takes a few minutes, and the whole course of radiotherapy may last approximately four weeks, depending on the stage and position of the endometrial cancer.

Some women have internal radiotherapy (brachytherapy) as well as external radiotherapy. During brachytherapy, the device that delivers radiation is placed in your vagina and stays there until the correct dose of radiation is delivered.

There are different types of brachytherapy, involving either low, medium or high dose rates. With low dose rate methods the radiation is delivered more slowly, so the device has to stay inside you for longer. You'll have to stay in hospital while you have the treatment. Your doctor will discuss this with you.

Radiotherapy has some side effects. Skin in the treated area can become red and sore, and hair loss may occur. Radiotherapy to the pelvic area can affect the bowel, and cause sickness and diarrhoea. As your course of treatment progresses, you're likely to get very tired. Most of these side effects will go away when your treatment finishes, although around 5% of women continue with long-term treatment effects, such as diarrhoea and rectal bleeding.

Chemotherapy

If you have stage three or four endometrial cancer, you may be given a course of chemotherapy. Chemotherapy can be used after surgery to try to prevent the return of the cancer or, in cases of advanced cancer, to slow the spread of the cancer and relieve symptoms.

Chemotherapy is usually given as an injection into the vein (intravenously). Most often, you'll have chemotherapy as an outpatient, but sometimes you may need a short stay in hospital. Chemotherapy is usually given in cycles, with a period of treatment being followed by a period of rest to allow the body to recover.

Side effects of chemotherapy can include:

  • nausea
  • vomiting
  • hair loss
  • fatigue

The side effects should stop once the treatment has finished.

Hormone therapy

Some endometrial cancers are affected by the female hormone oestrogen. These cancers may respond to treatment with hormone therapy. Your doctor will discuss with you whether this is a possible treatment for your endometrial cancer.

Hormone therapy most often replaces the progesterone that would naturally occur in your body. Artificial progesterone is used and this is usually given as tablets. It's mainly used to treat advanced-stage endometrial cancers or cancer that has come back, and it can help to shrink the tumour and control any symptoms. The treatment may have some side effects, including mild nausea, mild muscle cramps and weight gain. Your doctor will discuss these with you.

Clinical trials

A lot of progress has been made in the treatment of endometrial cancer, and more women are living longer with fewer side effects. Some of these advances were discovered through clinical trials, in which new treatments and combinations of treatments are compared with standard treatment. Participants in clinical trials often do better overall than those in routine care.

If you're invited to take part in a trial, you'll be given an information sheet. If you wish to take part, you'll be asked to sign your consent. You're always free to refuse or withdraw from a clinical trial without it affecting your care.

Healthy weight, diet and exercise

The most effective way to prevent endometrial cancer is to maintain a healthy weight.

The best way to avoid becoming overweight or obese is to eat healthily and exercise regularly.

A low-fat, high-fibre diet is recommended, including wholegrains and at least five portions a day of fresh fruit and vegetables.

For most people, at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (i.e. cycling or fast walking) every week, at least five times a week, is recommended.

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.

Soya

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.

Contraception

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.

 

Recovering from treatment and follow-up

Women with endometrial cancer usually have a hysterectomy. This can be a major operation, and recovery may take around six to twelve weeks. During this time you will have to avoid lifting things (for example children and heavy shopping bags) and doing heavy housework. You won't be able to drive for three to eight weeks after the operation. Most women need four to twelve weeks off work after a hysterectomy. The recovery time will depend on the type of surgery you have, whether or not post-op problems develop and what type of work you will return to.

Some of the treatments for endometrial cancer, particularly radiotherapy, can make you very tired. You may need to take a break from some of your normal activities for a while. Don't be afraid to ask for practical help from family and friends if you need it.

Follow-up

After your course of treatment has finished, you'll probably be invited back for regular check-ups. At the check-up, your doctor will examine you and possibly carry out blood tests or scans to see how your cancer is responding to treatment.

Relationships and sex

Relationships with friends and family

Knowing how to talk to your friends and family about your cancer can be difficult, and they may find it hard to talk to you as well. People deal with serious problems in different ways. It's hard to predict how a diagnosis of cancer will affect you. Being open and honest about how you feel and what your family and friends can do to help you may put them at ease. But don't feel shy about telling people that you want some time to yourself, if that's what you need.

Your sex life

Endometrial cancer and its treatment can affect your sex life. This can happen in several ways:

  • Early menopause: if you haven't already had the menopause, removing the ovaries means that you'll go through an early menopause. Symptoms can include vaginal dryness and loss of sexual desire. 
  • Changes to your vagina: radiotherapy for endometrial cancer can make your vagina narrower and less flexible. Sometimes the vagina gets so narrow that having sex becomes difficult. To stop this happening, you should be offered a set of vaginal dilators. These are plastic cones that you put into your vagina to stretch it. You can also stretch your vagina by having sex, or by using your fingers or a vibrator.
  • Not wanting to have sex: it's common for women to lose interest in sex after treatment for endometrial cancer. Your treatment may leave you feeling very tired. You may feel shocked, confused or depressed about being diagnosed with cancer. You may be grieving the loss of your fertility.

It's understandable that you may not feel like having sex while having to cope with all this. Try to share your feelings with your partner. If you feel that you have problems with sex that aren't getting better with time, you may want to speak to a counsellor or a sex therapist.

Talk to others

Being diagnosed with cancer can be hard, both for patients and their families. You'll need to deal with the emotional and practical difficulties. With endometrial cancer, you have to cope physically with recovering from a hysterectomy as well as with the possible emotional impact of losing your womb. Younger women may have to face the fact that they won't be able to have children, and all the grief and anger that may cause.

Often, it can help to discuss your feelings and other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness. There are various ways that you can find help and support:

  • Your hospital doctor, specialist nurse or GP can refer you to a counsellor. If you're struggling with feelings of depression, talk to your GP. A course of antidepressant drugs may be helpful, or your GP can arrange for you to get help from a counsellor or psychotherapist.
  • It may be helpful to talk to someone who's had the same experience as you. Many organisations have telephone helplines and forums that may be useful to you. If you wish, they can put you in touch with other people who've been through cancer treatment.

Dealing with dying

If you're told that nothing more can be done to treat your endometrial cancer, your care will focus on controlling your symptoms and helping you to be as comfortable as possible. This is called palliative care. Palliative care also includes psychological, social and spiritual support for you and your family or carers.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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