Endometrial cancer

Symptoms

Most cases of endometrial cancer develop in postmenopausal women, whose periods have stopped. The first clue that something is wrong may be abnormal vaginal bleeding.

Signs and symptoms of endometrial cancer may include:

• Any bleeding after menopause
• Prolonged periods or bleeding between periods
• An abnormal, nonbloody discharge from your vagina
• Pelvic pain
• Pain during intercourse
• Unintended weight loss

Causes

Healthy cells grow and divide in an orderly way to keep your body functioning normally. But sometimes cells become abnormal (mutate) and grow out of control. The cells continue dividing even when new cells aren't needed. These abnormal cells can invade and destroy nearby tissues and even have the ability to travel to other parts of the body and begin growing there.

In endometrial cancer, cancer cells develop in the lining of the uterus. Why these cancer cells develop isn't entirely known. However, scientists believe that estrogen levels play a role in the development of endometrial cancer. Factors that can increase the levels of this hormone and other risk factors for the disease have been identified and continue to emerge. In addition, ongoing research is devoted to studying changes in certain genes that may cause the cells in the endometrium to become cancerous.

Risk factors

The female reproductive system consists of two ovaries, two fallopian tubes, a uterus and a vagina. The ovaries produce two main female hormones — estrogen and progesterone. The balance between these two hormones changes each month, making the endometrium thicken during the early part of the monthly cycle. If no pregnancy occurs, the endometrium is then shed during the last phase of the menstrual cycle.

When the balance of these two hormones shifts toward more estrogen — which stimulates growth of the endometrium — a woman's risk of developing endometrial cancer increases. Factors that increase levels of estrogen in the body include:

• Many years of menstruation. If you started menstruating at an early age — before age 12 — or you began menopause later, you're at greater risk of endometrial cancer than is a woman who menstruated for fewer years. The more years you have had periods, the more exposure your endometrium has had to estrogen.
• Never having been pregnant. Pregnancy seems to decrease the risk of endometrial cancer, although experts aren't sure exactly why this might be. The body produces more estrogen during pregnancy, but it produces more progesterone, too. Increased progesterone production may offset the effects of the rise in estrogen levels. It's also possible that not having been pregnant may be the result of infertility caused by irregular ovulation, which may be the reason why women who've never been pregnant are at an increased risk of endometrial cancer.
• Irregular ovulation. Ovulation, the monthly release of an egg from an ovary in menstruating women, is regulated by estrogen. Irregular ovulation or failure to ovulate increases your lifetime exposure to estrogen. Ovulation irregularities have many causes, including obesity and a condition known as polycystic ovary syndrome (PCOS). This is a condition in which hormonal imbalances prevent ovulation and menstruation. Treating obesity and managing the symptoms of PCOS can help restore your monthly ovulation and menstruation cycle, decreasing your risk of endometrial cancer.
• Obesity. Ovaries aren't the only source of estrogen. Fat tissue can produce estrogen. Being obese can increase the level of estrogen in your body, putting you at a higher risk of endometrial cancer and other cancers. Obese women have three times the risk of endometrial cancer and overweight women have twice the risk, according to the American Cancer Society. However, thin women can also develop endometrial cancer.
• A high-fat diet. This type of diet may add to your risk of endometrial cancer by promoting obesity. Or, fatty foods may directly affect estrogen metabolism, further increasing a woman's risk of endometrial cancer.
• Diabetes. Endometrial cancer is more common in women with diabetes, possibly because obesity and type 2 diabetes often go hand in hand. However, even women with diabetes who aren't overweight have a greater risk of endometrial cancer.
• Estrogen-only replacement therapy (ERT). Estrogen stimulates growth of the endometrium. Replacing estrogen alone after menopause may increase your risk of endometrial cancer. Taking synthetic progestin, a form of the hormone progesterone, with estrogen — combination hormone replacement therapy — causes the lining of the uterus to shed and actually lowers your risk of endometrial cancer. However, this combination may cause other health risks, such as blood clots or breast cancer.
• Ovarian tumors. Some tumors of the ovaries may themselves be a source of estrogen, increasing estrogen levels.

Other factors that can increase your risk of endometrial cancer include:

Age. The older you are, the greater your risk of endometrial cancer. The majority of endometrial cancer occurs in women older than 55.

Personal history of breast cancer or ovarian cancer. If you've had breast or ovarian cancer, you may have an increased risk of endometrial cancer because all of these cancers share some of the same risk factors. However, the vast majority of women who have either breast or ovarian cancer never develop endometrial cancer.
Tamoxifen treatment. One in every 500 women whose breast cancer was treated with tamoxifen will develop endometrial cancer. Although tamoxifen acts mostly as an estrogen blocker, it does have some estrogen-like effects and can cause the uterine lining to grow. If you're being treated with this hormone, see your doctor for an annual pelvic examination and be sure to report any unusual vaginal bleeding.

Race. Black women have an increased risk of death from endometrial cancer, although white women are more likely to develop endometrial cancer.
Hereditary nonpolyposis colorectal cancer (HNPCC). This inherited disease is caused by an abnormality in a gene important for DNA repair. Women with HNPCC have a significantly higher risk of endometrial cancer as well as colon and other cancers.

Having risk factors for endometrial cancer doesn't mean you'll get the disease. It means that you're at risk and should be alert to possible signs and symptoms of the disease. Conversely, some women who develop endometrial cancer appear to have no risk factors for the disease.

Complications

The most serious complication of any cancer, including endometrial cancer, is that it can spread to other parts of your body (metastasize). Fortunately, when discovered early, endometrial cancer is usually treatable. Five-year survival rates are 95 percent for early-stage endometrial cancer. If endometrial cancer has reached an advanced stage before diagnosis, it may have already spread to other parts of your body and be more difficult to treat successfully.

Diagnosis

Your gynecologist or your primary care doctor will conduct a complete medical history and perform a physical and pelvic examination. During the pelvic examination, the doctor feels for any lumps or changes in the shape of the uterus that may indicate a problem.

Diagnosis may or may not involve these other tests:

• Transvaginal ultrasound. Your doctor may recommend a transvaginal ultrasound to look at the thickness and texture of the endometrium and help rule out other conditions. In this procedure, a wand-like device (transducer) is inserted into your vagina. The transducer uses sound waves to create a video image of your uterus. This test helps your doctor look for abnormalities in your uterine lining, and it may be done prior to an endometrial biopsy to locate suspicious-looking tissue.
• Endometrial biopsy. To get a sample of cells from inside your uterus, you'll likely undergo an endometrial biopsy. This involves removing tissue from your uterine lining for laboratory analysis. This may be done in your physician's office and usually doesn't require anesthesia. Because of the increased risk, women who have HNPCC mutations should talk with their doctors about yearly endometrial biopsies beginning around age 35.
• Dilation and curettage (D and C). If enough tissue can't be obtained during a biopsy or if the biopsy suggests cancer, you'll likely need to undergo a D and C. In this procedure, which requires you to be in an operating room under anesthesia, tissue is scraped from the lining of your uterus and examined under a microscope for cancer cells.
• Pap test. Your doctor takes a sample of cells from the cervix, the lower, narrower portion of the uterus that opens into your vagina. Doctors use the Pap test to detect another type of cancer — cervical cancer. Because endometrial cancer begins inside your uterus, it's rarely detectable by a Pap test.

If endometrial cancer is found, you'll likely be referred to a gynecologic oncologist — a doctor who specializes in treating cancers involving the female reproductive system. You'll need more tests (staging) to determine if the cancer has spread (metastasized) to other parts of your body. These tests may include a chest X-ray, a computerized tomography (CT) scan and some blood tests.

In endometrial cancer, final staging is done through a surgical procedure and is done at the same time as any surgical treatment:

• Stage I cancer is found only in your uterus and hasn't spread.
• Stage II cancer is present in both the body of your uterus and in your cervix. In this stage, cancer is no longer confined to the uterus, but hasn't spread beyond the pelvic region.
• Stage III cancer has not involved the rectum and bladder, though pelvic area lymph nodes may be involved.
• Stage IV cancer is the most serious and means that the cancer has spread past the pelvic region and can affect the bladder, rectum and more distant parts of your body.  

Treatments and drugs

Your options for treating your endometrial cancer will depend on the characteristics of your cancer, such as the stage, your general health and your preferences.

Surgery

Surgery to remove the uterus is recommended for most women with endometrial cancer. Most women with endometrial cancer undergo a procedure to remove the uterus (hysterectomy), as well as to remove the fallopian tubes and ovaries (salpingo-oophorectomy). A hysterectomy makes it impossible for you to have children in the future. Also, once your ovaries are removed, you'll experience menopause, if you haven't already.

During surgery, your surgeon will also inspect the areas around your uterus to look for signs that cancer has spread. Your surgeon may also remove lymph nodes for testing. This helps determine your cancer's stage.

Radiation

Radiation therapy uses powerful energy beams, such as X-rays, to kill cancer cells. In some instances, your doctor may recommend radiation to reduce your risk of a cancer recurrence after surgery. If you aren't healthy enough to undergo surgery, you may opt for radiation therapy only. In women with advanced endometrial cancer, radiation therapy may help control cancer-related pain.

Radiation therapy can involve:

• Radiation from a machine outside your body. Called external beam radiation, during this procedure you lie on a table while a machine directs radiation to specific points on your body.
• Radiation placed inside your body. Internal radiation, or brachytherapy, involves placing a radiation-filled device, such as small seeds, wires or a cylinder, inside your vagina for a short period of time.

Hormone therapy

Hormone therapy involves taking medications that affect hormone levels in the body. Hormone therapy may be an option if you have advanced endometrial cancer that has spread beyond the uterus. Options include:

• Medications to increase the amount of progesterone in your body. Synthetic progestin, a form of the hormone progesterone, may help stop endometrial cancer cells from growing.
• Medications to reduce the amount of estrogen in your body. Hormone therapy drugs can help lower the levels of estrogen in your body or make it difficult for your body to use the available estrogen. Endometrial cancer cells that rely on estrogen to help them grow may die in response to these medications.

Chemotherapy

Chemotherapy uses chemicals to kill cancer cells. You may receive one chemotherapy drug, or two or more drugs can be used in combination. You may receive chemotherapy drugs by pill (orally) or through your veins (intravenously). Chemotherapy may be an option for women with advanced endometrial cancer that has spread beyond the uterus. These drugs enter your bloodstream and then travel through your body, killing cancer cells. 

Coping and support

After you receive a diagnosis of endometrial cancer, you may have many questions, fears and concerns. How will the diagnosis affect you, your family, your work and your future? You may worry about tests, treatments, hospital stays and medical bills. Even if a full recovery is likely, you may worry about possible recurrence of your cancer.

Fortunately, many resources are available to help answer questions and provide support. The key is to remember that you don't have to face your questions or fears alone. Here are some strategies and resources that may make dealing with endometrial cancer easier:

• Know what to expect. Find out enough about your cancer so that you feel comfortable making decisions about your care. Ask your doctor for information about the stage, your treatment options and their side effects. In addition to talking with your doctor, look for information in your local library and on the Internet. 
• Be proactive. Although you may feel tired and discouraged, try to take an active role in your treatment. Before starting treatment, you might want a second opinion from a qualified specialist. Many insurance companies will pay for such consultations.
• Maintain a strong support system. Strong relationships may help you cope with treatment. Talk with your close friends and family members about how you're feeling. Connect with other cancer survivors through support groups in your community or online. Ask your doctor about support groups in your area.

Prevention

To reduce your risk of endometrial cancer, you may wish to:

• Talk to your doctor about the risks of hormone therapy after menopause. If you're considering hormone replacement therapy to help control menopause symptoms, talk to your doctor about the risks and benefits. Unless you've undergone a hysterectomy, replacing estrogen alone after menopause may increase your risk of endometrial cancer. Taking a combination of estrogen and progestin can reduce this risk. Hormone therapy carries other risks, such as a possible increase in the risk of breast cancer, so weigh the benefits and risks with your doctor.
• Consider taking birth control pills. Using oral contraceptives for at least one year may reduce endometrial cancer risk. The risk reduction is thought to last for several years after you stop taking oral contraceptives. Oral contraceptives have side effects, though, so discuss the benefits and risks with your doctor.
• Maintain a healthy weight. Obesity increases the risk of endometrial cancer, so work to achieve and maintain a healthy weight. If you need to lose weight, increase your physical activity and reduce the number of calories you eat each day.
• Exercise most days of the week. Work physical activity into your daily routine. Try to exercise 30 minutes most days of the week. If you can exercise more, that's even better.

References:

http://www.cancer.ie/cancer-information/womb-cancer#sthash.0ZYewHZC.dpbs

http://www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial-uterine-cancer-what-is-endometrial-cancer

https://en.wikipedia.org/wiki/Endometrial_cancer

http://www.medicinenet.com/uterine_cancer/article.htm

http://www.stjames.ie/Cancer/CancerType/EndometrialCancer/