A woman’s uterus is made up of two main parts, the wall of myometrium and the lining of the inside of the uterus or endometrium. The myometrium is the muscular wall of the uterus and the endometrium is the lining that is shed during menstrual period. Most cancers of the uterus involve endometrium or lining, this is endometrial cancer. 85% of endometrial cancers are detected in Stage I or at an early stage, this is because symptoms develop even in early cancer. In Singapore, uterine cancer is the 5th most common cancer in women, but only 8th most deadly cancer in women. So although uterine cancer may be fairly common, it can be treated effectively. That is why it is important to be aware of the symptoms associated with uterine cancer and to seek medical attention should these symptoms develop.
What is uterine cancer?
Our bodies are made up of tissues and tissues in turn are made up of groups of healthy cells. In uterine cancer, the cells of the tissues in the uterus become abnormal and behave abnormally. These abnormal cells begin to grow uncontrollably. Sometimes these changes reverse themselves when the body’s repair mechanisms kick in. Sometimes these changes cannot be reversed or repaired and the abnormal cells grow into tumors.
In the case of uterine cancer, the majority of these tumors arise from the endometrium or lining of the uterus. These tumors then invade the healthy tissues of the wall or myometrium. In early stage uterine cancer, the cancer is confined to the uterus or has not spread outside of the uterus. In advanced uterine cancer, the cancer cells will have spread to tissues outside of the uterus, to areas such as the cervix and vagina or to the lymph nodes in the pelvis and upper abdomen.
Who is at risk for uterine cancer?
Age. Uterine cancer rarely occurs in women younger than age 40. The age of peak incidence of uterine cancer is around age 60.
Estrogen therapy. A woman who still has her uterus who receives estrogen hormone therapy without being given progestin hormone therapy at the same time will be at increased risk for developing endometrial cancer. Most hormone replacement therapy treatments involve the use of both estrogen and progesterone. This combination therapy does not increase the risk of endometrial cancer.
Early menarche, Late menopause. If a woman began having her periods at a very young age and stopped having her periods late in life she has an increased risk of developing endometrial cancer.
Parity. The number of pregnancies and babies a woman has in her lifetime is associated with her risk of developing endometrial cancer. The more pregnancies, the lower the risk. The fewer pregnancies, the higher the risk.
Breastfeeding. The longer a woman breastfeeds the lower the risk for endometrial cancer.
Medical conditions. Women with a history of high blood pressure, gallbladder disease, diabetes or thyroid disease are at an increased risk for developing endometrial cancer.
Breast cancer. If a woman has had breast cancer, she will often be given oral Tamoxifen to decrease the risk of recurrent breast cancer (the cancer coming back). Tamoxifen use does increase a woman’s risk for developing endometrial cancer. It is important that if you are currently using Tamoxifen or have used Tamoxifen in the past, that you be in the care of a women’s healthcare specialist who will help monitor you for changes in the endometrium.
Symptoms of uterine Cancer
The most obvious symptom of endometrial cancer is abnormal bleeding. The most common bleeding pattern is that of bleeding in between your periods. So if your menstrual periods were previously regular and you notice that your periods have become irregular in both timing, quantity and character, you should consult a women’s healthcare provider promptly.
Women who have stopped having their periods because they have reached menopause or breast cancer patients (who sometimes stop having their periods after breast cancer treatment) should consult a women’s healthcare provider promptly if vaginal bleeding resumes.
How is uterine cancer diagnosed?
When a woman notices that she has irregular menstrual periods or unusual vaginal bleeding, she should consult with a women’s healthcare provider promptly. Test will immediately be recommended:
- Transvaginal ultrasonography. This is an ultrasound examination of the lining of the uterus. In menopausal women, this lining will appear as a thin stripe. This lining will be unusually thickened in endometrial cancer./
- Endometrial sampling. This is a simple test done in the office or clinic and is much like having a Pap smear test done. A small sampling straw is placed into the uterine cavity and a small sample of the endometrium or uterine lining is collected and sent to the laboratory for investigation. This test is associated with some mild abdominal cramping like period cramping.
If endometrial sampling cannot be safely of comfortably done in the office, then your healthcare provider will likely recommend a day procedure known as a “D&C” or dilation and curettage. This is a simple day procedure where you will be given medicine to help relax the opening of the uterus (the cervix) and the lining of the uterus is then collected using a curette. The uterine lining collected is then sent to the laboratory for investigation.
How is uterine cancer treated?
Endometrial cancer is usually detected early. Early endometrial cancer is treated surgically. Surgery for endometrial cancer involves removal of the uterus, Fallopian tubes and ovaries. Whether or not the lymph nodes of the pelvis and abdomen need to be removed is something you can discuss with your gynaecologic oncologist (a gynaecologist who has special training or experience in treating gynaecologic cancers).
There are also different ways in which the tumor can be successfully removed. The traditional approach has been to open the abdomen and to perform the necessary surgery through this abdominal opening. More contemporary methods include laparoscopy and robot-assisted techniques. Both these methods are similar in that they do not require opening the abdomen and as such, patients do not have to recover from an abdominal wound and have shorter hospital stays. The difference between these 2 methods is that laparoscopy for endometrial cancer is harder to carry out especially if the lymph nodes need to be removed.
At NUH, virtually all endometrial cancer surgery is done with robot-assistance. Our patients feel well enough to return home the very next day after major cancer surgery.
If you need surgery for endometrial cancer, you should consult a women’s healthcare provider and ask about the options that are available to you.
After surgery, examination of the tissues may show cancer cells outside of the uterus or may reveal features that increase the risk of spread outside of the uterus. In these cases, adjuvant radiation or radiation therapy that follows surgery may be recommended to decrease the risk of recurrent cancer. In most cases, no further treatment is necessary after surgery. This is why it is important to be in the care of a gynaecologic oncologist who has the training and experience to help you make the right treatment recommendations and decisions.
After completing your treatment, your healthcare team will continue to be follow up on your condition with up to 4 visits per year in the first 2 years after treatment. This is because the likelihood of cancer returning after treatment (recurrence) is highest during this period of time. Pap smears of the top of the vagina (vaginal vault) and pelvic examinations will allow your healthcare providers to monitor your progress and response to treatment.
The most common form of uterine cancer is endometrial cancer.
Endometrial cancer is usually detected early and can be successfully treated.
It is therefore important for women to seek medical attention for any abnormal bleeding such as bleeding in between periods (intermenstrual bleeding) or bleeding after they have stopped having periods (postmenopausal bleeding).
The treatment of uterine cancer is usually surgical. It is unlikely that women who have early stage uterine cancer will need any more treatment after surgery.
Women who are diagnosed with endometrial cancer should therefore be in the care of a gynaecologic oncologist.