Cancer of the endometrium, the lining of the uterus is a common cancer amongst women worldwide. Although it may be devastating to receive a diagnosis of cancer, endometrial cancer is detected early and easily curable. The cancer cells develop from the lining of the uterus which is under the influence of hormones- estrogens and progesterone. The ovaries produce estrogens and progesterone in equal amounts during the first and later half of menstrual cycle respectively. During the first half the endometrium grows in thickness, while in the later half it becomes more vascular and rich in glands. It is an imbalance between these hormones which is believed to cause endometrial cancer.
Although the exact cause of endometrial cancer is not known, many factors are known to increase the risk of endometrial cancer in women. Some of the important factors include:
- Many years of menstruation: An early menarche and late menopause increase the risks of endometrial cancer due to the increased exposure to estrogens.
- Never having been pregnant: Pregnancy seems to decrease the risk of endometrial cancer, although the reasons are not clear. It is possible that pregnancy has a beneficial effect on the balance of hormones thus reducing risk of endometrial cancer.
- Irregular ovulation: It has been observed that women with PCOS have a higher risk of endometrial cancer. Irregular ovulation may be implicated and this may again be due to hormonal imbalances.
- Obesity: Ovaries aren't the only source of estrogen, fat can also produce estrogen. 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:A high fat diet can also increase the risk of endometrial cancer by probably interfering with estrogen metabolism.
- Diabetes: Endometrial cancer is more common in women with diabetes, possibly because obesity and type 2 diabetes often go hand in hand.
- 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:Endometrial cancer is a disease of elderly women, aged over 55 years.The older you are, the greater your risk of endometrial cancer.
- Personal history of breast cancer or ovarian cancer: A history of breast cancer or ovarian cancer increases the risk of endometrial cancer. Some mutations associated with breast cancer causes endometrial cancer and women with such mutations amy be offered prophylactic hysterectomy.
- Tamoxifen treatment: One in every 500 women treated with tamoxifen for breast cancer 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.
- 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). Women with HNPCC are 40-60 more likely to develop endometrial cancer in addition to other cancers. This condition is associated with a mutation thus hampering DNA repair.
The common symptoms of endometrial cancer 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
The most common reason for consultation is bleeding either after menopause or bleeding between periods. Before you go to the doctor, you may want to recollect some important information like the exact character and duration of bleeding and time of onset. It is not necessary to accurately quantify bleeding but it helps if you can. Also mention any pelvic pain or foul smelling, non bloody vaginal discharge. You may also want to prepare a list of questions about your condition. The commonly asked questions are
- What causes endometrial cancer?
- What are the treatment options?
- Will I have my uterus and ovaries removed?
- How will it impact my life?
- Are there any alternative therapies?
It is also advisable to take a friend or relative to the consultation. The doctor will first take a detailed history from you. Mention any pertinent points the doctor could have missed. Following a general physical exam, the doctor will examine your abdomen. Lastly a pelvic exam may be done to ascertain the size and mobility of the uterus.
This is followed by a trans vaginal ultrasound which identifies any abnormalities in the endometrium and also is a good estimate of thickness of endometrium. The diagnosis of cancer of endometrium is done by examination of tissue obtained by biopsy. Tissue for pathology is obtained by a procedure called D&C. In this procedure, the cervix is dilated by means of serial dilators and the lining of the uterus is scraped and submitted for pathology.
Once cancer of the endometrium is diagnosed women will require further tests to stage the disease. A CT scan of the abdomen and chest X-Ray is also done. In addition blood tests and a PAP smear is also done.
Endometrial cancer is classified into following stages based on spread. The stages are:
- 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.
Surgery is the treatment of choice for endometrial cancer. The commonly done procedure is a simple Hysterectomy or a more radical procedure called Warthims Hysterectomy. In hysterectomy the uterus is removed. Depending on the local spread of cancer, along with the uterus ovaries, supports of uterus and the broad ligament may also be removed. Finally the lymph nodes of the pelvic and aortic groups may also be dissected and removed for more complete eradication of the cancer.
Apart from surgery few other treatment modalities are also used. They are
- Radiotherapy is often used as a adjunct in treatment of endometrial cancer either as a primary modality or as an adjunct to surgery or to prevent recurrence. Radiation administered from an external source is called external beam radiotherapy. Radiotherapy can also be delivered by placing a probe inside the uterus. This is called as brachytherapy. Brachytherapy has fewer side effects but can only be used for small limited cancers.
- Chemotherapy is generally reserved for stage III and IV cancer. Combination chemotherapy with two or more agents is used. Chemotherapy has plenty of side effects and women must discuss the pros and cons of chemotherapy with their doctor.
- Hormonal Therapy is sometimes used in locally contain cancers in women who wish to conserve fertility. However the risks of recurrence are high and all outstanding issues should be discussed with the doctor.
Although the precise cause of endometrial cancer is not known, some measures are known to provide protection against endometrial cancers. Prominent amongst them include
- Combined contraceptive pill: Women who take the combined pill are known to have lesser rates of endometrial cancer. This is probably mediated by the beneficial effect of OCP on estrogen-progesterone balance.
- Maintain healthy weight: Since obesity is one of the risk factors for endometrial cancer, weight loss can help reduce the risk of endometrial cancer to a great extant. Consumption of a low fat diet will also help reduce the risks.
- Exercise: Exercise is a very good way to prevent endometrial cancer. Women who exercise regularly have a 50% less risk of developing endometrial cancer.
Although the diagnosis of endometrial cancer can come as quite a shock to women, one can take solace from the fact that this cancer presents early and is easily curable. Women should remain proactive in their treatment and empower themselves with information about this deadly disease.