This has been prepared to help you understand more about cancer of the uterus. Cancer of the uterus is also called:
- cancer of the womb
- uterine cancer
- endometrial cancer
- cancer of the lining of the womb.
Many women feel understandably shocked and upset when told they have or may have cancer of the uterus. This information aims to help you to understand how cancer of the uterus is diagnosed and treated. We also include information about support services. We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors.
What is the uterus, and what does it do?
The uterus, or womb, is part of a woman’s reproductive system.
It is about the size and shape of a hollow, upside-down pear. The uterus sits low in the abdomen between the bladder and rectum and is held there by muscle. It is joined to the vagina (birth canal) by the cervix, which is the neck of the uterus. The uterus is where a foetus grows.
The uterus is made up of two layers:
- Myometrium – the outer layer of muscle tissue. This makes up most of the uterus.
- Endometrium – the inner layer or the lining of the uterus.
In a woman of childbearing age, the endometrium changes in thickness each month to prepare for pregnancy. If the egg is not fertilised, the lining is shed and flows out of the body through the vagina. This flow is known as a woman’s period (menstruation).
When a woman releases an egg from her ovary (ovulates), the egg travels down her Fallopian tube into the uterus. If the egg is fertilised by a sperm, it will implant itself into the lining of the uterus and grow into a baby.
Menopause occurs when a woman no longer releases the hormones that cause ovulation and menstruation. A menopausal woman’s periods stop, and she is not able to become pregnant. The uterus becomes smaller and the endometrium becomes thinner and inactive.
What is uterine cancer?
Uterine cancer commonly begins from abnormal cells in the lining of the uterus (endometrium) but may also begin in the muscle tissue (myometrium) or other connective tissue (called the stroma).
There are two main types of uterine cancer:
Endometrial cancers begin in the lining of the uterus. The most common type is called adenocarcinoma. Other types of endometrial cancers are adenosquamous carcinoma, serous carcinoma and clear cell carcinoma, which grow more rapidly and are usually more aggressive than adenocarcinoma.
Uterine sarcomas develop in the muscle layer or connective tissue of the uterus. They are rare and tend to spread to other parts of the body. The most common sarcoma is leiomyosarcoma. Other types are endometrial stromal sarcoma and mixed Müllerian sarcoma (or carcinosarcoma).
How common is it?
Cancer of the uterus is the most common gynaecological cancer:
- About 625 women in NSW are diagnosed each year
- Seventh most common cancer in women
- One in 52 females will develop uterine cancer by the age of 85
What is the cause?
In most cases, the exact cause of cancer of the uterus is unknown. Some factors may increase a woman’s risk:
- age – uterine cancer is more common in women aged over 50
- being menopausal – most common in postmenopausal women
- endometrial hyperplasia, a condition that occurs when the endometrium grows too thick
- never having children or infertility
- early menarche (first menstrual period)
- high blood pressure (hypertension) and diabetes
- a family history of ovarian, endometrial, breast or bowel cancer
- previous pelvic radiation for cancer
- ovarian tumours or polycystic ovary syndrome
- taking oestrogen hormone replacement without progesterone
- taking the drug tamoxifen for the treatment of breast cancer
In a small number of women diagnosed with endometrial cancer there may be an inherited faulty gene in their family that increases the risk of developing endometrial cancer. The genetic condition known to cause an increased risk of endometrial cancer is known as Lynch syndrome or hereditary non-polyposis colorectal cancer (HNPCC). Families with this inherited faulty gene are at increased risk of developing cancers of the bowel, endometrium, ovary and pancreas – often at a younger age than would normally be expected. You may want to discuss this with your doctor if you are concerned.
What are the symptoms?
The most common symptom of uterine cancer is abnormal bleeding or discharge from the vagina, especially after a woman has reached menopause. It may appear as watery or bloody and may be smelly. Less common symptoms can include discomfort or pain in the lower abdomen, difficult or painful urination, or pain during sex. Your GP will examine you and refer you for tests to see if you have cancer.
How is uterine cancer diagnosed?
A physical examination is often performed in women with abnormal vaginal bleeding. This will include an external examination to feel for abdominal swelling and an internal examination of the vagina, cervix and vulva. Further tests are then required to find out more about where the cancer is located and what sort of cells are involved. The following tests may be undertaken:
Transvaginal ultrasound is a type of pelvic ultrasound. A soundwave-emitting sensor is inserted into the vagina and a computer is used to generate a picture of the internal organs so the doctor can look at the size of the ovaries and uterus and the thickness of the lining of the uterus (endometrium). The procedure takes about 30 to 60 minutes and is painless, but you may feel a light amount of pressure.
Direct examination of the lining of the uterus by hysteroscopy is the most common way to diagnose endometrial cancer. It allows the doctor to thoroughly examine the uterine cavity and collect tissue samples from any abnormal areas which are then sent to a pathologist to look at under a microscope. Hysteroscopy can give an indication of how much of the lining is involved and whether the abnormal tissue extends to the cervix. Tissue biopsy provides information about the type of cells involved so that the care team can work out the best treatment.
Hysteroscopy may be performed as an outpatient with or without sedation or may be performed under light general anaesthesia in an operating theatre in a hospital or a day surgery unit. During this procedure, the cervix is stretched and opened with a speculum and a thin instrument attached to a television camera is inserted into the vagina and through the cervix into the uterine cavity. The hysteroscope send images from inside the uterus to a screen. The doctor can then take out a small sample of tissue by direct biopsy or by scraping the suspicious areas. Sometimes the entire lining of the uterus is removed by curettage during the procedure.
Hysteroscopy may take a couple of hours. There may be period-like cramps and some light bleeding for a few days afterwards.
Other tests may be conducted in order to check general health and see whether the cancer has spread. This may include blood tests, a chest X-ray or any of the following scans:
A CT (computerised tomography) scan uses X-ray beams to create a detailed, three-dimensional image of the body. The CT scanner is a large, circular machine. The patient lies on a table as the scanner rotates. The scan takes approximately 30 to 40 minutes. To make the image clearer, patients may be asked to drink a special liquid that contains a dye. The dye may cause the patient to experience a hot feeling all over for a few minutes. Tell your doctor if you are allergic to iodine or any dye.
MRI, also called nuclear magnetic resonance imaging or NMRI uses radio waves and a powerful magnet to create a cross-sectional image of the body. The image can show the difference between healthy tissue and diseased tissue. The MRI scanner is like a big metal tube. The patient lies on a table that moves in and out of the tube. The scan takes about an hour to complete. The patient may be injected with a dye before the scan to make the image clearer. Some women feel claustrophobic during this scan – your medical team may be able to give you medication to reduce this feeling.
Staging uterine cancer
The stage of a cancer is a term used to describe whether it has spread to other tissues including the lymph nodes. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment. Uterine cancer is divided into four stages, which are described below:
Stage I – The cancer is confined to the uterus.
Stage II -The cancer involves the uterine body and cervix.
Stage III – The cancer has spread beyond the uterus/cervix to the ovaries, fallopian tubes, vagina or nearby lymph nodes.
Stage IV – The cancer has spread further, to the inside of the bladder or rectum, throughout the abdomen or to other body parts. Your doctor may also tell you the grade of the cells. This tells you how quickly the cancer may develop. Low-grade cancer cells are slow growing and less likely to spread. High-grade cells look more abnormal and are more likely to grow and spread quickly. Knowing the stage and grade of the cancer helps your doctor decide on the most appropriate treatment.
Prognosis means the expected outcome of a disease. You will need to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of your disease.
The earlier the uterine cancer is diagnosed the higher the chances of successful treatment and cure.
Test results, the type of uterine cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and medical history are all important in assessing your prognosis.
Which health professionals will I see?
Specialists and other health professionals who care for people with cancer of the uterus include:
- General practitioner (GP) – arranges the first tests to investigate your symptoms
- Gynaecological oncologist – a surgeon with specialist training in cancer of the female reproductive system and its treatment
- Medical oncologist – prescribes and coordinates targeted therapies and chemotherapy.
- Radiation oncologist – prescribed and coordinates radiotherapy.
- Nurses – support you through all stages of your cancer treatment.
- Cancer care coordinator or clinical nurse consultant (CNC) – supports patients and families throughout treatment and liaises with other staff.
- Dietician – recommends an eating plan to follow while you’re in treatment and recovery.
- Social workers, counsellors, physiotherapists and occupational therapists – link you to support service social worker, and help with emotional, physical or practical issues.
Uterine cancer is often diagnosed before it has spread, so surgery is usually the best and most effective way to treat it. Many women do not need any other treatment. If the cancer has spread beyond the uterus, other therapies such as radiotherapy, hormone treatment or chemotherapy may be used in addition to surgery.
Most women with uterine cancer will be treated with the surgical removal of the uterus and cervix (total hysterectomy) and removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy). The ovaries are removed because cancer of the uterus is likely to spread there, but also because the ovaries produce hormones that may encourage any remaining cancer cells to grow and multiply.
Hysterectomy is done under general anaesthesia as open abdominal surgery (laparotomy), or in certain situations, as keyhole (laparoscopic) surgery. During the procedure, fluid from the pelvis is collected and sent for microscopic examination as part of the staging procedure. The surgeon also inspects the pelvis and abdomen for any signs that the cancer has spread to nearby lymph nodes or other tissue or organs. The uterus, fallopian tubes and ovaries are then removed and the uterus is opened to see the extent of spread into the muscle layer.
Depending on the type of uterine cancer and how far it has spread, a decision will be made regarding removal of nearby lymph nodes (lymphandenectomy). In certain tumour types the fatty apron that hangs from the stomach (omentum) may also be removed.
At the end of surgery, the abdomen is closed and the removed tissues and organs are sent to a pathologist for formal staging of the cancer and to confirm the grade and type of tumour. After the results become known, further treatment options will be discussed.
Radiotherapy targets high energy X-rays at cancer cells to damage or destroy them. Treatment is usually given as an outpatient. The number of treatments varies but can be up to 5 days a week for 4 to 6 weeks. The treatment takes just a few minutes, and it is painless.
Radiation can also be used to ease the pain of metastases and stop tumours from bleeding. Generally, doctors try to limit the amount of radiation that your vital organs receive, and do not like to treat large portions of the bowel and pelvis.
Radiotherapy may be recommended if you are not well enough for a major operation. It is also commonly used as an additional treatment to reduce the chance of the disease coming back. This is called adjuvant therapy. There are two ways radiotherapy is given:
From inside the body (internal) – radioactive material is put in thin tubes and placed near the cancer. This is called brachytherapy and may be given alone or in combination with external radiotherapy
From outside the body (external) – a machine directs radiation at the cancer and surrounding tissue.
In certain less common uterine cancers and sarcomas, chemotherapy is used because of a high risk of cancer spread, or because of known cancer spread or recurrence. There are many different chemotherapy drugs, and they are often given in combinations. You may have to go to a clinic to get the chemotherapy because many of the drugs have to be given through a vein in the arm. Different chemotherapy regimens are used for different purposes. Sometimes new combinations are tried if there is not a response to an initial combination.
There are advantages and disadvantages to each of the different regimens that your medical oncologist will discuss with you. Based on your health, your personal values and wishes, and side effects you may wish to avoid, you can work with your doctors to come up with the best regimen for your cancer and your lifestyle.
Hormones are substances that are produced naturally in the body. They act as chemical messengers and help control the growth and activity of cells. Some cancers of the uterus depend on hormones (such as oestrogen) to grow. Hormone treatment works by stopping the hormones reaching the cancer cells.
Hormone treatment can work well if the cancer has spread or if the cancer has come back (recurred). Your doctor will discuss with you how long you will need to have hormone treatment. It is also sometimes offered in the first instance if surgery is not an option. Hormone treatments that may be used as treatment for uterine cancer include:
Progesterone – This hormone occurs naturally in women. It may help to shrink the cancer and control symptoms. Artificial progesterone is available as tablets, but sometimes it’s given as an injection by your GP or nurse. The most common types are medroxyprogesterone (Provera) and megestrol (Megace). Progesterone is often given for several months or years.
Tamoxifen – An anti-oestrogen drug that is taken as a tablet. If you would like more information, talk to your doctor or pharmacist about the risks and benefits of this medication.
Women with advanced cancer are often referred for palliative care. Palliative treatment helps improve quality of life by alleviating the symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer. Sometimes treatment is concerned with pain relief and stopping the spread of cancer. In other cases, it manages emotional symptoms of cancer.
Palliative treatment may involve radiotherapy, chemotherapy and other medication.
After your treatment is over, you will need regular checkups with your doctor or your cancer treatment centre. Blood tests will be done to check your general health and your blood count. Regular checkups can help find a recurrence early, and this gives you the best chance of getting the disease under control.
Checkups will continue for several years but will become less frequent if you have no further problems.
Between follow-up appointments, let your doctor know immediately of any health problems.