Uterine cancer, which in the vast majority of cases is endometrial cancer, is the most common gynecological cancer in developed countries. It mainly affects women after menopause. It produces an early symptom, bleeding, which is why it is usually diagnosed at an early stage, when the chance of cure is very high.
What is uterine cancer?
The uterus is the shape and size of a pear and consists of the body and the cervix. The endometrium is the tissue that lines the inside of the body of the uterus. When its cells multiply uncontrollably, endometrial cancer develops. Less often, the tumor starts in the muscular wall (uterine sarcoma).
Symptoms of uterine cancer
- Postmenopausal bleeding, even a single spot. It is the most common and earliest sign.
- Bleeding between periods or unusually heavy periods before menopause.
- Watery or bloody vaginal discharge.
- Pain in the lower abdomen or during intercourse, usually at a more advanced stage.
Risk factors
The common denominator is prolonged exposure of the endometrium to estrogen without the protection of progesterone:
- Obesity, the most important modifiable factor.
- Diabetes and high blood pressure.
- Polycystic ovary syndrome with infrequent cycles.
- Early first period, late menopause, never having given birth.
- Taking estrogen without a progestin, and taking tamoxifen.
- Hereditary syndromes, mainly Lynch syndrome.
Protective factors include physical exercise, a normal weight, pregnancies and long-term use of combined birth control pills.
How the diagnosis is made
A gynecological examination and your personal medical history are the first step. Transvaginal ultrasound measures the thickness of the endometrium. When it is increased or the bleeding persists, the next steps are hysteroscopy and endometrial biopsy, which give the definitive diagnosis. If cancer is confirmed, your gynecologist refers you to a team specializing in gynecologic oncology, and imaging is done for staging.
Note: the Pap test checks the cervix and does not reliably detect endometrial cancer.
What is the appropriate treatment?
The main treatment is surgical: a total hysterectomy with removal of the fallopian tubes and ovaries and assessment of the lymph nodes. Today, in most cases it is done laparoscopically or robotically, with faster recovery. Depending on the stage and histological type, radiation therapy, chemotherapy or hormone therapy may be added. The stage determines the type of treatment.
In young women with very early, low-grade disease who want to have a child, conservative hormonal treatment under close monitoring is considered in selected cases.
Uterine cancer and cervical cancer: not the same thing
They are often confused, but they are different diseases. Cervical cancer develops in the lower part of the uterus, is almost always caused by HPV, occurs at younger ages and is prevented with the HPV vaccine and Pap test. Read more in the guide on cervical cancer.
Prevention and early diagnosis
There is no routine screening for the general population. Prevention relies on weight control, exercise, managing diabetes and, above all, prompt investigation of any abnormal bleeding. The annual gynecological check-up is the chance to mention anything that concerns you.
Bleeding after menopause: what else it can mean
Bleeding after menopause is a symptom that is always investigated. That does not mean, however, that it is usually caused by cancer. In most women the cause is benign:
- Atrophy of the endometrium or vagina, due to falling estrogen levels. It is the most common cause.
- Polyps of the endometrium or cervix. Read more in the guide on uterine polyps.
- Endometrial hyperplasia, with or without atypia.
- Menopausal hormone therapy, especially in the first months or when the regimen is not properly balanced.
- Submucosal uterine fibroids, less common at this age.
Endometrial cancer is found in about 1 in 10 women who bleed after menopause. A small percentage, but enough that you should not put off getting checked. An early examination makes the difference between a simple procedure and complex treatment.
What endometrial thickness on ultrasound shows
In a postmenopausal woman who is not taking hormones, an endometrium up to 4 mm thick is associated with a very low likelihood of cancer. Above this threshold, a biopsy or hysteroscopy is usually needed. This threshold, however, does not apply to everyone:
- In women taking hormone therapy the endometrium is normally thicker, and the assessment is based on the regimen and the symptoms.
- In women taking tamoxifen the endometrium often looks thick and uneven without any disease being present. Routine ultrasound screening without symptoms is not recommended, but any bleeding is investigated.
- If the bleeding persists, the investigation continues even with a thin endometrium.
Before menopause, thickness changes with the phase of the cycle, so on its own it is not enough. There, the type of bleeding and the risk factors matter more.
Endometrial hyperplasia: the stage before cancer
Hyperplasia is a thickening of the endometrium caused by excessive estrogen stimulation. The classification used today divides it into two categories with very different significance.
Hyperplasia without atypia
The risk of progressing to cancer is low. It is usually treated with progesterone, either by mouth or, preferably, with a hormonal intrauterine device (IUD), along with repeat biopsies. An important part of treatment is correcting the cause: weight loss, regulating the cycles, stopping estrogen taken without a progestin.
Atypical hyperplasia
It is considered a precancerous lesion. In a significant percentage of women who have surgery for atypical hyperplasia, cancer is already found in the final specimen. For this reason, in women who do not want more children, the recommended treatment is hysterectomy. In young women who want to preserve their fertility, hormone therapy with strict monitoring and biopsies at regular intervals is considered.
Types of endometrial cancer and molecular classification
Not all endometrial tumors behave the same way. Traditionally they are divided into two groups:
- Endometrioid carcinoma: the most common form, linked to estrogen and weight, and usually with a good prognosis.
- Non-endometrioid types (serous, clear cell, carcinosarcoma): less common, occur more often at older ages and with a thin endometrium, and are more aggressive.
Current European guidelines (ESGO, ESTRO, ESP) add the molecular classification of the tumor into four subgroups: POLE mutation, mismatch repair deficiency (MMRd), no specific molecular profile and p53 mutation. This information helps decide which women need additional treatment after surgery and which can safely avoid it. MMR testing also identifies women who may have Lynch syndrome.
Staging: what the stage of the disease means
The stage is determined mainly by the pathology examination after surgery, according to the FIGO system. In simple terms:
- Stage I: the tumor is confined to the body of the uterus. Most women are diagnosed at this stage.
- Stage II: it extends to the cervix.
- Stage III: it reaches the adnexa, the vagina or the pelvic or aortic lymph nodes.
- Stage IV: it invades the bladder or bowel, or there are distant metastases.
To assess the lymph nodes, doctors increasingly use a technique based on the sentinel lymph node: a special dye is used to locate and remove only the first lymph nodes that drain the area. This avoids extensive lymphadenectomy and significantly reduces the risk of lymphedema in the legs.
Lynch syndrome and inherited risk
Lynch syndrome is an inherited disorder that increases the risk of colorectal, endometrial and ovarian cancer. For women who carry it, the lifetime risk of endometrial cancer is many times that of the general population, and the disease can appear before age 50.
Suspect it if several relatives in your family have had bowel or uterine cancer, especially at a young age. In that case, genetic counseling is recommended. Carriers are monitored closely, and once their family is complete, usually around age 40 to 45, preventive hysterectomy with removal of the adnexa is discussed.
Life after treatment
Most women return fully to their daily lives. Follow-up is usually every 3 to 6 months for the first two to three years and less often until five years have passed. It is based mainly on clinical examination and symptoms, not on routine blood tests.
Report right away any vaginal bleeding, pain in the pelvis or lower back, swelling in the legs, unexplained weight loss or a persistent cough.
Removing the ovaries in a woman before menopause causes sudden symptoms, such as hot flashes and dryness. Vaginal radiation therapy can cause narrowing and painful intercourse, which can be prevented with vaginal dilators and lubricants. For women with early, low-risk disease, hormone therapy for menopausal symptoms can be discussed on an individual basis. If you are already in perimenopause, ask to have it explained in advance what will change.
Questions worth asking your doctor
- What is the histological type and grade of the tumor?
- Was molecular testing done, and what did it show?
- Will my ovaries be removed, and what are the consequences at my age?
- Will sentinel lymph node assessment be done?
- Will I need additional treatment after surgery?
- Is genetic testing needed for me or my children?
Write down the answers. In such an emotionally charged conversation, few people remember the details later.
How an endometrial biopsy is done
The word “biopsy” is frightening, but in practice it is a short procedure. There are two main methods:
- Office biopsy (pipelle): a thin flexible tube is passed through the cervix and suctions a small amount of tissue. It takes one to two minutes and causes a cramp similar to period pain. A pain reliever taken an hour beforehand helps.
- Hysteroscopy with targeted biopsy: preferred when a simple biopsy does not provide enough tissue, when a polyp is suspected or when bleeding persists despite a normal result. It lets the doctor look directly inside the uterus.
After the biopsy it is normal to have light bleeding for one to two days. Fever, severe pain or foul-smelling discharge mean you should contact your doctor. The pathology result usually comes back within one to two weeks.
Everyday choices that lower the risk
Endometrial cancer is one of the cancers most closely linked to body weight. Fat tissue produces estrogen, which after menopause stimulates the endometrium without any counterbalance. What helps in practice:
- Weight loss, even moderate. Studies show that sustained weight reduction is linked to a lower risk.
- Regular physical activity, at least 150 minutes of moderate intensity per week.
- Good blood sugar control in women with diabetes or insulin resistance.
- Regulating cycles in women with infrequent periods, so that the endometrium is shed regularly, using a progestin or a birth control pill.
- Telling your doctor if you take tamoxifen or estrogen, so that they know which symptoms to investigate.
When a biopsy is needed before menopause
In younger women, menstrual irregularities are very common and rarely mean cancer. An endometrial biopsy is recommended, however, when certain factors are present:
- Age over 45 with irregular or heavy bleeding.
- Younger age with obesity or polycystic ovaries and long stretches without a period.
- Bleeding that does not improve with treatment after three to six months.
- A family history of Lynch syndrome.
If you belong to any of these groups, do not settle for hormonal regulation before a serious cause has been ruled out.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
What is the first symptom of uterine cancer?
Abnormal vaginal bleeding. After menopause, any bleeding, however small, must be checked right away.
Does the Pap test detect it?
Not reliably. The Pap test checks the cervix. Endometrial cancer is diagnosed with ultrasound and endometrial biopsy.
Is endometrial cancer curable?
When it is found at an early stage, as happens in most women, surgical treatment leads to a cure in the great majority of cases.
Which women are at greatest risk?
Postmenopausal women with excess weight, diabetes, polycystic ovaries, tamoxifen use or a family history of Lynch syndrome.
How is it different from cervical cancer?
Endometrial cancer starts inside the body of the uterus and is linked to hormonal factors. Cervical cancer is caused by HPV and is prevented with vaccination and the Pap test.
Can endometrial cancer occur before menopause?
Yes, although it is less common. A small percentage of cases involve women under 40, usually with obesity, polycystic ovaries, chronic anovulation or Lynch syndrome. In these women, irregular and heavy periods that do not respond to treatment need an endometrial biopsy.
How soon should I get checked if I bleed after menopause?
Within a few days, not weeks. There is no need to panic, because the cause is usually benign, but the evaluation should not be put off, even if the bleeding was a single spot that stopped.
Does menopausal hormone therapy increase the risk?
Estrogen alone increases the risk in a woman who has a uterus. That is why it is always combined with a progestin, which protects the endometrium. With the right regimen, the risk does not increase meaningfully. Any unexpected bleeding during treatment should be reported.
Will I need chemotherapy after a hysterectomy?
Most women with early, low-risk disease need no further treatment. The decision is based on the stage, histological type, grade and molecular profile of the tumor, and is made by a tumor board.
Does treatment affect my sex life?
After recovery, usually in 6 to 8 weeks, most women return to a normal sex life. Vaginal dryness or narrowing after radiation therapy is managed with lubricants, moisturizers and vaginal dilators.
