Endometrial Cancer

Question 1

What is the most common type of endometrial cancer

Answer 1

80% = adenocarcinoma

Question 2

What hormone is implicated in endometrial cancer?

Answer 2

Oestrogen-dependent cancer - oestrogen stimulates the growth of endometrial cancer cells

Question 3

What is the precancerous condition of endometrial cancer?

Answer 3

Endometrial hyperplasia = involves the thickening of the endometrium

Question 4

What happens to most cases of endometrial hyperplasia?

Answer 4

Returns to normal over time

Question 5

How often does endometrial hyperplasia go onto be endometrial cancer?

Answer 5

<5%

Question 6

What are the 2 types of endometrial cancer?

Answer 6

• hyperplasia without atypia
• atypical hyperplasia

Question 7

How is endometrial hyperplasia treated?

Answer 7

By a specialist using progesterone with either:

• intrauterine system (eg Mirena coil)
• continuous oral progestogens (eg medroxyprogesterone or levonorgestrel)

Question 8

What is the basis for some of the risk factors for endometrial cancer?

Answer 8

Exposure to unopposed Estrogen
- refers to estrogen without progesterone
- stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer

Question 9

What are some risk factors for endometrial cancer due to unopposed estrogen exposure?

Answer 9

• increased age
• earlier onset of menstruation
• late menopause
• oestrogen only hormone replacement therapy
• no or fewer pregnancies
• obesity
• PCOS (lack of ovulation means no progesterone from the corpus luteum)
• tamoxifen

Question 10

What should women with PCOS have for endometrial protection?

Answer 10

One of the following:
* combined contraceptive pill
* intrauterine system (eg Mirena coil)
* cyclical progestogens to induce a withdrawal bleed

Question 11

How does obesity impact unopposed estrogen and thereby increase the risk of endometrial cancer?

Answer 11

Adipose tissue is a source of oestrogen - primary source in post menopausal women

Adipose tissue contains aromatase enzyme that converts androgens like testosterone into oestrogen

Question 12

How does tamoxifen impact unopposed estrogen production?

Answer 12

• anti-oestrogenic effect on breast tissue
• oestrogenic effecet on endometrium

Question 13

What are some additional risk factors for endometrial cancer not related to unopposed oestrogen?

Answer 13

• type 2 diabetes (increased insulin = stimulate endometrial cells)
• HNPCC or Lynch syndrome

Question 14

What are some protective factors for endometrial cancer?

Answer 14

• COCP
• Mirena coil
• increased pregnancies
• smoking (in post menopausal women by being anti-oestrogenic)

Question 15

How does endometrial cancer present?

Answer 15

• postmenopausal bleeding
• postcoital bleeding
• intermenstrual bleeding
• unusually heavy menstrual bleeding
• abnormal vaginal discharge
• Haematuria
• anaemia
• raised platelet count

Question 16

What are the referral criteria for endometrial cancer?

Answer 16

Referral for a 2 week wait = PMB

TVUS in women over 55 with unexplained vaginal discharge or visible Haematuria plus raised platelets, anaemia or elevated glucose levels

Question 17

What is PMB?

Answer 17

Bleeding more than 12 months after the LMP

Question 18

What 3 investigations are used for the diagnosis/exclusion of endometrial cancer?

Answer 18

• TVUS for endometrial thickness (normal <4mm post menopausal)
• pipelle biopsy (highly sensitive = useful for excluding) (outpatient)
• hysteroscopy with endometrial biopsy

Question 19

How is endometrial cancer staged?

Answer 19

FIGO
Stage 1 = confined to uterus

Stage 2 = invades cervix

Stage 3 = invades ovaries, Fallopian tubes, vagina or lymph nodes

Stage 4 = invades bladder, rectum or beyond pelvis

Question 20

What is the usual treatment for stage 1 & 2 endometrial cancer?

Answer 20

Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO)

Question 21

What other treatments are available for endometrial cancer?

Answer 21

• radical hysterectomy (includes pelvic lymph nodes, surrounding tissues and top of vagina)
• radiotherapy
• chemotherapy
• progesterone (slow progression of cancer)