Endometrial Cancer

Question 1

What are the risk factors for endometrial cancer?

Answer 1

Risk Factors (UNOPPOSED OESTROGEN)
• Obesity (adipose tissue produced androgens and so oestrogen)
• Early menarche – later menopause
• Nulliparity
• Polycystic ovarian disorder (irregular periods = anovulation = unopposed oestrogen)
• Tamoxifen
• Previous breast or ovarian cancer
• HNPCC (hereditary non-polyposis colorectal carcinoma)/Lynch syndrome
• BRCA 1/2 for specific types of endometrial cancer
• Endometrial polyps
• Diabetes

Question 2

What is protective against endometrial cancer?

Answer 2

• Continuous combined HRT
• Combined oral contraceptive pill
• Smoking
• Physical activity
• Tea and Coffee

Question 3

How does endoemtrial cancer usually present?

Answer 3

• If pre-menopausal – prolonged or irregular menstrual bleeding and intermenstrual bleeding
• If postmenopausal then postmenopausal vaginal bleeding and sometimes blood stained watery or purulent discharge
• Rarely – abnormal cervical smears
• Advanced disease may present with abdominal pain or weight loss

Question 4

What are the 2 histological types of endometrial cancer?

Answer 4

Type 1 80% : Endometrioid – More common, mimics proliferative glands i.e. looks like endometrium, typically arises associated with endometrial hyperplasia. Associated with unopposed oestrogen and obesity.
Type 2 20%: Papillary serous, clear cells or Carcinosarcoma (Sarcoma = very rare)

Question 5

What is the FIGO staging of endometrial cancer?

Answer 5

Stage, spread and 5 year survival percentage

1 Limited to myometrium 80%
2 Cervical spread 60%
3 Uterine, ovarian, pelvic/paraaortic lymph nodes 40%
4 Bladder/bowl involvement and distant metastases 20%

Question 6

What differentials should be considered for post menopausal bleeding?

Answer 6

• Vaginal atrophy – thinning, drying and inflammation of the walls of the vagina due to reduction in oestrogen following the menopause.
• HRT – periods or spotting can occur when on HRT especially is there is an oestrogen component as this will cause endometrial hyperplasia
• Endometrial hyperplasia
• Cervical cancer
• Vaginal cancer
• Trauma

Question 7

What is endometrial hyperplasia?

Answer 7

Frequent precursor to endometrial carcinoma. Increased gland to stroma ratio. Can be present with atypical cells in which case malignancy usually co exists. Can also cause post-menopausal bleeding, intermenstrual bleeding or irregular bleeding.

Question 8

What are the different types of endometrial hyperplasia?

Answer 8

Types
•	Simple
•	Complex
•	Simple atypical
•	Complex atypical

Question 9

How should endometrial hyperplasia be managed based upon its type?

Answer 9

Management
• Simple or complex endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. Mirena may be used.
• Atypia – a total hysterectomy is advisable for all women, due to the risk of malignant progression, with bilateral salpingo-oophorectomy in addition for postmenopausal women.

Question 10

How is endometrial cancer managed?

Answer 10

Surgical treatment options are preferred – hysteroscopy plus bilateral salpingo-oophorectomy and peritoneal washing. Can be laparoscopy or open. Factors influencing primary treatment are stage, age and fitness

Non-surgical alternatives
Progestogens and primary radiotherapy

Adjuvant radiotherapy if high risk of recurrence

In advanced disease or where surgery is not an option progesterone therapy is sometimes use as well as chemo, radio and palliative care.

Question 11

How should post menopausal bleeding be investigated?

Answer 11

One stop PMB clinic
Full vaginal and abdominal examination, urine dip, screen for infection
Transvaginal USS – use < 4mm cut off for endometrial thickness. If thicker then:
Pipelle biopsy
If high risk then Hysteroscopy and biopsy (gold standard)
CT if suspecting metastases
Important to check smear history