Gynae: Endometrial Cancer

Question 1

what is endometrial cancer and what is it dependent on?

Answer 1

cancer of the endometrium which is the lining of the uterus.

it is oestrogen-dependent and grown in response to oestrogen

Question 2

what is the most common type of endometrial cancer?

Answer 2

adenocarcinoma

Question 3

what age group is endometrial cancer most common in?

Answer 3

older women -64-74 years

Question 4

what is endometrial hyperplasia?

Answer 4

**precancerous **condition involving the thickening of the endometrium. risk factors, presentation and investigations are similar to endometrial cancer

less than 5% go on to become endometrial cancer

Question 5

what are the 2 types of endometrial hyperplasia?

Answer 5

• hyperplasia without atypia
• atypical hyperplasia

Question 6

how is endometrial hyperplasia treated?

Answer 6

Using progestogens:

• intrauterine system
• continuous oral progestogens

Question 7

what are the risk factors for endometrial cancer?

Answer 7

think unopposed oestrogen

type 2 diabetes

hereditary nonpolyposis colorectal cancer or lynch syndrome

Question 8

what are some situations where there is increased exposure to oestrogen in a patients lifetime and therefore increased risk of endometrial cancer? (endometrial cancer RF)

Answer 8

• Increased age
• Earlier onset of menstruation
• Late menopause
• Oestrogen only hormone replacement therapy
• No or fewer pregnancies
• Obesity
• Polycystic Ovarian syndrome
• Tamoxifen

Question 9

what things reduce risk of endometrial cancer?

Answer 9

continuous combined HRT

COCP

smoking

physical activity

coffee and tea

Question 10

how does PCOS lead to increased exposure to unopposed oestrogen?

Answer 10

lack of ovulation

usually the corpus luteum would release progesterone during the luteal phase after ovulation but as women with PCOS are less likely to ovulate progesterone is not produced

Question 11

why does obesity increase unopposed oestrogen?

Answer 11

adipose tissue is a source of oestrogen (the primary source in postmenopausal women)

in women with more adipose tissue, more androgens are converted to oestrogen due to higher levels of the aromatase enzyme in the adipose tissue (converts androgens to oestrogen)

Question 12

how does tamoxifen increase exposure of unopposed oestrogen?

Answer 12

anti-oestrogenic effect on breast tissue but an oestrogenic effect on endometrium = increased risk of endometrial cancer

Question 13

why does type 2 diabetes increase risk of endometrial cancer?

Answer 13

increased production fo insulin which may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer

Question 14

what are some protective factors for endometrial cancer?

Answer 14

• COCP
• mirena coil
• increased pregnancies
• cigarette smoking - in post menopausal as smoking is anti-oestrogenic, may be metabolised differently, tend to be leaner so less adipose tissue, smoking destroys oocytes = earlier menopause

NOTE - SMOKING NOT PROTECTIVE AGAINST OTHER OESTROGEN DEPENDENT CANCERS

Question 15

how does endomrteial cancer present?

Answer 15

• Postmenopausal bleeding - NO.1
• pre-menopausal = prolonged/frequent vaginal bleeding & intermenstrual bleeding
• Postcoital bleeding
• Intermenstrual bleeding
• Unusually heavy menstrual bleeding
• Abnormal vaginal discharge
• Haematuria
• Anaemia
• Raised platelet count

Question 16

what is the referral criteria for 2 week wait urgent cancer referral for endometrial cancer?

Answer 16

postmenopausal bleeding (more than 12 months after last menstrual period)

Question 17

aside from postmenopausal bleeding indicating 2ww, when is a transvaginal ultrasound in women over 55 indicated?

Answer 17

unexplained vaginal discharge

visible haematuria plus raised platelets, anaemia or elevated glucose levels

Question 18

what investigations are done for endometrial cancer?

Answer 18

1. transvaginal ultrasound for endometrial thickness (<4mm = normal post menopause)
2. pipelle biopsy - highly sensitive
3. hysteroscopy with endometrial biopsy

Question 19

what is a pipelle biposy?

Answer 19

speculum exam and inserting a thin tube through the cervix into the uterus. tube fills with sample of endometrial tissue and can be examined for signs of endometrial hyperplasia or cancer

can be done in outpatient setting

Question 20

Depending on local guidelines what 2 things are sufficient to demonstrate a very low risk of endometrial cancer and allow for pt to be discharged?

Answer 20

• normal transvaginal ultrasound (endometrial thickness < 4mm)
• normal pipelle biopsy

Question 21

what are the stages of endometrial cancer?

Answer 21

International Federation of Gynaecology and Obstetrics staging system

• Stage 1: Confined to the uterus
• Stage 2: Invades the cervix
• Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
• Stage 4: Invades bladder, rectum or beyond the pelvis

Question 22

how is endometrial cancer managed?

Answer 22

treatment for stage 1 and 2 = total abdominal hysterectomy with bilateral salpingo-oophrectomy

other options

• radical hysterectomy involves also removing pelvic lymph nodes, surrounding tissues and top of vagina
• radiotherapy
• chemotherapy
• progesterone may be used as a hormonal treatment to slow the progression of cancer