Endometrial Cancer

Postmenopausal Bleeding = Endometrial cancer until proven otherwise. 

 ABNORMAL VAGINAL BLEEDING IN PRE- AND PERI-MENOPAUSAL WOMEN

VAGINAL BLEEDING IN POST-MENOPAUSAL WOMEN A diagnostic guide for General Practitioners and Gynaecologists

Peak incidence 50-70 years

Fairly uncommon <45yo, including endometrial hyperplasia (supported by evidence)

Risk Factors

• Age, Obesity (unopposed oestrogen), Nulliparity, Late menopause
• Diabetes mellitus, Polycystic Ovaries
• Drugs (unopposed oestrogen, tamoxifen)
• Family history – breast, ovarian, colon cancer
• Lynch syndrome (used to be HNPCC) – have a lifetime risk of endometrial cancer 27-71% compared with 3% of general population (Screening or hysterectomy)

Symptoms

Abnormal bleeding (80%). Be suspicious if:

1. Postmenopausal 🡪 Any bleeding, including spotting. 20% of these have endometrial cancer, another 5-15% have endometrial hyperplasia
2. 45yo – Menopause 🡪 Any abnormal uterine bleeding, including intermenstrual bleeding who are ovulatory, frequent, heavy, or prolonged. Also suspect if anovulatory history.
3. <45yo 🡪 Abnormal uterine bleeding that is persistent, occurs in the setting of unopposed oestrogen history (obesity, chronic anovulation) or failed medical management of bleeding

Investigations

1. Exclude pregnancy
2. Pap smear  – Detects some cases. Adenocarcinoma could be uterine origin.
3. Transvaginal ultrasound – To exclude other causes, and endometrial thickness

• Endometrial thickness only if postmenopausal. 
• Normal is <4mm. 
• However if ongoing clinical suspicion if <4mm, needs biopsy. 

NOTE

Hasn’t been established on how to interpret endometrial thickness in premenopausal women. 

• Perform on day 4, 5, or 6 of menstruation, endometrium should be at its thinnest.
• In premenopausal women, proliferative phase is 4-8mm and in the secretory phase 8-14mm. 
• Also no clear cut off for patients on tamoxifen –Biopsy if concerns. 
• If on HRT, ultrasound is only useful if on continuous type (NOT cyclical or oestrogen only)

Prognosis

• Stage 1 – 80-90%,
• Stage 2 – 70-80%,
• Stage 3 & 4 – 20-60%

Treatment

• Hysterectomy and BSO
• If intermediate risk, might be offered adjuvant radiotherapy, if high risk should receive adjuvant chemo +/- radiotherapy.

Endometrial hyperplasia

• Proliferation of endometrial glands that may progress to or coexist with endometrial carcinoma. It’s essentially a precursor to cancer. Risk factors and symptoms are the same 
• If no atypia, progression to cancer is low (<1-3%), treat with progestin therapy
• If atypia and completed childbearing 🡪 hysterectomy.
  • If postmenopausal, take out ovaries too (5% ovarian involvement) 
  • If premenopausal, counsel risks vs benefits of ovaries out. 
• If atypia and wish to preserve fertility – progestin therapy. Repeat endometrial sampling in 3/12. If successful regression, then pursue conception.