Cancer of the uterus

Cancer of the uterus occurs when cells in any part of the uterus become abnormal, grow out of control and form a lump called a tumor. It is one of the most commonly diagnosed gynecological cancers, and it is most often found in women over the age of 50. Because it frequently causes symptoms early, it is often diagnosed before it has spread.

Anyone with a uterus can develop uterine cancer, including women, transgender men, non-binary people and people with intersex variations.

The uterus#

The uterus, or womb, is where a baby grows during pregnancy. It is about the size and shape of a hollow, upside-down pear and is part of the female reproductive system.

Signs and symptoms#

The most common symptom of cancer of the uterus is unusual vaginal bleeding. This may include:

• bleeding or spotting after menopause
• heavier than usual periods, or other changes to your periods
• bleeding between periods
• constant bleeding (periods that continue without a break)

A less common symptom is a smelly, watery vaginal discharge. In rare cases, symptoms include abdominal pain, unexplained weight loss, difficulty urinating or a change in bowel habits.

Any of these symptoms can happen for other reasons, but it is best to see your doctor for a check-up.

Risk factors#

The exact cause of cancer of the uterus is unknown, but factors that can increase the risk include:

• Age – uterine cancer is most common in women over 50, particularly after menopause
• Body weight – carrying extra body weight (being overweight or obese) is a major risk factor
• Medical factors – including having diabetes, previous pelvic radiation therapy, or endometrial hyperplasia
• Family history – having one or more close blood relatives diagnosed with uterine, ovarian, bowel or breast cancer, or inheriting a genetic condition such as Lynch syndrome or Cowden syndrome
• Reproductive history – not having children
• Hormonal factors – including starting periods before the age of 12, going through menopause after the age of 55, taking some types of estrogen-only menopause hormone therapy (MHT), or taking tamoxifen (an anti-estrogen drug)

Many people who have risk factors never develop cancer of the uterus, and some people who get this cancer have no risk factors. If you are concerned about any risk factors, talk to your doctor. Maintaining a healthy body weight and being physically active are among the best ways to reduce the risk.

Tests#

Your doctor may do some tests to check for cancer of the uterus, including:

• Pelvic examination – the doctor feels your abdomen to check for swelling and any masses. To check the uterus, the doctor places two fingers inside the vagina while pressing on your abdomen with the other hand.
• Pelvic ultrasound – uses soundwaves to create a picture of the uterus and ovaries.
• Endometrial biopsy – a long, thin tube is inserted through the cervix to gently suck up cells from the lining of the uterus, which are sent to a specialist for examination.
• Hysteroscopy and biopsy – the doctor gently widens (dilates) the cervix and removes some tissue from the uterine lining to examine for abnormalities.

Your doctor might ask you to have further tests, which can include:

• CT scan – often of your chest, abdomen and pelvis.
• MRI scan – uses a powerful magnet and radio waves to create detailed cross-sectional pictures of the inside of your body.
• PET scan – you are injected with a small amount of a glucose (sugar) solution, which makes cancer cells show up more brightly on the scan.
• Blood tests – which may include a full blood count and a tumor marker test.

Types#

Cancers that begin in the lining of the uterus (the endometrium) are called endometrial cancers. They make up around 95 per cent of all uterine cancers and fall into two main types:

• Type 1 cancers – linked to an excess of estrogen
• Type 2 cancers – not linked to estrogen

Uterine sarcomas make up around 5 per cent of all uterine cancers. They include endometrial stromal sarcoma, leiomyosarcoma and undifferentiated sarcoma.

Stages and grades#

The stage of a cancer means how far it has grown in your body. Uterine sarcomas are staged differently, so discuss this with your specialist.

• Stage 1 – the cancer is found only in the uterus.
• Stage 2 – the cancer has spread from the uterus to the cervix.
• Stage 3 – the cancer has spread beyond the uterus and cervix to the ovaries, fallopian tubes, vagina, or lymph nodes in the pelvis or abdomen.
• Stage 4 – the cancer has spread further, to the bladder, bowel or rectum, throughout the abdomen, to other parts of the body such as the bones or lungs, or to lymph nodes in the groin.

The grade of the cancer means how quickly it might grow. Low grades mean the cancer cells look only slightly abnormal, while high grades mean they look more abnormal. High-grade cancers tend to be more aggressive than lower-grade cancers. Knowing the stage and grade helps your doctor work out the best treatment plan for your situation. Ask your doctor or nurse to explain the stage and grade of your cancer.

Prognosis#

When someone is diagnosed with cancer of the uterus, their doctor will give them a prognosis – an opinion of how likely the cancer is to spread and the chances of recovery. A prognosis depends on the type and stage of the cancer, as well as the person’s age and general health.

In general, the earlier cancer of the uterus is diagnosed, the better the prognosis, and most early-stage endometrial cancers have high survival rates. If cancer is found after it has spread to other parts of the body (advanced cancer), the prognosis is not as good, and there is a higher chance of the cancer coming back or continuing to grow. Your doctor will talk to you about your individual situation.

Treatment#

Every person’s experience is different, and there is support available to you.

Surgery#

In many cases, surgery is the only treatment needed. Cancer of the uterus is usually treated with an operation that removes the uterus and cervix (a total hysterectomy), along with both fallopian tubes and ovaries (bilateral salpingo-oophorectomy). If your ovaries appear normal, you have no risk factors, and it is an early-stage, low-grade cancer, you may be able to keep your ovaries.

Radiation therapy#

Radiation therapy is commonly used as an additional treatment after surgery to reduce the chance of the disease coming back. This is called adjuvant therapy. In some cases, radiation therapy may be recommended as the main treatment if other health conditions mean you are not well enough for a major operation. There are two main ways of delivering it – internally or externally – and some people are treated with both.

Chemotherapy#

Chemotherapy uses drugs to kill or slow the growth of cancer cells while causing the least possible damage to healthy cells. It may be used for certain types of uterine cancer, if the cancer does not respond to hormone therapy, if it has spread beyond the pelvis, or when the cancer comes back after surgery or radiation therapy.

When radiation therapy is combined with chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy. High-risk endometrial cancer is often treated this way to reduce the chance of the cancer returning.

Hormone therapy#

Hormones such as estrogen and progesterone are produced naturally in the body and help control the growth and activity of cells. Some cancers of the uterus depend on estrogen or progesterone to grow. These are known as hormone-dependent or hormone-sensitive cancers and can sometimes be treated with hormone therapy. Hormone therapy may be recommended for uterine cancer that has spread or come back, particularly if it is a low-grade cancer. It is also sometimes offered as a first treatment if surgery has not been done.

Managing side effects#

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start. Talk to your doctor or nurse about any side effects you are experiencing – some can be upsetting and difficult, but there is help if you need it.

Menopause#

If both ovaries are removed, or if you have radiation therapy to the pelvic area, you will stop having periods. This is called menopause. For most women, menopause is a natural, gradual process that starts between the ages of 45 and 55. When it is caused by cancer treatment, the symptoms are usually more severe, because the body has not had time to adjust to the gradual decrease in hormone levels.

Fertility#

Surgery or radiation therapy for cancer of the uterus may mean you are unable to become pregnant. In certain cases it may be possible to preserve the ovaries, and sometimes the uterus, so you can still have children, but this is not standard treatment. If this matters to you, talk about fertility preservation with your doctor before treatment begins.

Learning that your reproductive organs will be removed or will no longer function, and that you may not be able to have children, can be devastating. Even if your family is complete or you did not want children, you may still feel a sense of loss and grief. These reactions are not unusual, and speaking to a counselor can help.

Fatigue#

It is common to feel very tired and lacking in energy during and after treatment. This can be a side effect of the treatment itself or a symptom of menopause. Traveling to appointments and dealing with your emotions can also cause fatigue, which may continue for a while after treatment finishes. It may help to talk with family and friends about how you feel and discuss ways they can support you.

Bladder changes#

Treatment can cause bladder problems, including:

• Urinary incontinence – when urine leaks from your bladder without your control.
• Radiation cystitis – you may feel the need to pass urine often, or have a burning sensation when you do.
• Blood in your urine – this can appear even months or years after treatment.

Bowel changes#

Treatment can also affect the way the bowels work, including:

• constipation – difficulty having a bowel movement regularly
• diarrhea – frequent passing of loose, watery feces
• radiation proctitis – inflammation and damage to the lining of the rectum
• blood in bowel movements – which can appear even months or years after treatment

These changes are usually temporary, but for some people they can be permanent and significantly affect quality of life. Talk to your treatment team if you are finding bowel issues hard to manage.

Lymphoedema#

After surgery or radiation therapy to the pelvic area, one or both legs, and the vulval area, may become swollen. Called lymphoedema, this occurs when lymph fluid does not circulate properly and builds up. The swelling may appear during treatment or months or years later, and it can make movement and some activities difficult. It is important to maintain a healthy body weight, avoid pressure, injury or infection to the legs, and manage symptoms as soon as they appear.

The skin on the legs may become infected more easily after lymph nodes are removed. A common skin infection is cellulitis, with signs that include redness, painful swelling, warm skin and fever. If you have any of these symptoms, see your doctor as soon as possible.

Sexuality#

Cancer of the uterus can affect your sexuality in both physical and emotional ways. Some treatments can cause dryness and narrowing of the vagina, which can make sexual penetration difficult or painful. Removal of the uterus, cervix and ovaries can also change how you experience sexual pleasure and orgasm. Your treatment team may advise using vaginal dilators, lubricants, moisturizers or hormone creams.

You may lose interest in intimacy and sex (low libido) because of the hormonal changes of menopause, the stress of the cancer experience, fatigue, and changes in how you feel about your body. If you have a partner and do not feel like having sex, or find it uncomfortable, talk openly about how you are both feeling and take things slowly, starting with hugs or a massage rather than penetrative sex. You may both need to be patient – things often improve with time and practice.

If you have ongoing concerns about how treatment has affected your sexuality, talk to your doctor or gynecological oncologist, or ask for a referral to a psychologist or sexual therapist.

Advanced cancer and palliative care#

Advanced cancer usually means cancer that is unlikely to be cured. Some people can live for many months or years with advanced cancer, and palliative care can help during this time.

Most people continue to have treatment for advanced cancer as part of palliative care, as it helps manage the cancer and improve day-to-day life. Many people think palliative care is only for those who are dying, but it is for any stage of advanced cancer. There are doctors, nurses and others who specialize in it.

Treatment may include chemotherapy, radiation therapy or another approach, and it can help you live more comfortably by managing symptoms such as pain. Treatment depends on your preferences and what you want to do. Ask your doctor about treatment and palliative care services that may help you.

Caring for someone with cancer can be difficult at times. If you are caring for someone, support services are available for carers as well as patients.

Key points#

• The most common symptom of cancer of the uterus is unusual vaginal bleeding, especially after menopause.
• A less common symptom is a smelly, watery vaginal discharge.
• These symptoms can happen for other reasons, but it is best to see your doctor for a check-up.
• Carrying extra body weight is a major risk factor.
• If you are concerned about any risk factors, talk to your doctor.
• Knowing the stage and grade helps your doctor work out the best treatment plan for your situation.