Epidemiology
Endometrial cancer is the fifth most common cancer in women in the UK. It largely affects post-menopausal women, particularly those aged 60–79 years and accounts for 5% of all female cancers.
It is the most common type of cancer of the uterus and the majority of cases are adenocarcinoma, of which there are three types: endometrioid (commonest), papillary serous and clear cell (rare). Carcinosarcoma of the uterus is rare and behaves in a more aggressive manner.
Aetiology
A high level of oestrogen unopposed by progestogen is associated with an increased risk of endometrial cancer. Therefore, factors that result in excess oestrogen levels or low progestogen levels increase a woman’s risk of endometrial cancer (Table 38.1).
Other factors associated with an increased risk of endometrial cancer include hypertension, diabetes mellitus, Lynch type II syndrome and endometrial hyperplasia with atypia (benign).
Protective factors include history of pregnancy and combined oral contraceptive pill use.
Clinical presentation
Endometrial cancer tends to present early, with post-menopausal bleeding (PMB), intermenstrual bleeding or recent-onset menorrhagia. All women over the age of 45 years presenting with PMB should be investigated. Other less common symptoms include lower abdominal discomfort, vaginal discharge and dyspareunia. On bimanual palpation and speculum examination the pelvis often appears normal.
Advanced disease may cause urinary frequency, fatigue, loss of appetite, back pain and constipation. Spread of endometrial cancer usually occurs directly through the myometrium to the cervix and vagina. Metastases occur via the lymphatic system but haematogenous spread occurs late and therefore widespread metastasis at presentation is unusual.
Investigations and staging
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