Endometrial Cancer - There are many causes for post-menopausal bleeding, but it is most likely an indicator of endometrial cancer

The warning signs

50-year-old Mrs. Rao was surprised when she noticed bleeding from her vaginal area. Her periods had stopped about 2 years ago. She had mild spotting on two earlier occasions, which she had assumed would stop on its own, but when this did not happen she finally decided to visit her gynaecologist.

Post-menopausal bleeding is a common problem accounting for about five percent of the OPO attendances to the gynaecologist. Any bleeding 12 months after menopause at normally expected age is considered as abnormal. Though there are many causes for post-menopausal bleeding, it would be safer to assume it to be due to cancer until proven otherwise.

What is endometrial cancer?

Endometrium is the innermost lining of the uterus (womb). This lining increases in size when the hormone estrogen in the body increases, and reduces when the hormone progesterone increases.

It plays an important role in implantation of the embryo after fertilization. Endometrial cancer is the most common type of uterine cancer. It commonly occurs in women between the ages of 60-70. Endometrial cancer is different from the more common cervical cancer that arises in the lower portion of the uterus.

Risk factors

Risk factors for endometrial cancer are quite similar to that of breast cancer. This includes early menarche, late menopause, use of estrogen replacements, obesity and infertility.

The Diagnosis

Post-menopausal bleeding is the most common way in which endometrial cancer presents itself. Premenopausal women who have bleeding between the periods or extremely long or heavy periods should be suspected of endometrial cancer. Some other patients may have white or clear vaginal discharge. The more advanced cases may have pelvic pain. After pelvic examination, most gynaecologists would order for an abdominal ultrasound. A thickened irregular endometrium on ultrasound increases the suspicion of endometrial cancer. When the level of suspicion is high, the next step would be to obtain a biopsy.

Biopsy is usually done by:

  • Dilation and curettage (0 & C)
  • Endometrial aspiration and biopsy
  • Hysteroscopy and biopsy

The material removed is sent to a pathologist who either confirms or disproves the diagnosis of cancer. Once the diagnosis is confirmed the next step would be to assess the spread of the disease, which is done by investigations like CT scan or MRI of the abdomen.

Depending on the extent of spread, the stage of the disease is determined:

  • Cancer which is confined to the uterus would be stage

  • Cancer which has gone on to the lower part of the uterus called the cervix would be stage II
  • Cancer which has spread outside the uterus but is still within the pelvic area would be stage III

Treatment plan

  • Treatment should be received preferably in a comprehensive cancer centre where surgery, radiation and chemotherapy facilities are available.

  • Surgery for endometrial cancer involves removal of the uterus from the abdomen along with removal of both the ovaries. Removal of the uterus from the vagina is not acceptable.

  • Hysterectomy is combined with removal of lymph nodes from the drainage areas.

  • Following surgery, the removed parts are examined by the pathologist, which helps in determining the final stage of the disease.

  • In very early cases (stage I) and when the tumour is less aggressive, only surgery is sufficient but in higher stages (stage II or III) or when the tumour is of an aggressive variety, radiation is recommended. Radiation is of two types, one that is given externally under CT scan guidance, a procedure known as teletherapy, and the other, in which radiation is given internally on the residual portion of the vagina by placing wires, a procedure known as brachytherapy.

    On quite a few occasions when the disease has already spread to the lymphnodes, it may be necessary to combine radiation with chemotherapy. A few patients may be in the advanced stage of disease, which has spread to liver, lungs or elsewhere in the abdomen. In this case the options would be either to give chemotherapy with limited benefit or to just offer symptomatic treatment without doing anything specific for the disease. On the whole, for patients like Mrs. Rao and many other women, maximum benefit of treatment can be given when they identify any abnormal vaginal bleeding or discharge and seek prompt medical attention for it. When detected at an early stage and promptly treated, the outcome is excellent and the patients can lead a normal life.

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