AKT · Obstetrics & gynaecology/Gynae oncology & screening

Endometrial cancer

Unopposed-oestrogen-driven adenocarcinoma

Overview

The commonest gynaecological cancer in the UK — usually an oestrogen-driven endometrioid adenocarcinoma presenting with POSTMENOPAUSAL BLEEDING. Risk factors are unopposed-oestrogen states; it usually presents early.

Recognise

POSTMENOPAUSAL BLEEDING (the cardinal symptom)
Premenopausal: intermenstrual/heavy bleeding
Risk: obesity, nulliparity, late menopause, PCOS, tamoxifen, unopposed oestrogen, Lynch syndrome

Red flags

Any postmenopausal bleeding → urgent 2-week-wait referral

Differentials & how to tell them apart

Atrophic vaginitis (GSM)commonest cause of PMB but a diagnosis of exclusion after cancer ruled out

Endometrial polyp/hyperplasiabiopsy distinguishes

Cervical cancerlesion on cervix

HRT-related bleedingstill investigate if unscheduled

Investigations

Transvaginal USS: endometrial thickness (>4 mm postmenopausal → further investigation). Endometrial biopsy (pipelle) / hysteroscopy is diagnostic.

Management

Total hysterectomy + bilateral salpingo-oophorectomy (early disease)

1Urgent referral for any PMB. Early disease: total hysterectomy + bilateral salpingo-oophorectomy.Gate: Postmenopausal endometrial thickness >4 mm → biopsy; <4 mm makes cancer unlikely
2Advanced/unfit: radiotherapy, chemotherapy; high-dose progestogen for fertility preservation in selected early grade-1.

Total hysterectomy + bilateral salpingo-oophorectomy — mainstay for early disease

Progestogen / radiotherapy — fertility-sparing or unfit/advanced cases

Key points

Postmenopausal bleeding is endometrial cancer until proven otherwise. Tamoxifen (anti-oestrogen in breast, pro-oestrogen on endometrium) and Lynch syndrome are key risk factors.

Monitor & prognosis

Post-treatment surveillance.

Good — usually presents early with PMB.

Source: NICE NG12