Endometrial cancer and postmenopausal bleeding
Endometrial cancer is cancer of the womb lining: typically an adenocarcinoma (cancer of gland-forming cells) that responds to oestrogen, with bleeding after the menopause as its classic presentation.
Remember
Endometrial cancer is typically an oestrogen-responsive adenocarcinoma of the womb lining, and bleeding after the menopause is its classic presentation, so such bleeding needs assessment rather than reassurance.
Endometrial cancer starts in the endometrium, the lining of the womb, a gland-lined tissue. Most womb cancer starts there. A cancer of gland-forming cells is an adenocarcinoma, so endometrial cancer is usually one. Its incidence peaks in women after the menopause.
Most endometrial cancers are oestrogen-responsive. Oestrogen makes the lining proliferate, meaning it drives cell division. If oestrogen acts for a long time without progesterone to balance it (called unopposed oestrogen), the lining can become hyperplastic (abnormally thickened) and, over time, malignant.
The risk factors are those that increase oestrogen exposure or its effect. The risk rises with early menarche (the first period), late menopause, being overweight, oestrogen-only hormone replacement therapy (HRT) and tamoxifen (a breast cancer medicine).
The usual presentation is abnormal bleeding: between periods in younger women or, in the commonest age group, post-menopausal bleeding, meaning bleeding after periods have stopped for good. Bleeding is a common feature but it is not specific to cancer. Only a minority of women with postmenopausal bleeding turn out to have endometrial cancer, so the bleeding needs investigation rather than assuming cancer. An ultrasound scan can be used, and a thickened endometrium warrants further investigation.
Other cancers of the female genital tract are easy to confuse with it. Cervical cancer (the cervix is the neck of the womb) is linked to human papillomavirus (HPV) and is mostly squamous. Squamous cells are flat cells, such as those covering the part of the cervix that faces the vagina. Leiomyosarcoma is a rare malignant smooth muscle tumour of the myometrium, the muscular wall of the uterus. Ovarian cancer more often causes bloating and feeling full quickly after eating.
Key facts
- Cell type
- usually an adenocarcinoma, a cancer of gland-forming cells, of the endometrium
- Hormones
- oestrogen drives proliferation, and progesterone opposes it
- Presentation
- abnormal uterine bleeding, most often after the menopause
- Frequency of bleeding
- more than 90% of women with endometrial cancer present with abnormal uterine bleeding
- Bleeding after the menopause
- only a minority of women with it turn out to have endometrial cancer, so it needs investigation
Exam traps
- Endometrial cancer is not progesterone-driven: progesterone opposes oestrogen's growth signal, so the cancer is usually oestrogen-responsive.
- A squamous cell carcinoma linked to HPV infection suggests cervical cancer rather than endometrial cancer, which is usually an oestrogen-responsive adenocarcinoma.
- A malignant tumour of the smooth muscle of the myometrium is possible but rare, whereas cancers of the lining are far more frequent, so it is not the commonest type of womb cancer.
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