Endometrial (womb) cancer

Endometrial cancer is a malignant cancer in the body of the uterus. The disease begins in the uterine lining, which is also referred to as the endometrium. A tumor forms when the cells of the endometrium mutate and multiply rapidly. The tumor grows into the cavity of the uterus and/or into the underlying muscle layer.  

Uterine cancer, corpus cancer, womb cancer, cancer of the uterine body – endometrial cancer has many names. Colloquially, it is often referred to as womb or uterine cancer. However, both of these terms are imprecise since the womb and the uterus can also be affected by other types of cancer.

The following warning signs can be early symptoms of endometrial cancer:

• vaginal bleeding after menopause
• bleeding outside of the normal menstrual cycle (breakthrough bleeding)
• unusually heavy or long periods prior to menopause 

Unusual vaginal bleeding is the most common warning sign of endometrial cancer, particularly after menopause. Any vaginal bleeding is considered a warning signal in postmenopausal women.

Doctors often do not initially investigate unusual bleeding in premenopausal women since endometrial cancer is not common in younger women. Unusual bleeding in younger women can also indicate other diseases, many of which are comparatively harmless. However, if the bleeding does not abate even after treatment with medication or if the blood loss is putting the patient at risk, doctors will take a closer look.

Like most cancers, endometrial cancer is caused by changes in the genetic material of cells. Consequently, normal body cells mutate into malignant cancer cells and begin to reproduce rapidly. Most gene mutations occur randomly over a lifetime but some can be hereditary. 

Approximately 5 in 100 cases of endometrial cancer are caused by hereditary changes. Carriers of certain gene mutations have an increased risk of developing some types of cancer. For example, those with Lynch Syndrome have an increased risk of developing endometrial cancer or bowel (colon) cancer.  

The risk for endometrial cancer is also elevated in the case of a family history of bowel cancer, ovarian cancer, or cancer of the renal pelvis without a known hereditary cause. 

Long-term exposure to estrogen can increase the risk for endometrial cancer.  

This includes women who:

• take estrogen-only hormone therapy. 
• are overweight: fat tissue also produces estrogen. 
• have their final period (menopause) at an advanced age. 
• have their first period at a very young age. 

In addition to estrogen and genetic predisposition, there are additional risk factors for endometrial cancer: 

• advanced age 
• certain metabolic diseases, for example, diabetes (diabetes mellitus)
• increased growth of mutated cells of the endometrium (atypical endometrial hyperplasia)  
• antihormone therapy with tamoxifen (depending on the duration of intake) 

Endometrial cancer is the most common cancer of the female reproductive organs and the fifth most common cancer among women in Germany.  

Each year, approximately 11,000 women are diagnosed with endometrial cancer with the average age at the time of diagnosis being 68 years. 

Movement and exercise can help to lower the risk for endometrial cancer because they help to maintain a normal body weight.   

There are also other protective factors that can prevent endometrial cancer: 

• hormone therapy with a combination of estrogen and gestagen taken daily on a sustained basis 
• taking the birth control pill 
• intrauterine devices with copper or the hormone levonorgestrel 
• giving birth to a child later in life 

In contrast to cervical cancer, there is no national endometrial cancer screening program in Germany. On the one hand, there is no examination method for definitively diagnosing endometrial cancer in asymptomatic women. On the other hand, there are often early indicators of endometrial cancer.   

Since there is no targeted screening program, it is even more important to go to the gynecologist in the case of unusual bleeding. Women with an increased risk for endometrial cancer should have a conversation with their gynecologist. Special examinations beginning at age 30 to 35 can sometimes be helpful. 

First, the gynecologist asks the patient about her general health (medical history) and performs a gynecological examination. Then a vaginal ultrasound examination of the endometrium is performed to evaluate the thickness of the lining.  

Is there abnormal thickening of the endometrium? In the case of suspicion of endometrial cancer, doctors then examine the uterus (hysteroscopy). The intervention is performed under anesthesia and allows doctors to inspect the inside of the uterus with a camera. They check for abnormal changes in the uterine lining. They also take tissue samples from suspicious areas (biopsies).  

Following hysteroscopy, abrasion or curettage is performed to scrape out the entire uterine lining. Tissue is removed from the cervix and the body of the uterus. The samples from the biopsy and the tissue from the curettage procedure are both sent to the lab for analysis.  

Laboratory physicians examine the tissue samples under a microscope and conduct molecular biology tests. If testing shows that the tissue is cancerous, additional examinations are needed. The goal of these additional examinations is to provide information about the extent to which the tumor has spread and whether metastases have already developed. These examinations include: 

• magnetic resonance imaging (MRI)
• computed tomography (CT)
• abdominal ultrasound 
• chest X-ray

To find out more about microscopic and molecular biology testing, how imaging examinations are performed and if there are any side effects, please visit the Cancer Information Service of the German Cancer Research Center website for detailed information (in German).

Patients with endometrial cancer should go to a certified gynecological cancer center for treatment. The type of treatment is based on the risk associated with the individual tumor. However, the primary treatment for endometrial cancer is always surgery.

Surgery for endometrial cancer

Surgeons remove the tumor as completely as possible: the uterus with the cervix and the ovaries are always removed and the fallopian tubes are almost always removed. Depending on the extent to which the tumor has spread, additional tissue must be removed, e.g. adjacent lymph nodes or tissue in the abdomen and pelvis.

Additional treatments

After surgery, patients with an increased risk of recurrence can additionally undergo radiation therapy. Brachytherapy is then typically performed. This is close-range radiation therapy inside the vagina performed with the intention of preventing recurrence in the vagina in particular. In the case of advanced tumor stages, external pelvic radiotherapy is performed to destroy metastases in the pelvic area.

If the cancer has spread to the surrounding tissue, the pelvic lymph nodes, or to other organs, chemotherapy can be considered. Chemotherapy, which is also referred to as chemo, also destroys distant metastases.

In rare cases in younger patients with a desire to conceive, hormone therapy with gestagen can be used to delay surgery. However, this is only possible in very early stages of the disease. The goal is to achieve complete remission after approximately 6 months and to then try to conceive.

Even patients who can no longer be cured can receive this kind of hormone treatment with the aim of slowing the growth of the tumor as much as possible. Alternatively, patients receive chemotherapy or immunotherapy. It is also possible to individually treat problems and symptoms that are caused by the illness or treatment. For example, pain and bleeding can be alleviated by radiotherapy.

To find out more about the treatment of endometrial cancer, its side effects and how to deal with them, please visit the website of the Cancer Information Service of the German Cancer Research Center for detailed information (in German).

Endometrial cancer treatment can cause both physical and emotional stress. Medical rehabilitation (rehab) after cancer treatment can help patients to regain their strength. Another goal of rehab is to help patients deal with the effects of the disease and treatment to the best of their ability.  

Medical rehab programs are therefore based on patients’ personal medical history and physical limitations. Possible rehabilitation options for endometrial cancer patients include: 

• physiotherapy exercises, e.g. targeted pelvic floor training
• sexual therapy to help patients adjust to a changed sex life
• psycho-oncological therapy to help patients overcome concerns and fears

Aftercare 

After the end of treatment, patients receive aftercare to try to ensure early detection of a recurrence in the vagina and any long-term treatment effects so that the necessary steps can be taken.  

Once treatment has been completed, patients are examined regularly, initially at short intervals, then at longer ones. However, if experiencing symptoms, patients can visit the doctor more frequently.  

The following examinations are included in aftercare: 

• questions regarding the general health condition, e.g., any new symptoms
• palpation of the vagina and the rectum
• gynecological examination including endoscopic examination of the vagina
• ultrasound examination as needed

Which examinations are helpful in each individual case depends greatly on the individual situation and the tumor-specific risk of recurrence. For patients with concrete symptoms, additional examinations, primarily imaging, can be performed. Patients should also discuss mental symptoms at aftercare appointments.  

If the cancer is incurable

Follow-up appointments and regular care can help to ensure early detection and alleviation of problematic symptoms. The aim is to maintain the patient’s quality of life for as long as possible.  

It is not always easy for patients to return to their daily lives with or after endometrial cancer. Cancer and its treatment can have long-term effects.  

The appropriate supportive measures for coping with the disease and possible treatment effects are determined on an individual basis. The following are initially particularly problematic in endometrial cancer:  

• pain, inflammation, dryness, and narrowing of the vagina
• emotional distress 
• urinary incontinence
• lymphedema

Patients must learn to cope with a changed sex life, vaginal dryness, and pain. However, today, most side effects and treatment effects can be addressed or even prevented by corresponding preparation and support. Patients should speak with their doctors about support options as needed.  

Doctors from various disciplines work closely together to treat endometrial cancer. Hospitals that are particularly experienced in the treatment of patients with gynecological cancers can have this confirmed with certification. The German Cancer Society (Deutsche Krebsgesellschaft) regularly checks their compliance with the relevant professional requirements.  

You can find the addresses of the certified centers on the OncoMAP website.   

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German).

Contact the Cancer Information Service with any questions regarding endometrial cancer under the toll-free number 0800 - 420 30 40 or by e-mail: krebsinformationsdienst@dkfz.de.