The uterus is part of a woman's reproductive system. It is the hollow, pear-shaped organ where a baby grows. The uterus is in the pelvis between the bladder and the rectum.
The narrow, lower portion of the uterus is the cervix. The broad, middle part of the uterus is the body, or corpus. The dome-shaped top of the uterus is the fundus. (The fundus is the larger part of a hollow organ that is farthest away from the organ's opening.) The fallopian tubes extend from either side of the top of the uterus to the ovaries.
The uterus and other reproductive organs.
The wall of the uterus has two layers of tissue. The inner layer, or lining, is the endometrium. The outer layer is muscle tissue called the myometrium.
In women of childbearing age, the lining of the uterus grows and thickens each month to prepare for pregnancy. If a woman does not become pregnant, the thick, bloody lining flows out of the body through the vagina. This flow is called menstruation.
When uterine cancer spreads (metastasizes) outside the uterus, cancer cells are often found in nearby lymph nodes, nerves, or blood vessels. If the cancer has reached the lymph nodes, cancer cells may have spread to other lymph nodes and other organs, such as the lungs, liver, and bones.
The most common type of cancer of the uterus begins in the lining (endometrium). It is called endometrial cancer, uterine cancer, or cancer of the uterus. In this booklet, we will use the terms uterine cancer or cancer of the uterus to refer to cancer that begins in the endometrium.
A different type of cancer, uterine sarcoma, develops in the muscle (myometrium).
Incidence of Uterine Cancer
Uterine cancer is the second most common gynaecological cancer in Singapore currently. However, the incidence is rising and it is expected to overtake ovarian cancer as most common gynaecological cancer soon.
Uterine Cancer: Who's at Risk?
No one knows the exact causes of uterine cancer. Studies have found the following risk factors:
- Age
Cancer of the uterus occurs mostly in women over age 50.
- Endometrial hyperplasia
The risk of uterine cancer is higher if a woman has endometrial hyperplasia.
- Hormone Replacement Therapy (HRT)
HRT is used to control the symptoms of menopause, to prevent osteoporosis (thinning of the bones), and to reduce the risk of heart disease or stroke.
Women who use estrogen without progesterone have an increased risk of uterine cancer. Long-term use and large doses of estrogen seem to increase this risk. Women who use a combination of estrogen and progesterone have a lower risk of uterine cancer than women who use estrogen alone. The progesterone protects the uterus.
Women should discuss the benefits and risks of HRT with their doctor. Also, having regular checkups while taking HRT may improve the chance that the doctor will find uterine cancer at an early stage, if it does develop.
- Obesity and related conditions
The body makes some of its estrogen in fatty tissue. That's why obese women are more likely than thin women to have higher levels of estrogen in their bodies. High levels of estrogen may be the reason that obese women have an increased risk of developing uterine cancer. The risk of this disease is also higher in women with diabetes or high blood pressure (conditions that occur in many obese women).
- Tamoxifen
Women taking the drug tamoxifen to prevent or treat breast cancer have an increased risk of uterine cancer. This risk appears to be related to the estrogen-like effect of this drug on the uterus. Doctors monitor women taking tamoxifen for possible signs or symptoms of uterine cancer.
The benefits of tamoxifen to treat breast cancer outweigh the risk of developing other cancers. Still, each woman is different. Any woman considering taking tamoxifen should discuss with the doctor her personal and family medical history and her concerns.
- Colorectal cancer
Women who have had an inherited form of colorectal cancer have a higher risk of developing uterine cancer than other women.
Other risk factors are related to how long a woman's body is exposed to estrogen. Women who have no children, begin menstruation at a very young age, or enter menopause late in life are exposed to estrogen longer and have a higher risk.
Women with known risk factors and those who are concerned about uterine cancer should ask their doctor about the symptoms to watch for and how often to have checkups. The doctor's advice will be based on the woman's age, medical history, and other factors.
Symptoms
Uterine cancer usually occurs after menopause. But it may also occur around the time that menopause begins. Abnormal vaginal bleeding is the most common symptom of uterine cancer. Bleeding may start as a watery, blood-streaked flow that gradually contains more blood. Women should not assume that abnormal vaginal bleeding is part of menopause.
A woman should see her doctor if she has any of the following symptoms:
- Unusual vaginal bleeding or discharge
- Difficult or painful urination
- Pain during intercourse
- Pain in the pelvic area
These symptoms can be caused by cancer or other less serious conditions. Most often they are not cancer, but only a doctor can tell for sure.
Diagnosis
If a woman has symptoms that suggest uterine cancer, her doctor may check general signs of health and may order blood and urine tests. The doctor also may perform one or more of the exams or tests described on the next pages.
- Pelvic exam
A woman has a pelvic exam to check the vagina, uterus, bladder, and rectum. The doctor feels these organs for any lumps or changes in their shape or size. To see the upper part of the vagina and the cervix, the doctor inserts an instrument called a speculum into the vagina.
- Pap test
The doctor collects cells from the cervix and upper vagina. A medical laboratory checks for abnormal cells. Although the Pap test can detect cancer of the cervix, cells from inside the uterus usually do not show up on a Pap test. This is why the doctor collects samples of cells from inside the uterus in a procedure called a biopsy.
- Transvaginal ultrasound
The doctor inserts an instrument into the vagina. The instrument aims high-frequency sound waves at the uterus. The pattern of the echoes they produce creates a picture. If the endometrium looks too thick, the doctor can do a biopsy.
- Biopsy
The doctor removes a sample of tissue from the uterine lining. This usually can be done in the doctor's office using a device called the Pipelle. In some cases, however, a woman may need to have a dilation and curettage (D&C). For a short time after the biopsy, some women have cramps and vaginal bleeding.
Staging
If uterine cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has spread, and if so, to what parts of the body.
The doctor may order blood and urine tests and chest x-rays. The woman also may have other x-rays, CT scans, an ultrasound test, magnetic resonance imaging (MRI), sigmoidoscopy, or colonoscopy.
(A sigmoidoscopy is an examination of the lower colon using a sigmoidoscope, inserted into the rectum. A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease.)
In most cases, the most reliable way to stage this disease is to remove the uterus (hysterectomy). After the uterus has been removed, the surgeon can look for obvious signs that the cancer has invaded the muscle of the uterus. The surgeon also can check the lymph nodes and other organs in the pelvic area for signs of cancer.
Methods of Treatment
Women with uterine cancer have many treatment options. Most women with uterine cancer are treated with surgery. Some have radiation therapy. A smaller number of women may be treated with hormonal therapy. Some patients receive a combination of therapies.
The doctor is the best person to describe the treatment choices and discuss the expected results of treatment.
Most women with uterine cancer have surgery to remove the uterus (hysterectomy). The doctor also removes both fallopian tubes and both ovaries. (This procedure is called a bilateral salpingo-oophorectomy.)
The doctor may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it may mean that the disease has spread to other parts of the body. If cancer cells have not spread beyond the endometrium, the woman may not need to have any other treatment. The length of the hospital stay may vary from several days to a week.
In radiation therapy, high-energy rays are used to kill cancer cells. Like surgery, radiation therapy is a local therapy. It affects cancer cells only in the treated area.
Some women with Stage I, II, or III uterine cancer need both radiation therapy and surgery. They may have radiation before surgery to shrink the tumor or after surgery to destroy any cancer cells that remain in the area. Also, the doctor may suggest radiation treatments for the small number of women who cannot have surgery.
Hormonal therapy involves substances that prevent cancer cells from getting or using the hormones they may need to grow. Hormones can attach to hormone receptors, causing changes in uterine tissue. Before therapy begins, the doctor may request a hormone receptor test. This special lab test of uterine tissue helps the doctor learn if estrogen and progesterone receptors are present. If the tissue has receptors, the woman is more likely to respond to hormonal therapy.
Hormonal therapy is called a systemic therapy because it can affect cancer cells throughout the body. Usually, hormonal therapy is a type of progesterone taken as a pill.
The doctor may use hormonal therapy for women with uterine cancer who are unable to have surgery or radiation therapy. Also, the doctor may give hormonal therapy to women with uterine cancer that has spread to the lungs or other distant sites. It is also given to women with uterine cancer that has come back.
Side Effects of Cancer Treatment
Because cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, doctors and nurses will explain the possible side effects and how they will help you manage them.
- Surgery
After a hysterectomy, women usually have some pain and feel extremely tired. Most women return to their normal activities within four to eight weeks after surgery. Some may need more time than that.
Some women may have problems with nausea and vomiting after surgery, and some may have bladder and bowel problems. The doctor may restrict the woman's diet to liquids at first, with a gradual return to solid food.
Women who have had a hysterectomy no longer have menstrual periods and can no longer get pregnant. When the ovaries are removed, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause.
Hormone replacement therapy (HRT) is often given to women who have not had uterine cancer to relieve these problems. However, doctors usually do not give the hormone estrogen to women who have had uterine cancer. Because estrogen is a risk factor for this disease, many doctors are concerned that estrogen may cause uterine cancer to return. Other doctors point out that there is no scientific evidence that estrogen increases the risk that cancer will come back.
For some women, a hysterectomy can affect sexual intimacy. A woman may have feelings of loss that may make intimacy difficult. Sharing these feelings with her partner may be helpful.
- Radiation Therapy
The side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Common side effects of radiation include dry, reddened skin and hair loss in the treated area, loss of appetite, and extreme tiredness. Some women may have dryness, itching, tightening, and burning in the vagina. Radiation also may cause diarrhea or frequent and uncomfortable urination. It may reduce the number of white blood cells, which help protect the body against infection.
Doctors may advise their patients not to have intercourse during radiation therapy. However, most can resume sexual activity within a few weeks after treatment ends. The doctor or nurse may suggest ways to relieve any vaginal discomfort related to treatment.
- Hormonal Therapy
Hormonal therapy can cause a number of side effects. Women taking progesterone may retain fluid, have an increased appetite, and gain weight. Women who are still menstruating may have changes in their periods.
- Nutrition
People need to eat well during cancer therapy. They need enough calories and protein to promote healing, maintain strength, and keep a healthy weight. Eating well often helps people with cancer feel better and have more energy.
Patients may not feel like eating if they are uncomfortable or tired. Also, the side effects of treatment such as poor appetite, nausea, or vomiting can make eating difficult. Foods may taste different.
The doctor, dietitian, or other health care provider can advise patients about ways to maintain a healthy diet.
- Follow-up Care
Follow-up care after treatment for uterine cancer is important. Women should not hesitate to discuss follow-up with their doctor. Regular checkups ensure that any changes in health are noticed. Any problem that develops can be found and treated as soon as possible. Check-ups may include a physical exam, a pelvic exam, x-rays, and laboratory tests.
- Support for Women with Uterine Cancer
Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group.
