Overview

Cancer of the womb (uterus) is a common cancer that affects the female reproductive system. It's also called uterine cancer and endometrial cancer.

Abnormal vaginal bleeding is the most common symptom of womb cancer.

If you have been through the menopause, any vaginal bleeding is considered abnormal. If you have not yet been through the menopause, unusual bleeding may include bleeding between your periods.

You should see your GP as soon as possible if you experience any unusual vaginal bleeding. While it's unlikely to be caused by womb cancer, it's best to be sure.

Your GP will examine you and ask about your symptoms. They will refer you to a specialist for further tests if they suspect you may have a serious problem, or if they are unsure about a diagnosis.

Title
Uterine Cancer

Types

The vast majority of womb cancers begin in the cells that make up the lining of the womb (called the endometrium), which is why cancer of the womb is often called endometrial cancer.

In rare cases, womb cancer can start in the muscles surrounding the womb. This type of cancer is called uterine sarcoma and may be treated in a different way from endometrial cancer.

This article uses the term womb cancer, and mostly includes information about endometrial cancer.

Womb cancer is separate from other cancers of the female reproductive system, such as ovarian cancer and cervical cancer.

Symptoms
Symptoms

The most common symptom of womb cancer is abnormal bleeding from the vagina, although most people with abnormal bleeding don't have cancer.

Bleeding may start as light bleeding accompanied by a watery discharge, which may get heavier over time. Most women diagnosed with womb cancer have been through the menopause, so any vaginal bleeding will be unusual.

In women who haven't been through the menopause, unusual vaginal bleeding may consist of:

Less common symptoms include pain in the lower abdomen (tummy) and pain during sex.

If womb cancer reaches a more advanced stage, it may cause additional symptoms. These include:

  • pain in the back, legs, or pelvis
  • loss of appetite
  • tiredness
  • nausea
When to seek medical advice

If you have postmenopausal vaginal bleeding, or notice a change in the normal pattern of your period, visit your GP.

Only 1 in 10 cases of unusual vaginal bleeding after the menopause are caused by womb cancer, so it's unlikely your symptoms will be caused by this condition.

However, if you have unusual vaginal bleeding, it's important to get the cause of your symptoms investigated. The bleeding may be the result of a number of other potentially serious health conditions, such as:

  • endometriosis – where tissue that behaves like the lining of the womb is found on the outside of the womb
  • fibroids – non-cancerous growths that can develop inside the uterus
  • polyps in the womb lining  
  • Other types of gynaecological cancer can also cause unusual vaginal bleeding, particularly cervical cancer.
Causes

It's not known exactly what causes womb cancer, but certain things can increase your risk of developing it.

Cancer begins with a change (mutation) in the structure of the DNA in cells, which can affect how they grow. This means cells grow and reproduce uncontrollably, producing a lump of tissue called a tumour.

If left untreated, cancer can grow and spread to other parts of your body, either directly or through the blood and lymphatic system.

Increased risk

A number of things have been identified that increase the risk of developing womb cancer. Some of these are discussed below.

Age

The risk of developing womb cancer increases with age. The majority of cases occur in women aged 40 to 74, with only 1% of cases being diagnosed in women under 40.

Oestrogen

The risk of developing womb cancer is linked to the body's exposure to oestrogen. Oestrogen is one of the hormones that regulates the reproductive system in women.

  • oestrogen stimulates the release of eggs from your ovaries and causes the cells of the womb lining to divide
  • progesterone gets the lining of your uterus ready to receive the egg from the ovaries

The levels of oestrogen and progesterone in your body are usually balanced with each other. If oestrogen isn't kept in balance by progesterone, the level in the body can increase. This is called unopposed oestrogen.

After the menopause, the body stops producing progesterone. However, there are still small amounts of oestrogen being produced. This unopposed oestrogen causes the cells of the endometrium to divide, which can increase the risk of womb cancer.

Hormone replacement therapy (HRT)

Because of the link between increased levels of unopposed oestrogen and womb cancer, oestrogen-only hormone replacement therapy (HRT) should only be given to women who have had their womb surgically removed (hysterectomy).

In all other cases, both oestrogen and progesterone (combination HRT) must be used in HRT to reduce the risk of womb cancer.

Being overweight or obese

As oestrogen can be produced in fatty tissue, being overweight or obese increases the level of oestrogen in your body. This significantly increases your chances of developing womb cancer.

Women who are overweight are three times more likely to develop womb cancer compared with women who are a healthy weight. Very obese women are six times more likely to develop endometrial cancer compared with women who are a healthy weight.

One way to assess whether your weight is healthy is to calculate your body mass index (BMI). In the UK, people with a BMI of between 25 and 30 are overweight, and those with an index above 30 are obese.

Reproductive history

Women who have not had children are at a higher risk of womb cancer. This may be because the increased levels of progesterone and decreased levels of oestrogen that occur during pregnancyhave a protective effect on the lining of the womb.

Tamoxifen

Women who are treated with tamoxifen (a hormone treatment for breast cancer) can be at an increased risk of developing womb cancer. However, this risk is outweighed by the benefits that tamoxifen provides in preventing breast cancer.

It's important to visit your GP if you're taking tamoxifen and experience any abnormal vaginal bleeding.

Diabetes

Women with diabetes are twice as likely to develop womb cancer as women without the condition.

Diabetes causes an increase in the amount of insulin in your body, which in turn can raise your oestrogen levels.

Many women with type 2 diabetes are also overweight, which further increases the risk.

Polycystic ovarian syndrome (PCOS)

Women with polycystic ovarian syndrome (PCOS) are at a higher risk of developing womb cancer, as they have high levels of oestrogen in their bodies.

Women with PCOS have multiple cysts in the ovary, which can cause symptoms such as irregular or light periods, or no periods at all, as well as problems getting pregnant, weight gain, acne, and excessive hair growth (hirsutism).

Endometrial hyperplasia

Endometrial hyperplasia is when the lining of the womb becomes thicker. Women with the condition may be at an increased risk of developing womb cancer.

Diagnosis

You should visit your GP if you have abnormal vaginal bleeding. While it's unlikely to be caused by womb cancer, it's best to be sure.

Your GP will probably carry out a physical examination of your pelvic area, including your vagina, womb, ovaries, and bladder. They will ask about your symptoms, when they happen, and how often.

You may be referred to a specialist in conditions of the female reproductive organs (a gynaecologist) for further tests. Some of these tests are outlined below.

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of gynaecological cancer and refer people for the right tests faster. To find out if you should be referred for further tests for suspected endometrial cancer, read the NICE 2015 guidelines on Suspected Cancer: Recognition and Referral.

Transvaginal ultrasound (TVU)

Another test you may have is called a transvaginal ultrasound (TVU). TVU is a type of ultrasound scan that uses a small scanner in the form of a probe.

This is placed directly into the vagina to obtain a detailed picture of the inside of the uterus. The probe can feel a little uncomfortable, but shouldn't be painful.

The TVU checks whether there are any changes to the thickness of the lining of your uterus that could be caused by the presence of cancerous cells.

Biopsy

If the results of the TVU detect changes in the thickness of the lining of the uterus, you will usually have a biopsy to confirm the diagnosis.

In a biopsy, a small sample of cells is taken from the lining of the womb (the endometrium). The sample is then checked at a laboratory for the presence of cancerous cells.

The biopsy can be carried out in several ways, including:

  • aspiration biopsy – a small flexible tube is inserted into your vagina and up into your womb, and then sucks up a small sample of cells
  • hysteroscopy – this allows the doctor to look at the inside of the womb using a thin type of telescope called a hysteroscope, which is inserted through your vagina and into your womb, allowing the doctor to look at the lining of the womb and take a sample from it

In some cases, a hysteroscopy may be used before dilatation and curettage (D&C). D&C is a minor surgical procedure carried out under general anaesthetic, where some tissue from the womb lining is removed. The tissue is then sent off to a laboratory for further testing.

Blood test

A blood test can sometimes help diagnose womb cancer. This is because some cancerous tumours release certain chemicals into your blood, known as tumour markers, which can be detected during a blood test.

However, this type of test isn't very reliable. The presence of these chemicals doesn't mean you definitely have womb cancer. Some people with womb cancer don't have these chemicals in their blood.

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Tests if you have womb cancer

If you're diagnosed with womb cancer, you may have further tests to help determine the stage of the cancer. Staging the cancer will allow the doctors to work out how large the cancer is, whether or not it has spread, and the best treatment options for you.

These tests may include:

  • a chest X-ray – where radiation is used to check if the cancer has spread to the lungs
  • magnetic resonance imaging (MRI) – where magnetic fields are used to create a detailed image of the inside of your body to check if the cancer has spread
  • a computerised tomography (CT) scan – where a series of X-rays are used to create a detailed image of the inside of your body to check if the cancer has spread
  • further blood tests – these are usually done to check your general health and how well some of your organs are functioning
Treatment

Surgery is the main treatment for womb cancer, although different methods can be used depending on your personal circumstances.

Cancer treatment team

People with cancer should be cared for by a team of specialists who work together to provide the best treatment and care. This is called a multidisciplinary team (MDT).

The team will consist of specialist cancer surgeons (gynaecological oncologists), a clinical oncologist (a specialist in radiotherapy treatment), a medical oncologist (a chemotherapy specialist), and a specialist nurse.

Other members will include a radiologist and pathologist. Specialists in supportive care, such as a palliative care physician and specialist palliative care nurses, may also be involved, as well as a dietitian, a physiotherapist, and an occupational therapist.

When deciding which treatment is best for you, your doctors will consider:

  • the stage of your cancer (how big it is and how far it has spread)
  • your general health
  • whether fertility is a matter of concern (this is rare because of the age at which womb cancer usually occurs)

Your MDT will recommend the best treatment for you based on these considerations, but the final decision is yours.

Before going to hospital to discuss your treatment options, it can be useful to write a list of questions you'd like to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

The stages of womb cancer and the main treatment options are outlined below.

Stages of womb cancer

Health professionals use a staging system to describe how far womb cancer has advanced. These stages are:

  • stage 1 – the cancer is still contained inside the womb (uterus)
  • stage 2 – the cancer has spread to the neck of the womb (the cervix)
  • stage 3 – the cancer has spread outside the womb into nearby tissues in the pelvis or the lymph nodes
  • stage 4 – the cancer has spread to the soft tissues of the abdomen, or into other organs, such as the bladder, bowel, liver, or lungs

Your chances of surviving womb cancer depend on the stage at which it's diagnosed.

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Treatment overview

The main treatment for womb cancer is to remove the womb (hysterectomy), together with the ovaries and fallopian tubes. This is sometimes followed by radiotherapy or chemotherapy to try to kill any possible remaining cancer cells, depending on the stage and grade of the cancer.

Treatment for women who haven't been through the menopause

Having a hysterectomy means you will no longer be able to get pregnant. Younger women who haven't already reached the menopause may not want to have their womb and ovaries removed if they wish to have children.

In this case, under very specific circumstances it may be possible to treat the cancer using hormone therapy.

Treating advanced cancer

Advanced womb cancer requires a different course of treatment, usually depending more on chemotherapy.

Advanced cancer may not be curable, but the treatment aims to achieve a remission, where the cancer shrinks, making you feel normal and able to enjoy life to the full.

Even if there's no chance of a cure, surgery may be carried out to remove as much of the cancer as possible.

Radiotherapy, chemotherapy or hormone therapy can reduce symptoms such as pain by shrinking the cancer or slowing its growth.

Surgery for stage 1 womb cancer

If you have stage 1 cancer, you'll probably have a hysterectomy. This involves removing both ovaries and the fallopian tubes in a procedure called a bilateral salpingo-oophorectomy (BSO), as well as the uterus (hysterectomy).

The surgeon may also take samples from the lymph nodes in the pelvis and abdomen and other nearby tissue. These will be sent to the laboratory to see whether the cancer has spread.

The most common hysterectomy technique involves using one large cut across your tummy to access the womb and remove it.

It's sometimes possible to use a technique called a laparoscopic hysterectomy, also known as a keyhole hysterectomy. This involves using several small cuts so a special type of telescope (laparoscope) and other surgical instruments can be used.

This means the surgeon can see inside your body and remove your womb through your vagina with little scarring.

You'll probably be ready to go home three to five days after your operation, or less if you had keyhole surgery. But it can take many weeks to recover fully.

After your operation, you'll be encouraged to start moving about as soon as possible. This is very important, and even if you have to stay in bed you'll need to keep doing regular leg movements to help your circulation and prevent blood clots. You'll be shown exercises by the nurses or physiotherapist to help prevent complications.

When you go home, you'll need to exercise gently to build up your strength and fitness. Discuss with your doctor or physiotherapist which types of exercise would be suitable for you.

Surgery for stage 2 or 3 womb cancer

If you have stage 2 or 3 womb cancer and the cancer has spread to the cervix or nearby lymph nodes in the pelvis, you may have a radical or total hysterectomy.

This involves the additional removal of the cervix and the top of your vagina, as well as the removal of the pelvic lymph nodes. You may also need radiotherapy or chemotherapy treatment after surgery to reduce the risk of the cancer returning.

Surgery for advanced cancer (stage 4)

If you have advanced womb cancer, you may have surgery to remove as much of the cancer as possible. This is called debulking surgery.

This won't cure the cancer, but it may ease some of the symptoms. Your doctor will discuss whether debulking surgery is suitable for you.

Radiotherapy

A course of radiotherapy will be recommended if your treatment team thinks there's a significant risk the cancer could return in the pelvis. Radiotherapy may also be used to slow the spread of cancer when a surgical cure is not possible.

There are two types of radiotherapy used to treat womb cancer:

  • internal radiotherapy (also known as brachytherapy) – where a plastic tube is inserted inside the uterus and radiation treatment is passed down the tube into the womb
  • external radiotherapy – where a machine is used to deliver pulses of radiation to your pelvis

A course of external radiotherapy is usually given to you as an outpatient for five days a week with a break at the weekend. The treatment takes a few minutes. The whole course of radiotherapy may last approximately four weeks depending on the stage and position of the womb cancer.

Some women have internal radiotherapy (brachytherapy) as well as external radiotherapy. During brachytherapy, the device that delivers radiation is placed in your vagina.

There are different types of brachytherapy, involving either low, medium, or high dose rates. With low dose rate methods the radiation is delivered more slowly, so the device has to stay inside you for longer. You'll have to stay in hospital while you have the treatment. Your doctor will discuss this with you.

Radiotherapy has some side effects. Skin in the treated area can become red and sore, and hair loss may occur. Radiotherapy to the pelvic area can affect the bowel and cause sickness and diarrhoea.

As your course of treatment progresses, you're likely to get very tired. Most of these side effects will go away when your treatment finishes, although around 5% of women continue with long-term treatment effects, such as diarrhoea and rectal bleeding.

Chemotherapy

If you have stage 3 or 4 womb cancer, you may be given a course of chemotherapy. Chemotherapy can be used after surgery to try to prevent the return of the cancer. In cases of advanced cancer, it may be used to slow the spread of the cancer and relieve symptoms.

Chemotherapy is usually given as an injection into the vein (intravenously). You'll usually be able to go home the same day you have chemotherapy, but sometimes you may need a short stay in hospital.

Chemotherapy is usually given in cycles, with a period of treatment being followed by a period of rest to allow the body to recover.

Side effects of chemotherapy can include:

There is also an increased risk of an infection developing in your bloodstream (sepsis), as your body's ability to fight infection is reduced by chemotherapy.

The side effects should stop once treatment has finished.

Hormone therapy

Some womb cancers are affected by the female hormone oestrogen. These cancers may respond to treatment with hormone therapy. Your doctor will discuss whether this is a possible treatment for your womb cancer.

Hormone therapy usually replaces a hormone called progesterone, which naturally occurs in your body. Artificial progesterone is used and is usually given as tablets.

It's mainly used to treat advanced-stage womb cancers, or cancer that has come back, and can help shrink the tumour and control any symptoms.

The treatment may have some side effects, including mild nausea, mild muscle cramps, and weight gain. Your doctor will discuss these with you.

Clinical trials

A lot of progress has been made in the treatment of womb cancer, and more women are living longer with fewer side effects. Some of these advances were discovered through clinical trials, where new treatments and combinations of treatments are compared with standard treatment.

All cancer clinical trials in the UK are carefully monitored to make sure the trial is worthwhile and safely conducted. Participants in clinical trials often do better overall than those in routine care.

If you're invited to take part in a trial, you'll be given an information sheet. If you wish to take part, you'll be asked to sign your consent. You're always free to refuse or withdraw from a clinical trial without it affecting your care.

Living with

A diagnosis of cancer is a challenge for most people. How cancer affects your daily life depends on the stage of your cancer and the treatments used.

There are many ways to get help coping with cancer. Not all of them work for everybody, but one or more should prove helpful:

  • keep talking to your friends and family – they can be a powerful support system
  • communicate with others in the same situation
  • learn about your condition
  • set reasonable goals
  • take time out for yourself
After treatment

Women with womb cancer usually have a hysterectomy. This can be a major operation, and recovery may take from 6 to 12 weeks.

During this time you will have to avoid lifting things (for example, children and heavy shopping bags) and doing heavy housework. You won't be able to drive for between three and eight weeks after the operation.

Most women need 4 to 12 weeks off work after a hysterectomy. The recovery time will depend on the type of surgery you have, whether or not any problems develop, and what type of work you will return to.

Some of the treatments for endometrial cancer, particularly radiotherapy, can make you very tired. You may need to take a break from some of your normal activities for a while. Don't be afraid to ask for practical help from family and friends if you need it.

Follow-up

After your course of treatment has finished, you'll probably be invited back for regular check-ups. At the check-up, your doctor will examine you (this is likely to include an internal examination) and possibly carry out blood tests or scans to see how your cancer is responding to treatment.

Relationships and sex Relationships with friends and family

Knowing how to talk to your friends and family about your cancer can be difficult, and they may find it hard to talk to you, too. People deal with serious problems in different ways.

It's hard to predict how a diagnosis of cancer will affect you. Being open and honest about how you feel and what your family and friends can do to help may put them at ease. But don't feel shy about telling people that you want some time to yourself, if that's what you need.

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Your sex life

Womb cancer and its treatment can affect your sex life. This can happen in several ways:

  • early menopause – if you haven't already had the menopause, removing the ovaries means you'll go through an early menopause; symptoms can include vaginal dryness and loss of sexual desire
  • changes to your vagina – radiotherapy for endometrial cancer can make your vagina narrower and less flexible. Sometimes the vagina gets so narrow that having sex becomes difficult. To stop this happening, you should be offered a set of vaginal dilators, which are plastic cones you put into your vagina to stretch it. You can also stretch your vagina by having sex, or by using your fingers or a vibrator.
  • not wanting to have sex – it's common for women to lose interest in sex after treatment for womb cancer. Your treatment may leave you feeling very tired. You may feel shocked, confused or depressed about being diagnosed with cancer, and you also may be grieving the loss of your fertility.

It's understandable that you may not feel like having sex while having to cope with all this. Try to share your feelings with your partner. If you feel you have problems with sex that aren't getting better with time, you may want to speak to a counsellor or a sex therapist.

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    Talk to others

Being diagnosed with cancer can be hard, both for patients and their families. You'll need to deal with the emotional and practical difficulties.

With womb cancer, you have to cope physically with recovering from a hysterectomy, as well as the possible emotional impact of losing your womb.

Younger women may have to face the fact they won't be able to have children and all the grief and anger that may cause.

Often, it can help to discuss your feelings and other difficulties with a trained counsellor or therapist. You can ask for this kind of help at any stage of your illness. There are various ways to find help and support:

  • your hospital doctor, specialist nurse or GP can refer you to a counsellor
  • if you're struggling with feelings of depression, talk to your GP – a course of antidepressant drugs may be helpful, or your GP can arrange for you to get help from a counsellor or psychotherapist
  • it may be helpful to talk to someone who's had the same experience as you – many organisations have telephone helplines and forums that may be useful to you, and they can put you in touch with other people who have been through cancer treatment.