Gynecological Cancer

Cancers of the female reproductive tract and genital region, otherwise known as gynecological cancer, are relatively uncommon, and represent a wide range of clinical presentations. Some of these cancers may have a strong genetic risk,  such as ovarian cancer, while others may be due to exposure to virus, such as cervical cancer or exposure to estrogens, as in the case of endometrial cancer.

About Uterine & Endometrial Cancers

There are several different types of cancers which affect the uterus, and these all fall under the category of Uterine Cancer. The uterus is an organ in the female anatomy composed of two basic components, the myometrium and endometrium.  Cells from either of these two areas can become malignant, and the kind of cancer which may develop is based on the originating location and type of originating cell. In general, uterine cancers include:

Uterine Sarcomas

Which are the type of cancer that involves the muscular layer of the uterus. The most common type of uterine sarcoma is a leiomyosarcomas.

Endometrial Cancers

These cancers originate from cells in the glands of the endometrium, or uterine lining. The most common uterine cancer is an endometrial adenocarcinoma, which is sometimes just referred to as endometrial cancer, and this is the cancer that is going to be the focus of this passage. Other types of endometrial cancers include papillary serous carcinoma and uterine clear-cell carcinoma. Mixed Müllerian tumors are rare endometrial tumors, which show both glandular and sarcomatous features.

As noted above, endometrial adenocarcinoma, typically referred to as endometrial cancer, is the most common form of uterine cancer, and will be the cancer discussed in the remainder of this website entry.

Endometrial cancer is the most common gynecologic cancer with an estimated 40,100 women diagnosed in the US in 2008, according to American Cancer Society statistics.  It is the fourth most common cancer in women. One in approximately 41 women will be diagnosed with endometrial cancer in her lifetime. The peak incidence is in women ages 50 to 70 years. Seventy-five percent of women are postmenopausal at diagnosis. It is more common in Caucasian women; however African American women are more likely to die from endometrial cancer.

How is Uterine Cancer Diagnosed?

If a woman has abnormal bleeding or other suspicious symptoms, she should see her gynecologist for a pelvic examination and pap test. A transvaginal ultrasound done at that time can determine whether there are any abnormal areas of endometrial thickening and identify suspicious areas, which may warrant a biopsy.

In order to diagnose endometrial carcinoma, a sample of tissue must be examined under a microscope. An endometrial biopsy can be done in the office. It does not require anesthesia and is generally well tolerated.

Once endometrial cancer has been diagnosed, the patient may undergo additional imaging or testing to evaluate the extent of disease. These include chest xray, CT or MRI of the abdomen and pelvis, cystoscopy, and sigmoidoscopy depending on a patient’s symptoms.

Treatment for Uterine and Endometrial Cancers

The primary treatment for uterine and endometrial cancer is surgery. The primary surgery is typically removal of the uterus and both ovaries, known as a total abdominal hysterectomy and bilateral salpingo-oopherectomy, or TAH-BSO. The staging of the cancer is done to determine the extent of the cancer, and the best plan treatment options. Women with low grade disease confined to the uterus may need no further treatment. Women with disease confined to the uterus with an increased risk of recurrence or if the disease extends to the cervix should undergo radiation therapy. If the cancer has spread beyond the uterus and cervix, chemotherapy may be warranted as well.

Signs & Symptoms

The most common sign of uterine cancer is vaginal bleeding and/or spotting in postmenopausal women. In premenopausal women, abnormal uterine bleeding such as bleeding in between, or abnormal menstrual periods such as extremely long, heavy, or frequentepisodes of bleeding which may indicate premalignant changes. It is also an important sign, especially in women over 40.

Other Signs Include

• Anemia, which can be caused by chronic loss of blood
(This may occur if the woman has ignored symptoms of prolonged or frequent abnormal menstrual bleeding)
• Lower abdominal pain or pelvic cramping
• Thin white or clear vaginal discharge in postmenopausal women
• If any of these symptoms occur a woman should contact her gynecologist for further evaluation.

Risk Factors

There are many risk factors that a woman can have which increase her risk of developingendometrial cancer. Many of these risk factors seem to be related to how long a woman has been exposed to natural circulating (within the body) estrogen during her lifetime. For example, estrogen levels are highest in women during their childbearing years, and women who had their first period (menarche) earlier have an increased risk of developing uterine cancer than women who had their first period later. Likewise, a woman who went into menopause at a later age has a higher risk of developing uterine cancer. Women who have never had children or who have had infertility issues may be at higher risk as well. Age itself is a risk factor, as endometrial cancer typically affects women within a decade or two of menopause. Obesity is also associated with higher amounts of circulating estrogen and a higher risk of developing uterine cancer, as is the use of hormone replacement therapy (HRT).

Genetics and family history also play a role. Older women or women with a family history are at higher risk, as are those who have themselves had breast, colon or ovarian cancer, as well as certain treatments for cancers such as prior pelvic radiation therapy or use of the drug Tamoxifen. Certain genetic diseases ormedical conditions can also increase a woman’s risk of developing uterine cancer, including polycystic ovarian syndrome, hereditary polyposis, diabetes, and endometrial hyperplasia.

Types of Radiation Therapy for Uterine/Endometrial Cancers

There are two main types of radiation therapy for endometrial cancer. The most common type is external beam radiotherapy, which includes Intensity Modulated Radiation Therapy (IMRT).  In IMRT, the radiation source is in a linear accelerator, which focuses the energy  on the area of the body being treated, which in the case of uterine cancer is the pelvis.The machine and therefore, the radiation source, never comes into contact with the body. The treatment is entirely noninvasive and painless. It is similar to receiving a chest xray.

Treatment is delivered 5 days a week (Monday thru Friday) for approximately 5 weeks and lasts only 3-4 minutes per session. The patient is in the treatment room for about 10 minutes, including set up. The other type of radiation therapy used to treat uterine cancer is called high dose rate (HDR) brachytherapy. For this type of therapy, the radiation is delivered internally. Nearby structures such as the bladder and rectum get little radiation exposure. Treatment is delivered once a week for 3 to 5 weeks and each treatment lasts approximately 10-12 minutes.

Risks & Side Effects

What are the risks and side effects? Possible side-effects during the treatment of uterine cancer may include fatigue, diarrhea, and discomfort during urination. Longer term side-effects include vaginal dryness and stenosis. The latter can be prevented by using a dilator or engaging in intercourse a few times a week. Does radiation therapy make me radioactive? No. Whether undergoing external beam radiation or internal brachytherapy, patients are not radioactive, nor at risk to others.