Cancer of the womb body (endometrial cancer)

The womb has two parts: the body, inside which a baby is carried, and the cervix, the narrow opening into the vagina. When people say "womb cancer" they nearly always mean cancer of the body of the womb, growing out of its inner lining, the endometrium. It is the commonest malignant tumour of the female reproductive organs, and all it shares with cervical cancer is the word "womb": different causes, different prevention, different ways of finding it. Muddling the two is expensive, because it leaves women waiting for a bad smear result where the smear will show nothing at all. The good news is that this cancer speaks up early, and when it is found in time most women are cured.

Why this is not cervical cancer

The difference is not a technicality; it changes what you should do.

• Cervical cancer is almost always caused by the human papillomavirus. It is prevented by vaccination and caught at a pre-cancerous stage by cervical cytology and testing for that virus — the very screening women are invited to at regular intervals.
• Cancer of the womb body has nothing to do with that virus. It grows from the endometrium, and its main driver is prolonged oestrogen action with nothing to balance it. There is no vaccine, and no population screening for well women either, because none is needed: the disease announces itself with bleeding, and that works better than any programme.

Hence the practical point worth committing to memory: a cervical smear is not designed to pick up cancer of the womb body, and it misses it. A clear smear taken a month ago cancels out not one drop of blood that has appeared after the menopause. Occasionally a smear happens to show unusual glandular cells, which then prompts a look inside the womb, but that piece of luck is not something to rely on.

In the same way, a routine examination or a scan done "just in case" is no substitute for investigating a symptom. Here the symptom counts for more than any scheduled check.

The bleeding that should not be there

Eight or nine women in ten come to the doctor precisely because of blood, and that is why this disease is so often caught early.

If the menopause has already happened — that is, if there have been no periods for a year or more — the rule is simple and has no exceptions: any bleeding or spotting after the menopause needs to be seen by a doctor, however small the amount. One pink spot on your underwear, a single episode of brown staining, pinkish water after washing: all of it counts. It makes no difference whether it happened once or keeps happening, whether it hurts, whether there is anything else wrong. In most women the cause will turn out to be harmless: a thinned lining, a polyp, a fibroid, a side effect of hormone treatment. But every case has to be checked, because that is how a tumour a few millimetres across gets found.

If the menopause has not yet arrived, the signal is harder to read, because blood is part of ordinary life. What should prompt a second look:

• bleeding between periods;
• periods that have become unusually heavy or long, especially if that is new for you;
• bleeding after sex;
• a cycle that has lost all order, when it used to be regular.

The yardstick is straightforward: compare not with someone else's normal but with your own former one. A change that persists for more than two or three cycles is worth raising with a doctor.

Other signs, and what they get mistaken for

Besides blood there are complaints that get noticed less often:

• watery, pinkish or foul-smelling discharge without blood;
• a dragging ache low in the abdomen or in the small of the back, unrelated to the cycle;
• pain during sex;
• a feeling of pressure in the pelvis, needing to pass urine more often, or a change in bowel habit;
• unexplained weight loss and tiredness — these are already late signs.

All of this occurs in benign conditions many times more often than in cancer, so there is no cause to panic. But there is equally no sense in putting it down to age, stress or "the change", particularly when the complaint is new and does not settle.

A word about the urgent end of things. Immediate help is needed for heavy bleeding that soaks a pad within an hour and does so repeatedly, and for bleeding accompanied by marked weakness, dizziness, pallor, a racing heart or fainting. In that situation call an ambulance (112 is the single European number; your country may have its own). Everything else on these lists is not an emergency but a doctor's appointment in the next few days.

What raises the risk, and what can be changed

Almost all the factors point the same way: the longer the endometrium spends under oestrogen with no progesterone to balance it, the greater the chance that its cells will start growing wrongly. Hence the list below, the first half of which is open to change.

• Excess weight is the most significant of the modifiable factors. Fat tissue makes oestrogen in its own right and after the menopause becomes the main source of it, so the risk climbs with the weight.
• Type 2 diabetes and insulin resistance add risk in themselves, not only by way of weight.
• Taking oestrogen without a progestogen when the womb is still there. Oestrogen-only hormone therapy suits only women whose womb has been removed; in every other case a progestogen is added to protect the lining. If you have been prescribed hormones, ask what is protecting your endometrium — it is a fair question.
• Tamoxifen, used to treat and to prevent breast cancer. It saves lives and must never be stopped on your own initiative, but on the womb it acts like a weak oestrogen. In women taking it, any bleeding needs checking especially promptly.
• Polycystic ovary syndrome, in which ovulation is infrequent and progesterone is scarce.
• Early first periods and a late menopause, never having been pregnant, and past radiotherapy to the pelvis are things that cannot be changed.

Working in the opposite direction: a healthy weight, regular movement, past pregnancies and breastfeeding, several years of combined contraceptives, and a progestogen-releasing intrauterine system. Nothing guarantees anything, but weight and activity really are in your hands.

Lynch syndrome: a reason to start earlier

A small proportion of cases are inherited. In Lynch syndrome a fault in the genes responsible for repairing DNA runs in the family, and it markedly raises the risk of bowel, endometrial and ovarian cancer. The striking part is that in women, cancer of the womb body is often the first tumour of their lives — arriving before the bowel one.

It is worth suspecting if close relatives have had bowel, womb or ovarian cancer, especially under the age of fifty, or if one person in the family had several such tumours. In that case a genetics consultation and testing are discussed. Where the syndrome is confirmed, surveillance starts earlier than usual and is kept up regularly, and once a woman has settled her plans about having children, preventive removal of the womb and ovaries is discussed. It is not an easy decision and it is made together with a doctor, but knowing the option exists is something to have in advance.

How it is investigated

Working up a bleed is a well-practised routine and does not take long.

• Examination and a scan through the vagina. A probe the size of a finger allows the thickness of the lining to be measured. In a woman past the menopause a thin lining argues strongly against a tumour; a thickened one means looking further.
• Endometrial biopsy. A fine tube is passed through the cervix and a piece of lining is taken for analysis. It is done in the clinic room, in a matter of minutes, without a general anaesthetic; the sensation resembles strong period cramps, and you can ask for pain relief.
• Hysteroscopy. A slim camera is passed into the cavity of the womb and the inside is inspected, with targeted samples taken or a polyp removed at the same time. It is carried out under local or general anaesthetic.
• Blood tests, to see whether anaemia has set in and to check general condition.
• If the diagnosis is confirmed, an MRI or CT scan is added to establish how deeply the tumour has grown and whether it has gone beyond the womb. The tumour tissue is also examined for its molecular features, which govern the choice of treatment.

The biopsy result is usually ready within one to two weeks. The wait is hard, but a few days' delay does not change the outlook.

Treatment and outlook

The foundation of treatment is surgery: the womb is removed together with the cervix, along with the tubes and ovaries, and where necessary the lymph nodes are examined, including by the sentinel node technique, which spares having to take them all. Many women are operated on through small incisions, which speeds recovery appreciably. If the ovaries are removed before the natural menopause, the menopause arrives at once, and how to manage it is discussed with the doctor separately.

Depending on the stage and the features of the tumour, radiotherapy — including the kind given inside the vagina — chemotherapy, or a combination of the two is added to surgery. In advanced disease progestogens are used, and with certain molecular features of the tumour, immunotherapy. In young women with the very earliest form, treatment with progestogens while keeping the womb is considered in selected cases so that a pregnancy remains possible; this is not always an option and calls for close monitoring.

The outlook deserves plain speaking, because the word "cancer" frightens more than this situation warrants. Thanks to that early bleeding, around three-quarters of cases are found while the tumour is still confined to the womb, and at that stage the great majority of women recover — survival is above ninety per cent. The gap between early and late stage is enormous, and it is determined almost entirely by how quickly a woman came in with her first bleed.

Online consultation

A remote appointment settles the main question: whether what you have noticed belongs among the warning signs and how urgently it needs investigating. A doctor will go through the nature of the bleeding in the light of your age, your cycle and the medicines you take, explain how hormone therapy with a progestogen differs from oestrogen alone, and say which test makes sense to arrange first so that no weeks are lost. Online is also a convenient place to go through a scan or biopsy report you already have, to talk over the family history and work out whether there is reason for a genetics referral, and, after treatment, to raise questions about follow-up and how you are feeling. Heavy bleeding with weakness and dizziness is not something to sort out online: that is a reason to call an ambulance.

This material is for information only and does not replace medical advice.