Endometrial Cancer

Today on the podcast we welcome Dr. Lindsey Beffa, clinical associate professor in the Division of Gynecologic Oncology at Women and Infants Hospital and the Warren Alpert Medical School at Brown University.

Endometrial cancer (or cancer of the endometrial lining) represents approximately 90% of uterine cancers overall. It’s the 4th most common cancer among US women and the most common GYN malignancy in the US. It has been increasing in incidence and has a peak incidence in women aged 60-70.

Type I Endometrial Cancer

These are low grade (1 or 2) cancers that generally have endometrioid histology. They overall have a favorable prognosis. When you think of endometrial cancer, this is probably what you imagine. They are estrogen-driven, have precursor lesions (EIN), and often present at an early stage.

Risk factors for type I cancers can be summarized with the type of tumor. These are estrogen-driven tumors. Thus, exogenous estrogen, or excess endogenous estrogen states, such as PCOS, chronic anovulatory states, obesity, diabetes mellitus, and rarely, granulosa cell tumors of the ovary that are estrogen secreting.

There are also genetic risk factors, including the Lynch syndrome, which is an autosomal dominant disorder of mismatch repair proteins. These are known as MLH 1, MSH 2, MSH 6, and PMS 2. Additionally, the Cowden syndrome is an autosomal dominant mutation of PTEN.

Type II Endometrial Cancer

On the other hand, these are high grade endometrioid or other aggressive histologies, such as clear cell or carcinosarcoma. These are fortunately much rarer but also have a less favorable prognosis. The risk factors for these are less clear, but do tend to appear in older, thinner patients; these tumors are additionally not estrogen-sensitive.

Presentation and Diagnosis

The most common presentation (75-90%) of endometrial cancer is abnormal uterine bleeding or postmenopausal bleeding. Additionally, abnormal Pap smears (AGC) or a thickened endometrial lining on ultrasound (>4mm postmenopausal) may prompt evaluation.

An endometrial biopsy is the simplest and very reliable way to achieve diagnosis, as long as >50% of the cavity is involved. If symptoms persist despite a negative biopsy, hysteroscopy and dilation and curettage should be performed.

Staging of Endometrial Cancer

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(c) NCCN

Abnormal Uterine Bleeding: The Basics

Today we talk through the varied etiologies and a basic workup for a common GYN complaint: abnormal uterine bleeding. ACOG PB 128 makes for good companion reading for women of reproductive age.

The terminology of AUB has changed quite a bit, and you may still hear older terms being used. “Dysfunctional uterine bleeding” or DUB has fallen out of favor, as have terms such as metrorrhagia or menorrhagia, yielding instead to simpler terminology such as prolonged menstrual bleeding and heavy menstrual bleeding, respectively. The terms such as oligomenorrhea (bleeding cycles > 35 days apart) and polymenorrhea (cycles < 21 days apart) are also in use to some degree.

Heavy bleeding is difficult to discern, but for research purposes has been described as >80cc blood loss per cycle. In clinical practice, this is obviously impractical, so we rely on subjective descriptions of heavy bleeding to guide care.

The biggest takeaways from this episode include the PALM-COIEN classification of bleeding by FIGO, as well as the common culprits of bleeding by age group. Remember also the criteria for working up for disorders of coagulation, which we’ve put here (though contained in the practice bulletin).

Stay tuned for future episodes about the treatments of these various etiologies, or check out our friends at The OBG Project for excellent summaries of guidelines and new literature!

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ACOG PB 128

ACOG PB 128