Endometrial cancer is the most common cancer of the female genital tract in the US, with a peak incidence between 55 and 64 years of age. It is divided into two types based on histological characteristics; type I cancers account for 80% of all endometrial cancers and are of endometrioid origin, while type II cancers primarily originate from serous or clear cells. Although several risk factors are associated with the development of endometrial cancer, the most important of these is long-term exposure to unopposed estrogen levels, especially in type I cancer. Painless, abnormal uterine bleeding (AUB) is the main symptom and often manifests in the early stages of the disease. In later stages, pelvic pain and a palpable mass may be present. Most patients with suspected endometrial cancer undergo transvaginal ultrasound followed by an endometrial biopsy to confirm the diagnosis; however, an endometrial biopsy may also be performed as the initial study. Additional imaging studies (e.g., CT, MRI, or PET/CT scan) may be ordered by a specialist for the detection of metastases. Treatment and surgical staging typically involve a total hysterectomy with bilateral salpingo-oophorectomy, lymphadenectomy, and peritoneal washings. In patients with cancer confined to the endometrium and myometrium, further treatment is generally not required; if cancer has advanced, surgery is combined with radiotherapy, hormone therapy, and/or chemotherapy. The prognosis is usually favorable in cancers diagnosed at an early stage.
- Type I endometrial cancer: endometrioid adenocarcinomas (grade 1 and 2) derived from atypical endometrial hyperplasia 
- Type II endometrial cancer: endometrioid adenocarcinomas (grade 3) and tumors of nonendometrioid histology; (serous, clear cell, mucinous, squamous, transitional, and undifferentiated cells) 
- Directly related to long-term exposure to increased estrogen levels
- Some genetic mutations (e.g., in the PTEN gene or mismatch repair genes) are also associated with this type of cancer.
- Mostly estrogen-independent
- Associated with endometrial atrophy (especially in postmenopausal women)
- Strongly associated with a genetic predisposition
Risk factors for estrogen-dependent tumors
- Early menarche and late menopause
- (esp. obesity and diabetes mellitus type 2 )
- Unopposed estrogen replacement therapy (e.g., for menopausal symptoms)
- History of breast cancer and tamoxifen treatment
- (hereditary nonpolyposis colorectal cancer)
- Combination oral contraceptive pills
- Regular physical exercise
- Lifelong soy-rich diet 
- Prevalence 
- Incidence: ∼ 20–28 per 100,000 women per year 
- Age 
Epidemiological data refers to the US, unless otherwise specified.
Localized disease 
- Abnormal uterine bleeding (AUB)
- Pelvic exam is often normal (uterus may be enlarged)
The majority of endometrial cancers are diagnosed at an early stage and have a good prognosis. 
Regional extension 
- Pelvic pain
- Vaginal mass and/or bleeding
- Abnormalities on cervix
- Abdominal distension
- Changes in bowel and/or bladder function
Metastatic disease 
- Perform initial , including:
- For postmenopausal women, obtain either of the following as a first-line study:
- For premenopausal/perimenopausal women:
- In confirmed cancer, organize:
- Genetic studies
- Staging studies
Transvaginal ultrasonography 
- Postmenopausal women: TVUS as an initial study (alternative: endometrial biopsy)
- Perimenopausal women: Consider as part of the initial workup of abnormal uterine bleeding. 
- All patients: possible visualization of masses or
- Postmenopausal women: measurement of endometrial thickness
Endometrial biopsy with histology 
- Postmenopausal patients, either as a first-line investigation or if any of the following are present on TVUS: 
- Premenopausal with any of the following: 
- Known Lynch syndrome 
- Atypical glandular cells on routine cervical cytology 
Procedures for endometrial sampling 
- In-office endometrial sampling
- First line for most patients
- Can be performed; using disposable equipment during the pelvic exam
Hysteroscopy-guided dilatation and curettage (D&C)
- Allows for visualization of endometrial pathology and simultaneous biopsy
- Preferred for patients with: 
- Typically performed as an outpatient procedure
Endometrial hyperplasia with or without atypia 
- Endometrial hyperplasia with atypia (endometrial intraepithelial neoplasia) is considered premalignant and concomitant adenocarcinomas are common.
- If not already performed, hysteroscopy with D&C is recommended to exclude malignancy.
- See “Endometrial hyperplasia” for more information on diagnosis and management.
- Endometrial carcinoma; or serous adenocarcinoma: a pronounced proliferation of disorganized glandular tissue 
- See also “Pathology of endometrial cancer.”
Genetic studies 
- Lynch syndrome testing: all women with endometrial cancer 
- Advanced studies may be requested by a specialist depending on clinical presentation. 
Staging studies 
- All patients: MRI pelvis (with and without IV contrast) to determine locoregional extension and assess for myometrial invasion
- Patients with high-grade tumors or symptoms suggestive of metastatic disease: Further imaging is recommended. 
- Patients who undergo surgery: surgical staging including lymphadenectomy 
Endometrioid adenocarcinoma 
- Prevalence: most frequent form
- Pronounced glandular proliferation, which presents as atypical glandular tubes
- The glands are positioned, in part, back-to-back ("dos-à-dos") with no separating stroma
- Lined with pseudostratified epithelial cells, the nuclei of which are enlarged in an atypical vesicular form.
- These glandular cells frequently demonstrate mitosis.
- Tumor cell nests may also be observed and infiltrate the myometrium in high-grade tumors.
Tumors of nonendometrioid histology
|2023 International Federation of Gynecology and Obstetrics (FIGO) surgical staging of endometrial cancer |
|FIGO stage||Anatomical involvement|
- Patients of any age 
- Premenopausal patients and perimenopausal patients 
- Postmenopausal patients: endometrial or vulvovaginal atrophy 
The differential diagnoses listed here are not exhaustive.
General principles 
- Treatment is based on:
- Most patients are managed with surgery; adjuvant radiotherapy and/or chemotherapy may be required depending on the extent of disease.
- If disease extends beyond the endometrium and myometrium, arrange to assess suitability for treatments.
- Patients should be provided with Principles of cancer care”). to optimize outcomes (see “
Disease confined to the endometrium and myometrium
Postmenopausal patients and patients who do not wish to preserve fertility 
- First-line: total hysterectomy with bilateral salpingo-oophorectomy
- Alternative: hysterectomy with ovarian preservation (select patients only) 
Adjuvant treatment is not normally required for this group, but radiotherapy should be considered for high-risk patients (i.e., those with high-grade disease, invasion of the lymphovascular space or outer third of the myometrium). 
Patients wishing to preserve fertility 
- Uterine preservation may be possible for women who wish to carry a pregnancy in the future. ; 
- Hysterectomy with ovarian preservation can be used for patients willing to use a surrogate. 
Lymph node involvement or locally advanced disease 
- Total hysterectomy with bilateral salpingo-oophorectomy
- PLUS adjuvant chemotherapy and/or radiotherapy
Metastatic disease 
- Follow-up visits should occur: 
- Every 3–6 months for the first 2 years
- Every 6 months for the next 3 years
- Then annually
- At each visit obtain: 
- Imaging is not required as part of routine screening but should be requested if disease recurrence is suspected. 
- Address underlying risk factors (see “Prevention of endometrial cancer”) and provide . 
- An accumulation of pus in the uterine cavity
- Caused by infection resulting from obstruction of the cervical opening by the tumor and secondary blood stasis (hematometra)
- Can develop in patients with duplication of the cervix or as an uncommon complication of gynecological malignancy
- Presented with purulent vaginal discharge, lower abdominal pain, and enlarged uterus
- Diagnosed by imaging studies (e.g., abdominal ultrasound or CT scan)
- Treated with drainage and dilation of the cervical lumen
We list the most important complications. The selection is not exhaustive.
- Endometrial cancer has the 2nd best prognosis (after cervical cancer) of all gynecological cancers in the US. 
- Cancer stage at diagnosis determines the 5-year survival rate: 
- Death rate: ∼ 5 per 100,000 women per year 
- Types of endometrial carcinomas that are well-differentiated and possess estrogen receptors (type I) have a more favorable prognosis.
- Clear cell and papillary serous carcinomas (type II) have an aggressive course and a poor prognosis.
- Routine screening tests are not available. 
- Screen for and address risk factors:
- Educate the following patients on recognizing the : 
- Patients with Lynch syndrome who wish to preserve their uterus should undergo yearly TVUS with aspiration biopsy from age 35 years.