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BackTable / OBGYN / Article
Endometrial Cancer in the Clinic: Symptoms, Diagnosis & Referral Pathways
Faith Taylor • Updated Dec 10, 2024 • 35 hits
Endometrial cancer is typically indicated by irregular bleeding, making it detectable in its early stages. However, delays in diagnosis are common due to factors such as misattribution of symptoms by physicians, patient demographics, inaccurate screening strategies, and inadequate referral pathways.
To help close the gap in timely diagnosis, gynecologic oncologist Dr. Amanda Fader and gynecologist Dr. Matthew Powell provide an overview of the symptoms, diagnostic approaches, and referral pathways for endometrial cancer. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Abnormal uterine bleeding, including postmenopausal spotting and premenopausal irregularities, is the most common early symptom of endometrial cancer
• Obesity, diabetes, polycystic ovarian syndrome, and metabolic syndromes increase the risk of endometrial cancer, particularly in younger and racially diverse populations.
• Guidelines recommending evaluation for women over 35 with abnormal uterine bleeding are now outdated; prolonged irregular menses in patients as young as their 20s should prompt evaluation for endometrial cancer.
• Pelvic ultrasound reliably detects type 1 endometrial cancer, often indicated by a thickened endometrial lining or polyps.
• Pelvic ultrasound is less accurate in detecting aggressive non-endometrioid endometrial cancers, making biopsy essential for diagnosing irregular bleeding regardless of ultrasound findings
• Sentinel lymph node biopsies help provide comprehensive staging and guide long-term care for patients with invasive or high-risk endometrial cancer.
• Up to 45% of endometrial intraepithelial neoplasia cases are associated with invasive cancer, making referral to high-volume gynecologic oncologists essential for comprehensive care.
Table of Contents
(1) Endometrial Cancer Symptoms
(2) Demographic Disparities in Endometrial Cancer
(3) Endometrial Cancer Diagnosis: Ultrasound & Biopsy Screening Strategies
(4) Optimizing Referral Pathways for Endometrial Cancer & Endometrial Intraepithelial Neoplasia
Endometrial Cancer Symptoms
The onset of endometrial cancer in patients is often signaled by abnormal uterine bleeding. While postmenopausal bleeding is a well-known red flag, premenopausal women may also experience changes such as intermenstrual bleeding, prolonged heavy periods, or shorter menstrual intervals. In fact, the incidence of endometrial cancer and abnormal bleeding has risen among younger patients, largely due to increasing rates of obesity, diabetes, and polycystic ovarian syndrome.
[Dr. Amy Park]
For our listeners, what are the signs or symptoms that we need to be looking out for? I know postmenopausal bleeding is one of the things, but what if they're premenopausal? How do you screen for it? What are the things that you guys think are getting missed when the patients present to you?
[Dr. Amanda Fader]
I think that's a really great question. Matt, if you don't mind, I'll start with this answer. The good news is that this disease is largely preventable. This is a modifiable preventable cancer in not all cases but the majority of cases. The onset of the cancer is almost always heralded by some sort of bleeding. In postmenopausal bleeding, we know that any bleeding spotting discharge is abnormal and we would recommend women immediately seek care in that situation.
We're seeing with the increased obesity and polycystic ovarian syndrome, diabetes, as Matt said, so many different metabolic syndrome diagnoses also going up. We're seeing the incidence of endometrial cancer increase in younger women. Premenopausal women can experience abnormal uterine bleeding. That can manifest in many different ways, from bleeding between periods, prolonged heavier cycles, shorter intervals between cycles.
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Demographic Disparities in Endometrial Cancer
Patients with metabolic syndromes that belong to certain racial and ethnic groups face a higher risk of endometrial cancer. Research has shown that when compared to other populations, Black and Hispanic women have higher rates of pathological findings on endometrial biopsies, which increase with the prevalence of obesity and diabetes [1]. However many of these cases go undiagnosed due to patients delaying seeking medical evaluation for irregular bleeding or the misattribution of symptoms by physicians to other factors like perimenopause or missed contraceptive pills.
[Dr. Amanda Fader]
There was actually a study done by my colleague Anna Beavis here at Hopkins that we looked at a population of women here, premenopausal women who had undergone endometrial biopsy and evaluations to determine, can we do better than our current guidelines in terms of pivoting to performing a biopsy in these patients? She interestingly found that, not surprisingly, increasing obesity and the incidence of obesity, as well as diabetes, and in certain ethnic racial groupings, especially in Black and Hispanic women, those populations had an increased incidence of pathology on endometrial biopsy when it was obtained.
I would just encourage women who have any irregular bleeding in the premenopausal setting that just doesn't seem right or just change from prior trends or any postmenopausal women with bleeding to immediately present to their physicians. Then, providers I think need to be very astute about this and not blow off these symptoms. Unfortunately, I know Matt and I see, not all the time, but not uncommonly, we'll see patients who presented for care to their physicians and they had this concern and were told, "Okay, well it's probably just perimenopause or it maybe because you missed your pill."
These women are not always evaluated diagnostically for this problem, and delays in care can occur. There's been a lot of literature about this as well. Kemi Doll, one of our two oncology colleagues from the University of Washington writes about this, how you can have these vulnerabilities and care cycles that women actually present to care but are not necessarily triaged appropriately and undergo the proper workups. That can affect the delay in diagnosis and a delay in treatment for some patients.
Endometrial Cancer Diagnosis: Ultrasound & Biopsy Screening Strategies
Prolonged irregular menses in patients as young as their 20s should prompt evaluation, as guidelines recommending assessment only for women over 35 are now outdated. Type 1 endometrial cancer can be found through pelvic ultrasound, which identifies thickened endometrial lining or polyps. If the endometrial lining is thicker than 5mm, Dr. Powell recommends proceeding with a biopsy.
Pelvic ultrasound often fails to diagnose aggressive non-endometrioid subtypes, especially in African-American and elderly patient populations. Therefore, an endometrial biopsy for irregular bleeding should be performed regardless of ultrasound findings. If symptoms persist after a negative biopsy, further evaluation with dilation and curettage or hysterectomy is necessary to rule out serious pathology.
[Dr. Amy Park]
What are your thoughts about the pelvic ultrasound? I know for screening and if you look at the guidelines for postmenopausal women, at least, looking at the lining, I know it's not as good as catching the non-endometrioid type cancers. What are the warning signs? I see so many older patients. It's so hard to figure out if this is like a little bit of discharge, is it some pessary juice? What's going on here?
What would be your little just low threshold to biopsy? I literally have a low threshold to biopsy, endometrial biopsy or vulvar biopsy. I catch a lot of BIN and vulvar cancer actually, so I just biopsy a lot. What are your thoughts? You guys see these patients after they present for care and it's too late.
[Dr. Matthew Powell]
I do get two caveats. One is we used to say, any abdominal bleeding over age 35 should be evaluated. Now, throw that out. I think, especially with adolescent obesity, we're seeing young 20 year olds getting endometrial cancer. Really, if they've had irregular menses for a long period of time or for more than 6 to 12 months, I think they need to be assessed even if they're in their 20s. Take that caveat.
The other issue about use of ultrasound, you point out, ultrasound does a good job picking up the type 1 endometrial cancer. The garden variety endometrial cancer, you'll see either polyp or thickened lining. You're going to see an enlargement of the lining. Usually in a postmenopausal state, we use something 5 millimeters or greater to really want to proceed with a biopsy.
Now, it doesn't do a very good job picking up the non-endometrioid cancers. Especially our African-American patients and our very elderly patients, if they're bleeding, you really want to think about a biopsy because it could represent a serious cancer. The tricky part is there's obviously a lot of cervical stenosis that can happen. Sometimes it's mucus in the lining of the uterus that you're seeing.
Really, if they've had symptoms or there's thickening on the ultrasound, error on biopsy I think is the key. If you get a negative biopsy and they're still having symptoms or problems, make sure you're following up with either DNC or even moving to hysterectomy and somebody that maintains persistent symptoms.
Optimizing Referral Pathways for Endometrial Cancer & Endometrial Intraepithelial Neoplasia
Early detection and referral are critical for managing endometrial cancer and its precursor, endometrial intraepithelial neoplasia (EIN). Up to 45% of EIN cases are associated with invasive cancer, making referral to high-volume gynecologic oncologists essential for comprehensive care, including sentinel lymph node biopsy and surgical staging.
While in-office procedures like hysteroscopy and biopsy can address immediate concerns, patients with confirmed EIN or complex atypical hyperplasia benefit most from specialized evaluation. Matching patients with the appropriate provider, timing, and procedure ensures expert care, reducing the risks of incomplete staging and complications from post-operative findings of invasive cancer.
[Dr. Amy Park]
I know one of my colleagues, Linda Bradley, she is such a proponent of doing office hysteroscopy. She gives meso at the drop of a hat, like some PO Ativan, all the things like magnesium, I guess. I was just doing a co-case with her the other day and she gives IV magnesium to help with the cramping postoperatively. I hadn't heard of that trick, but I haven't dilated somebody in a long time.
In any case, I think when you get into the day-to-day of your clinic and you're looking at your template, you're like, oh my God, I have to-- especially for a generalist, I have a little bit more time on my template, but it's like, how are you going to-- they're like, "Oh, by the way, I have some bleeding." Then you got to get them to that point.
I know for me, oftentimes I'm like, "Let's just take care of this while you're here," because I'm never sure when they're going to come back. You want to catch them when you can. I think having the right kind of counseling mechanisms where you can just have your spiel to be like, "Okay, I would really want to diagnose this. We just want to make sure it's nothing bad. Let's just make sure." Then if you have a pretty high suspicion for this, we usually wait for the tissue diagnosis before sending to GYN onc. Where do you guys stand on-- there's all these terminology now but I know it's called EIN. Is that something usually is referred to GYN onc or generalists or how does that work?
[Dr. Amanda Fader]
I think this is a variable practice at our center and within our system because EIN or pre-invasive disease is associated with upwards of a 40 to 45% risk of cancer on final hysterectomy specimen, especially if there's complex atypical cells seen under the microscope, which is by definition EIN, we manage this, the GYN oncologists manage this at our institution.
I think it's important that whoever is managing this is a very high volume provider, can counsel patients about the risks of underlying malignancy, can appropriately and surgically stage the patients in those cases if needed. At our institution, we generally will perform sentinel lymph node biopsies because there's such a high risk of concurrent invasive cancer in this population.
I think what's most important is understanding that the patient is getting the care from the right provider, so right provider, right time, right procedure. In most cases, the GYN oncologist is going to have the most experience and have the highest volume approach to managing those patients. I don't know, Matt, if you did the same thing at your institution.
[Dr. Matthew Powell]
Yes, I completely agree. Sometimes we'd use the amount of thickness on the ultrasound to help us gauge whether there's higher risk of cancer than 40%. In reality, it's just not accurate. We do tend to err on performing sentinel lymph nodes. That's certainly not uniform. Across our practice and across the country, if I have a cancer or pre-cancer, I want to have as much information to help guide the patient as we can.
There's nothing worse than your post-op having had the uterus out, you have a deeply invasive cancer, then you're not so sure about how to follow that patient because the lymph nodes certainly are repressed and how best to follow that patient is a big controversy. If we can take the sentinel lymph nodes out with really low morbidity, more information, the better to help us in this situation.
Additional resources:
[1] Surveillance Strategies in Endometrial Cancer Care: Why Less Represents Progress, Beavis, A. & Fader, A., (2022). https://pubmed.ncbi.nlm.nih.gov/36201708/
Podcast Contributors
Dr. Amanda Fader
Dr. Amanda Fader is a professor of gynecology, obstetrics and oncology and a gynecologic oncologist with Johns Hopkins Medicine in Baltimore, Maryland.
Dr. Matthew Powell
Dr. Matthew Powell is a professor of obstetrics and gynecology and a gynecologic oncologist with Washington University in St. Louis, Missouri.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 25). Ep. 58 – Understanding Rising Endometrial Cancer Rates [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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