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Snapshot
  • A 72-year-old woman presents to her gynecologist for vaginal bleeding. She denies any vaginal pain or trauma and is not on any medications. A transvaginal ultrasound is performed, which demonstrates endometrial thickening of 6 mm. She underdgoes an endometrial biopsy, which is consistent with endometrial cancer.
Introduction
  • Overview
    • malignancy affecting the endometrium of the uterus
  • Epidemiology
    • incidence
      • most commonly affects women > 40 years of age
    • risk factors
      • elevated estrogen exposure
        • unopposed estrogen use
        • polycystic ovarian syndrome
        • early menarche
        • estrogen producing tumor
      • obesity
      • nulliparity or history of infertility
      • longterm tamoxifen use
      • Lynch syndrome
      • family history
  • Pathophysiology
    • estrogen acts on estrogen receptors in the endometrium, promoting endometrial proliferation and increasing the risk of cancer development
      • normally progesterone inhibits proliferation of the endometrium, thus abnormalities in progesterone lead to unopposed endometrial proliferation
  • Associated conditions
    • cervical adenocarcinoma
    • primary or ovarian cancer
  • Prognosis
    • prognostic factors
      • improved
Presentation
  • Symptoms
    • abnormal uterine bleeding
      • postmenopause
        • any bleeding
      • 45 to menopause
        • frequent, heavy, or prolonged bleeding
      • < 45 years of age
        • persistent bleeding
          • concerning in patients with risk factors (e.g., chronic anovulation and obesity)
Imaging
  • Transvaginal ultrasound
    • indication
      • an alternative to endometrial biopsy in patients who cannot tolerate the in office procedure
        • determines endometrial thickness
  • Hysteroscopy
    • indication
      • performed with dilation and curettage (D&C) in cases where transvaginal ultrasound and endometrial biopsy is unremarkable
Studies
  • Invasive studies
    • endometrial biopsy
      • indication
        • first-line in evaluating the endometrium for endometrial hyperplasia or endometrial cancer 
Differential
  • Uterine leiomyoma
    • differentiating factors
      • enlarged smooth muscle tumor
  • Adenomyosis
    • differentiating factors
      • endometrial gland and stroma in the myometrium
Treatment
  • Treatment depends whether the tumor is confined to the uterus or has metastasized
    • treatment involves surgery with or without chemotherapy, hormonal therapy, and radiation
  • Medical
    • progestine therapy
      • indication
        • endometrial cancer confined to the uterus in women who want to preserve fertility
  • Surgical
    • total hysterectomy and bilateral salpingo-oophorectomy
      • indication
        • initial management for endometrial cancer
          • along with pelvic and para-aortic lymphadenectomy
          • also collecting peritoneal fluid for cytology
Complications
  • Anemia
  • Metastasis

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Questions (3)
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(M2.ON.15.4662) A 31-year-old woman presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to 3 months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are planning to have children in the near future. What is the next best step?

QID: 107049
1

Total abdominal hysterectomy with bilateral salpingo-oopherectomy

4%

(1/25)

2

Partial, cervix-sparing hysterectomy

16%

(4/25)

3

Start combination estrogen and progestin therapy

8%

(2/25)

4

Start progestin-only therapy

48%

(12/25)

5

Observation with annual endometrial biopsies

20%

(5/25)

M 7 E

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Evidence (2)
EXPERT COMMENTS (8)
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