ESSENTIALS OF DIAGNOSIS
AUB is the presenting sign in 90% of cases.
After a negative pregnancy test, endometrial tissue is required to confirm the diagnosis.
Adenocarcinoma of the endometrium is the most common cancer of the female genital tract in developed countries. It occurs most often in women 50–70 years of age. Obesity, nulliparity, diabetes mellitus, polycystic ovaries with prolonged anovulation, unopposed estrogen therapy, and the extended use of tamoxifen for the treatment of breast cancer are risk factors. Women with a family history of colon cancer (hereditary nonpolyposis colorectal cancer, Lynch syndrome) are at significantly increased risk, with a lifetime incidence as high as 30%.
Abnormal bleeding is the presenting sign in 90% of cases. Any postmenopausal bleeding requires investigation. Pain generally occurs late in the disease, with metastases or infection.
Papanicolaou smear of the cervix occasionally shows atypical endometrial cells but is an insensitive diagnostic tool. Endocervical and endometrial sampling is the only reliable means of diagnosis and is important to differentiate endometrial cancer from hyperplasia, which often can be treated hormonally. Simultaneous hysteroscopy can be a valuable addition to localize polyps or other lesions within the uterine cavity. Pelvic ultrasonography may determine the thickness of the endometrium as an indication of hypertrophy and possible neoplastic change. The finding of a thin endometrial lining on ultrasound (4 mm or less) in a postmenopausal woman is clinically reassuring in cases where very little tissue is obtainable through endometrial biopsy (eFigure 18–20).
Endometrial carcinoma. A: Longitudinal sonogram from a patient with vaginal bleeding. A large soft-tissue mass (arrows) is identified within the uterus. This tissue has the appearance of endometrium but is nonspecific and could represent hyperplasia, polyps, or carcinoma. B: Endovaginal sonogram from the same patient. Prominent soft tissue is seen in the expected location of the endometrium (arrows). At biopsy this proved to be endometrial carcinoma. (Used, with permission, from Peter W. Callen, MD.)
Prompt endometrial sampling for patients who report abnormal menstrual bleeding or postmenopausal uterine bleeding will reveal many incipient and clinical cases of endometrial cancer. Younger women with chronic anovulation are at risk for endometrial hyperplasia and subsequent endometrial cancer; they can significantly reduce the risk of hyperplasia with the use of oral contraceptives, cyclic progestin therapy, or a hormonal IUD.
Staging and prognosis are based on surgical and pathologic evaluation only. Examination under anesthesia, endometrial and endocervical sampling, chest radiography, intravenous urography, cystoscopy, sigmoidoscopy, transvaginal sonography, and MRI will help determine the extent of the disease and its appropriate treatment.