I have bleeding after menopause. What should I do?

Have a transvaginal ultrasound and, if the endometrium is thickened or the bleeding recurs, an endometrial biopsy. In most cases the cause is benign, but this is how endometrial cancer is found at an early stage.

Do the ovaries have to be removed?

Usually yes: the tubes and ovaries are removed together with the uterus. In premenopausal patients with stage I low-grade cancer, the ovaries can sometimes be preserved to avoid early menopause; the decision is made individually.

What is a sentinel lymph node biopsy?

It is finding and removing, with the help of a dye, the first lymph nodes that drain the tumor. If they are clear, the other nodes are usually clear too. The method gives accurate staging with a lower risk of leg swelling than removing all nodes.

Will I need radiotherapy after surgery?

It depends on the risk group: stage, depth of invasion, histology and molecular type. At low risk — no; at intermediate risk — most often vaginal brachytherapy; at high risk — external beam radiotherapy and/or chemotherapy.

Can the uterus be preserved?

Only in selected cases: a young patient planning pregnancy with a low-grade tumor confined to the endometrium. Hormonal treatment with follow-up biopsies every 3–6 months is then used, and removal of the uterus is recommended once childbearing is complete.

Endometrial cancer: laparoscopic surgery and staging

Endometrial (uterine body) cancer is, in developed countries, the most common malignant tumor of the female reproductive organs and, at the same time, one of the most often detected early: its main symptom, bleeding after menopause, prompts women to see a doctor in time. At early stages the main treatment is surgery, most often laparoscopic: removal of the uterus with the tubes and ovaries and assessment of the lymph nodes. Whether treatment is needed after surgery is now decided not only by stage but also by the tumor’s molecular type.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why endometrial cancer develops

The most common, endometrioid, type is linked to prolonged exposure to estrogen not balanced by progesterone. The main risk factors are therefore obesity, diabetes, polycystic ovary syndrome, late menopause, never having been pregnant, estrogen therapy without a progestin, and long-term tamoxifen. Endometrial hyperplasia with atypia is a precancerous condition that needs treatment.

Some cases are hereditary: in Lynch syndrome the risk of endometrial cancer is high, and it is often the first tumor in the family. That is why every patient’s tumor is tested for mismatch repair deficiency (MMR), and if it is found, further tests and, when indicated, genetic counseling follow.

Are there symptoms

The main symptom is vaginal bleeding after menopause, even a single, light episode. Before menopause, heavy, prolonged or intermenstrual bleeding should raise concern, especially after age 40. Lower abdominal pain, an enlarging abdomen and weight loss usually appear at later stages.

Any bleeding after menopause is a reason for a work-up — ultrasound and, when indicated, endometrial biopsy — not for waiting.

Examinations needed

Transvaginal ultrasound — endometrial thickness and the state of the uterus and ovaries.
Endometrial biopsy — by aspiration or during hysteroscopy; it gives the histologic type and grade of the tumor.
Molecular classification of the tumor: POLE mutation, MMR deficiency, p53 changes. It determines the risk of recurrence and the need for treatment after surgery.
Pelvic MRI — depth of invasion into the uterine wall, extension to the cervix, state of the lymph nodes.
CT of the chest and abdomen — for high-risk tumors or suspected spread.
Blood tests and assessment of the heart, lungs and blood glucose — before surgery.

When surgery is possible

Surgery is the main treatment for most patients if the tumor has not spread beyond the pelvis and they are fit for anesthesia. The standard is total hysterectomy with removal of the fallopian tubes and ovaries. In premenopausal patients with stage I low-grade cancer and no disease outside the uterus, the ovaries can sometimes be preserved.

For young women planning pregnancy with a confirmed low-grade tumor confined to the endometrium without invasion into the uterine wall, fertility-sparing treatment with progestins and follow-up hysteroscopies is possible. After childbearing is complete, removal of the uterus is recommended.

If MRI or CT shows enlarged lymph nodes or the tumor has spread to the cervix, the operation is extended: enlarged nodes are removed, and with cervical involvement the extent of surgery is decided individually. When the tumor has spread beyond the uterus but can be removed completely, surgery is discussed by the MDT, and treatment afterward is based on stage and molecular type.

If surgery is not possible now

If surgery is contraindicated because of other illnesses, radiotherapy — external beam and brachytherapy — becomes the main treatment. For selected patients with low-grade tumors, hormonal therapy is an option.

With distant metastases, treatment is based on drug therapy: chemotherapy, combined with immunotherapy in MMR-deficient tumors and in some other patients. If the tumor has spread across the peritoneum but can be removed completely, the MDT may consider cytoreductive surgery.

How the operation is performed

The uterus with the cervix, the fallopian tubes and the ovaries are removed. To stage the lymph nodes, a sentinel lymph node biopsy is performed: a dye is injected into the cervix, and the surgeon finds and removes the first nodes that drain lymph from the tumor. This gives accurate staging with a lower risk of leg swelling than removing all pelvic lymph nodes. In serous and undifferentiated cancer and carcinosarcoma, the omentum is also removed.

The standard approach for early cancer is laparoscopic, through several small incisions; the uterus is removed intact, without morcellation. For a large uterus or advanced tumor, the operation is performed open.

Bleeding after menopause is not “just hormones.” It is the symptom that most often leads to finding endometrial cancer early, when treatment is most effective.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After laparoscopic hysterectomy, patients are usually discharged within a few days and usually return to normal activity in 2–4 weeks.

After surgery, the risk group is determined by stage, histology and molecular type. At low risk no further treatment is needed; at higher risk — vaginal brachytherapy or external beam radiotherapy, chemotherapy, or a combination. Premenopausal patients enter surgical menopause after removal of the ovaries.

Follow-up

For the first 2–3 years, a gynecologic oncology check-up every 3–6 months, then less often; tests are ordered according to symptoms and risk group. Vaginal bleeding, pain or leg swelling should be reported right away.

What to bring to the consultation

the endometrial biopsy pathology report and, if available, molecular classification and MMR results;
tissue blocks and slides — for review by another laboratory;
ultrasound reports, pelvic MRI and CT discs, if performed;
the discharge summary and operative report, if the uterus has already been removed;
information about other illnesses, medications and cancer in the family.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.