Endometrial cancer — cancer of the uterine lining — is the most common gynaecological cancer in developed countries and increasingly prevalent in India, rising in step with rising rates of obesity, diabetes, and delayed childbearing. The good news is that it has a prominent early warning sign that most women recognise: abnormal uterine bleeding. When women respond to this sign promptly, endometrial cancer is usually caught early — and early-stage endometrial cancer is highly curable.

Dr. Shachi Singh, consultant gynaecologist at Prakash Hospital, Sector 33, Noida, explains.

---

The Warning Sign: Postmenopausal Bleeding

Any vaginal bleeding in a woman who has been through menopause (12 months without a period) is abnormal and must be investigated. Every single time, without exception, regardless of how light.

Postmenopausal bleeding (PMB) has multiple causes — most of them benign (atrophic vaginitis, endometrial polyps, hormonal changes). But endometrial cancer is found in approximately 5 to 10% of women presenting with PMB — and that proportion rises with age. Because the downside of missing a cancer vastly outweighs the inconvenience of investigating a benign cause, PMB is always investigated.

In premenopausal women: Symptoms are subtler and easier to attribute to benign causes:

• Intermenstrual bleeding (bleeding between periods)
• Postcoital bleeding (after intercourse)
• Unusually heavy periods — particularly a change in the pattern of previously normal periods
• Abnormal uterine bleeding in the perimenopause that is out of proportion to what would be expected

Endometrial cancer before menopause is much less common but does occur — particularly in women with risk factors (see below).

---

Who Is at Risk

Endometrial cancer is driven primarily by unopposed oestrogen — oestrogen stimulation of the endometrium without sufficient progesterone opposition to prevent excessive growth (hyperplasia) and eventual malignant transformation.

Major risk factors:

Obesity: Fat tissue produces oestrogen through peripheral aromatisation of androgens — the more adipose tissue, the more oestrogen produced independently of the ovaries. Obesity is the single most important modifiable risk factor — women with BMI above 35 have approximately 6 times the endometrial cancer risk of normal-weight women.

PCOS: Chronic anovulation means the endometrium is continuously exposed to oestrogen without the monthly progesterone from the corpus luteum. Women with PCOS have significantly elevated endometrial cancer risk.

Diabetes and insulin resistance: Insulin directly stimulates endometrial cell proliferation via insulin receptors in the endometrium.

Unopposed oestrogen therapy: Oestrogen-only HRT in women with a uterus (without progestogen) causes endometrial hyperplasia and cancer — this is why combined HRT (oestrogen + progestogen) is standard for women with a uterus.

Nulliparity: Women who have never been pregnant have had fewer months of progesterone exposure — higher cumulative oestrogen-to-progesterone ratio.

Late menopause: Longer exposure to endogenous oestrogen.

Tamoxifen use: Tamoxifen (used for breast cancer treatment/prevention) has weak oestrogenic effects on the endometrium — increases endometrial cancer risk. Women on tamoxifen require annual endometrial monitoring.

Lynch syndrome: The most important hereditary endometrial cancer syndrome — associated with mutations in mismatch repair genes (MLH1, MSH2, MSH6, PMS2). Women with Lynch syndrome have a lifetime endometrial cancer risk of 40 to 60%. Genetic testing is recommended for women with Lynch-associated cancers in the family.

---

Diagnosis

Transvaginal ultrasound: First investigation — measures endometrial thickness. In postmenopausal women, endometrial thickness above 4 to 5 mm on TVS warrants further investigation (biopsy). In younger women, the threshold is higher because the lining varies with the cycle.

Endometrial biopsy: Tissue from the uterine lining is obtained (via Pipelle aspiration — an outpatient procedure) and examined by a histopathologist. Confirms or excludes endometrial cancer and hyperplasia. Insufficient sample in 10 to 15% of cases — if insufficient and symptoms persist, hysteroscopy is needed.

Hysteroscopy with directed biopsy: Definitive investigation — direct visualisation of the uterine cavity, targeted biopsy of any suspicious area. Gold standard for diagnosis.

---

Staging

Endometrial cancer is surgically staged — the stage is determined by what is found at the time of surgery.

• Stage I: Confined to the uterus
• IA: Limited to endometrium or invading less than half the myometrium
• IB: Invading half or more of the myometrium
• Stage II: Extends to the cervical stroma
• Stage III: Extends beyond the uterus but within the pelvis
• Stage IV: Distant spread (bladder, bowel, or beyond the pelvis)

The majority of endometrial cancers present at Stage I — because of the early warning sign of bleeding — and Stage I endometrial cancer has a 5-year survival of above 90%.

---

Treatment

Surgery — the cornerstone: Total hysterectomy (removal of the uterus and cervix) with bilateral salpingo-oophorectomy (removal of both tubes and ovaries). Pelvic and para-aortic lymph node sampling to assess nodal spread. This is performed laparoscopically (total laparoscopic hysterectomy — TLH) at appropriate centres — associated with faster recovery, lower complication rates, and equivalent oncological outcomes to open surgery.

Adjuvant radiotherapy: For Stage IB, II, and III — adjuvant vaginal vault brachytherapy (internal radiotherapy) and/or external beam pelvic radiotherapy depending on stage and histological grade.

Chemotherapy: For high-grade histologies and Stage III/IV disease — typically carboplatin and paclitaxel.

---

Gynaecological Care in Noida and Greater Noida

Dr. Shachi Singh at Prakash Hospital, Sector 33, Noida, investigates abnormal uterine bleeding including postmenopausal bleeding — and performs endometrial biopsy, hysteroscopy, and surgical staging where indicated — for women across Noida and Greater Noida.

Never ignore postmenopausal bleeding. To book an urgent assessment, call: +91 97023 46853

Clinic Hours: Monday to Saturday, 9 AM – 6 PM | Sunday, 10 AM – 2 PM

Address: D-12A, 12B, Sector-33, G.B. Nagar, Noida, UP 201301

---

This blog is for educational purposes only. Postmenopausal bleeding requires prompt medical assessment.