How is endometrial cancer diagnosed?

There is no test recommended to find this cancer before symptoms develop (except for women at high risk). Routine pelvic exams rarely find this disease. Most women are diagnosed because they have symptoms.

Signs and symptoms of endometrial cancer

Unusual bleeding, spotting, or other discharge

About 90% of patients diagnosed with endometrial cancer have abnormal vaginal bleeding, such as a change in their periods or bleeding between periods or after menopause. This symptom can also occur with some non-cancerous conditions, but it is important to have a doctor look into any irregular bleeding right away. If you have gone through menopause, it is especially important to report any vaginal bleeding, spotting, or abnormal discharge to your doctor.

Non-bloody vaginal discharge may also be a sign of endometrial cancer. Even if you cannot see blood in the discharge, it does not mean there is no cancer. In about 10% of cases, the discharge associated with endometrial cancer is not bloody. Any abnormal discharge should be checked out by your doctor.

Pelvic pain and/or mass and weight loss

Pain in the pelvis, feeling a mass (tumor), and losing weight without trying can also be symptoms of endometrial cancer. These symptoms are more common in later stages of the disease. Still, any delay in seeking medical help may allow the disease to progress even further. This lowers the odds for successful treatment.

History and physical exam

If you have any of the symptoms of endometrial cancer described above, you should visit your doctor. The doctor will ask you about your symptoms, risk factors, and family medical history. The doctor will also perform a general physical exam and a pelvic exam.

Seeing a specialist

If the doctor thinks you might have endometrial cancer, you should be examined by a gynecologist, a doctor qualified to diagnose and treat diseases of the female reproductive system. Gynecologists can diagnose endometrial cancer, as well as treat some early cases. Specialists in treating cancers of the endometrium and other female reproductive organs are called gynecologic oncologists. These doctors treat both early and advanced cases of endometrial cancer.

Sampling endometrial tissue

To find out whether endometrial hyperplasia or endometrial cancer is present, the doctor must remove some tissue so that it can be looked at under a microscope. Endometrial tissue can be obtained by endometrial biopsy or by dilation and curettage (D&C) with or without a hysteroscopy. A specialist such as a gynecologist usually does these procedures, which are described below.

Endometrial biopsy

An endometrial biopsy is the most commonly performed test for endometrial cancer and is very accurate in postmenopausal women. It can be done in the doctor's office. In this procedure a very thin flexible tube is inserted into the uterus through the cervix. Then, using suction, a small amount of endometrium is removed through the tube. The suctioning takes about a minute or less. The discomfort is similar to menstrual cramps and can be helped by taking a nonsteroidal anti-inflammatory drug such as ibuprofen before the procedure. Sometimes numbing medicine (local anesthetic) is injected into the cervix just before the procedure to help reduce the pain.

Hysteroscopy

For this technique doctors insert a tiny telescope (about ¹/₆ inch in diameter) into the uterus through the cervix. To get a better view of the inside of the uterus, the uterus is filled with salt water (saline). This lets the doctor see and biopsy anything abnormal, such as a cancer or a polyp. This is usually done with the patient awake, using a local anesthesia (numbing medicine).

Dilation and curettage (D&C)

If the endometrial biopsy sample doesn't provide enough tissue, or if the biopsy suggests cancer but the results are uncertain, a D&C must be done. In this outpatient procedure, the opening of the cervix is enlarged (dilated) and a special instrument is used to scrape tissue from inside the uterus. This may be done with or without a hysteroscopy.

The procedure takes about an hour and may require general anesthesia (where you are asleep) or conscious sedation (medicine given into a vein to make you drowsy) either with local anesthesia injected into the cervix or a spinal (or epidural). A D&C is usually done in an outpatient surgery area of a clinic or hospital. Most women have little discomfort after this procedure.

Testing of endometrial tissue

Endometrial tissue samples removed by biopsy or D&C are looked at under the microscope to see whether cancer is present. If cancer is found, it will be described. The lab report will state what type of endometrial cancer it is (like endometrioid or clear cell) and what grade it is.

Endometrial cancer is graded based on how much it looks like normal endometrium. A cancer is called grade 1 if 95% or more of the cancer forms glands similar to those of normal endometrial tissue. Grade 2 tumors have between 50% and 94% gland formations. Cancers with less than half of the tissue forming glands are given a grade of 3. Women with lower grade cancers are less likely to have advanced disease or recurrences.

If the doctor suspects hereditary nonpolyposis colon cancer (HNPCC) as an underlying cause of the endometrial cancer, the tumor tissue can be tested for protein changes (decreased amount of mismatch repair proteins) or DNA changes (called microsatellite instability, or MSI) that can be caused when one of the genes that causes HNPCC is faulty. If these protein or DNA changes are present, the doctor may recommend that you see a genetic counselor to consider genetic testing for the genes that cause HNPCC. Testing for low mismatch repair protein levels or for MSI is most often ordered in patients who are found to have endometrial cancer at an earlier than usual age or who have a family history of endometrial or colon cancer.

Imaging tests for endometrial cancer

Transvaginal ultrasound or sonography

Ultrasound tests use sound waves to take pictures of parts of the body. For a transvaginal ultrasound a probe that gives off sound waves is inserted into the vagina. The sound waves create images of the uterus and other pelvic organs. These images often help show whether the endometrium is thicker than usual, which can be a sign of endometrial cancer. It may also help see if a cancer is growing into the muscle layer of the uterus (myometrium).

In order for the doctor to see the uterine lining more clearly, salt water (saline) may be put through a small tube into the uterus before the sonogram. This procedure is called a saline infusion sonogram or hysterosonogram. Sonography may help doctors direct their biopsy if other procedures didn't detect a tumor.

Cystoscopy and proctoscopy

If a woman has problems that suggest the cancer has spread to the bladder or rectum, the inside of these organs can be looked at through a lighted tube. In cystoscopy the tube is placed into the bladder through the urethra. In proctoscopy the tube is placed in the rectum. These exams allow the doctor to look for possible cancers. Small tissue samples can also be removed during these procedures for pathologic (microscopic) testing. They can be done using a local anesthetic but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure. These procedures were used more often in the past, but now are rarely part of the work up for endometrial cancer.

Computed tomography (CT)

The CT scan is an x-ray procedure that creates detailed, cross-sectional images of your body. For a CT scan, you lie on a table while an X-ray takes pictures. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as the camera rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of many slices of the part of your body that is being studied.

Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.

The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans are not used to diagnose endometrial cancer. However, they may be helpful to see whether the cancer has spread to other organs and to see if the cancer has come back after treatment.

CT scans can also be used to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table while a doctor moves a biopsy needle toward the mass. CT scans are repeated until the doctor is sure that the needle is inside the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than ¹/₈ inch in diameter) is removed and looked at under a microscope.

CT scans take longer than regular x-rays. You might feel a bit confined by the ring you lie within when the pictures are being taken.

Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. This creates cross sectional slices of the body like a CT scanner and it also produces slices that are parallel with the length of your body.

MRI scans are particularly helpful in looking at the brain and spinal cord. Some doctors also think MRI is a good way to tell whether, and how far, the endometrial cancer has grown into the body of the uterus. MRI scans may also help find enlarged lymph nodes with a new technique that uses very tiny particles of iron oxide. These are given into a vein and settle into lymph nodes where they can be spotted by MRI.

Sometimes a contrast material is injected into a vein, just as with CT scans. The contrast used for MRI is different than the one used for CT. MRI scans are a little more uncomfortable than CT scans. First, they take longer, often up to an hour. Also, you have to be placed inside a tube, which is confining and can upset people with fear of enclosed places. Special, “open” MRI machines can help with this if needed, however the drawback is that the images may not be as good. The machine also makes a thumping or buzzing noise that you may find disturbing. Many places will provide headphones with music to block this out.

Positron emission tomography (PET)

In this test radioactive glucose (sugar) is given to look for cancer cells. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful for spotting small collections of cancer cells. But PET scans are not a routine part of the work-up of endometrial cancer, and their role is still being studied.

Chest x-ray

This test can show whether the cancer has spread to the lungs. It may also be used to look for serious lung or heart problems, especially before surgery.

Blood tests

Complete blood count

The complete blood count (CBC) is a test that measures the different cells in the blood, such as the red blood cells, the white blood cells, and the platelets. Many times women with a lot of blood loss from the uterus will have low red blood cell counts (anemia).

CA 125 blood test

CA 125 is a substance released into the bloodstream by many, but not all, endometrial and ovarian cancers. In someone with endometrial cancer, a very high blood CA 125 level suggests that the cancer has probably spread beyond the uterus. If CA 125 levels are high before surgery, some doctors use follow-up measurements to find out how well the treatment is working (levels will drop after surgery if treatment is effective) and to see if the cancer has come back after initially successful treatment.