About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Most common gynaecological cancer in UK. ~9,700 new cases/year. Predominantly affects postmenopausal women
- Classic presentation: postmenopausal bleeding (PMB). PMB = cancer until proven otherwise
- Risk factors: obesity (most important modifiable factor), unopposed oestrogen (HRT without progesterone, tamoxifen), nulliparity, PCOS, Lynch syndrome, diabetes
- Investigation: TVUSS (endometrial thickness ≥4 mm in PMB → biopsy). Pipelle endometrial biopsy in outpatient setting
- Treatment: total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO). ± Adjuvant radiotherapy/chemotherapy based on stage and grade
- Protective factors: COCP, LNG-IUS, multiparity — all oppose endometrial proliferation
Overview
Endometrial cancer is a malignancy arising from the endometrium (lining of the uterus). It is the most common gynaecological cancer in the UK and the 4th most common cancer in women overall. The majority (80%) are endometrioid adenocarcinomas (Type 1), which are oestrogen-dependent, lower grade, and carry a better prognosis. Type 2 tumours (serous, clear cell, carcinosarcoma) are non-oestrogen-dependent, higher grade, and have a worse prognosis. The strong association with unopposed oestrogen exposure explains why obesity, anovulation, and oestrogen-only HRT are major risk factors.
Epidemiology
Endometrial cancer accounts for approximately 9,700 new cases per year in the UK. Peak incidence is age 60–74. Approximately 75% of cases are diagnosed at an early stage (FIGO I), leading to an overall 5-year survival of ~75%. The incidence is rising, driven primarily by increasing obesity rates. Risk factors include obesity (3–10x increased risk), diabetes, PCOS, tamoxifen use, oestrogen-only HRT, nulliparity, early menarche, late menopause, Lynch syndrome (HNPCC — 40–60% lifetime risk), and endometrial hyperplasia. Protective factors include COCP use (50% risk reduction after 4 years), multiparity, smoking (paradoxically, via anti-oestrogenic effect), and LNG-IUS.
Clinical Features
Symptoms
Postmenopausal bleeding (PMB) — the hallmark symptom. ANY PMB must be investigated
Abnormal premenopausal bleeding: heavy, prolonged, or intermenstrual bleeding
Vaginal discharge — watery, blood-stained, or offensive
Pelvic pain (advanced disease)
Haematuria or rectal bleeding (local invasion — advanced)
Signs
Often no abnormal findings on examination in early disease
Bulky uterus on bimanual examination (advanced disease)
Obesity (associated risk factor — present in many patients)
Blood at the cervical os on speculum
Investigations
First-line
Transvaginal USS (TVUSS)First-line for PMB. Endometrial thickness ≥4 mm in postmenopausal women → requires endometrial sampling. <4 mm has >95% NPV for cancer
Pipelle endometrial biopsyOutpatient procedure — blind endometrial sampling. Sensitivity ~90% for endometrial cancer. First-line tissue diagnosis
Second-line
Hysteroscopy and biopsyIf Pipelle insufficient/failed, or if USS shows focal lesion. Allows direct visualisation and targeted biopsy
MRI pelvisPre-operative staging — assess depth of myometrial invasion, cervical involvement, lymph node status
CT chest/abdomen/pelvisFor higher-grade or advanced tumours — assess distant metastases
Specialist
Molecular classificationPOLE mutation, MSI status, p53 status — increasingly used to guide adjuvant treatment
Lynch syndrome testingIf age <50, family history, or MSI-high on tumour testing — refer for genetic counselling
1
Referral
- 2-week wait referral for: PMB in any woman ≥55 years, or USS showing endometrial thickness ≥4 mm with PMB
- Consider referral for unexplained vaginal bleeding in women ≥55 with normal USS
- Non-urgent referral for endometrial hyperplasia on biopsy
2
Surgery (mainstay of treatment)
- Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH-BSO) — standard operation
- Pelvic ± para-aortic lymphadenectomy or sentinel lymph node biopsy — depending on risk stratification
- Laparoscopic/robotic approach preferred where possible — lower morbidity, faster recovery
- Peritoneal washings for cytology
3
Adjuvant treatment
- Low-risk (stage IA, grade 1–2, endometrioid): surgery alone — no adjuvant treatment
- Intermediate-risk: vaginal brachytherapy (reduces local recurrence) ± external beam radiotherapy
- High-risk (grade 3, deep invasion, serous/clear cell, stage II+): adjuvant chemotherapy (carboplatin/paclitaxel) ± radiotherapy
- Advanced/metastatic: systemic chemotherapy, hormonal therapy (progestogens for low-grade), or immunotherapy (pembrolizumab for MSI-high tumours)
4
Endometrial hyperplasia
- Simple hyperplasia without atypia: progesterone (LNG-IUS or oral progestogens). Repeat biopsy at 6 months
- Complex hyperplasia with atypia: hysterectomy recommended (25–30% progression to cancer). LNG-IUS if fertility desired, with close surveillance
Complications
- Uterine perforation: During hysteroscopy or biopsy (rare)
- Surgical complications: Haemorrhage, infection, VTE, injury to bladder/ureter/bowel
- Lymphoedema: After lymphadenectomy
- Recurrence: Vaginal vault recurrence most common site — treated with radiotherapy
- Psychological impact: Cancer diagnosis, premature menopause after BSO
UKMLA Exam Tips
- 1PMB = endometrial cancer until proven otherwise. ALWAYS investigate
- 2Endometrial thickness ≥4 mm on TVUSS in PMB → needs biopsy. <4 mm = reassuring (>95% NPV)
- 3Obesity is the most important MODIFIABLE risk factor — oestrogen production from adipose tissue (aromatase)
- 4Tamoxifen is anti-oestrogenic in breast but PRO-oestrogenic in endometrium → increases endometrial cancer risk
- 5Type 1 (endometrioid, oestrogen-dependent, better prognosis) vs Type 2 (serous/clear cell, poorer prognosis)
- 6Lynch syndrome (HNPCC): 40–60% lifetime risk of endometrial cancer — offer genetic testing if early onset or family history
- 7COCP is protective against endometrial cancer — risk reduction of ~50% after 4 years of use
practicetest your knowledge on endometrial cancerApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
open q-bank