Uterine Cancer

with David Hoogerland, M.D., Gynecologic Oncologist, Columbia St. Mary’s

Posted: Oct. 1, 2004

The good news about this most common gynecologic cancer is that it’s relatively easy to detect in its early stages. The bad news about uterine cancer is that too few women are aware of it. Unlike breast, cervical and ovarian cancer, which have gotten a lot of press attention over the past decades, the facts about uterine cancer have been kept much too quiet.

David Hoogerland, M.D., a gynecologic oncologist with Columbia St. Mary’s, is working to change that reality.

The most common symptom of uterine cancer is abnormal bleeding. A biopsy of the uterus can quickly detect the presence of cancer, or determine whether the bleeding is from a benign cause.

David Hoogerland, M.D., Gynecologic Oncologist, Columbia St. Mary’s "The younger someone is who has uterine cancer, the more it is linked to excessive weight."

“Probably 80 to 90 percent of the occurrences of this disease is in post-menopausal women,” said Dr. Hoogerland. About one-third of the cases he treats are preventable.

“The major risk factor for getting uterine cancer is obesity,” he said. Some doctors will tell patients that adult-onset diabetes is a risk factor for the disease. There is a question, however, about whether the link between uterine cancer and diabetes exists because of the link between diabetes and obesity.

“The younger someone is who has uterine cancer, the more it is linked to excessive weight,” he said. “The youngest person I’ve treated with uterine cancer was 23, but I’ve taken care of a lot of women in their 20s and 30s who are overweight.”

Dr. Hoogerland emphasized that he was not talking about women who needed to lose 15 or 20 pounds. “I’m talking about women who are significantly obese,” he said, “the people bariatric surgeons are seeing.”

Role of estrogen
The theory that uterine cancer was caused by an overproduction of estrogen was confirmed in the mid-1970s when doctors began prescribing hormone replacement therapy (HRT) for post-menopausal women. Early HRT was pure estrogen. When the number of uterine cancer cases jumped at the same time, medical researchers quickly discovered the cause.

When progesterone, another naturally occurring hormone, was added to HRT, the risk of contracting uterine cancer dropped from 2.5 to 8 times the norm back to slightly above the 1.0 figure considered normal. The recent controversy surrounding HRT is unrelated to the earlier situation.

The reason obesity and estrogen are linked, he said, is because of a hormone called androstenedione, a mild male hormone which occurs naturally in both men and women.

“That hormone is converted peripherally in fat cells,” he said, “and the fat cells convert it to a weak estrogen called estrone. The bottom line is that estrone is a weak estrogen, but if you have a lot of fat cells you make a lot of weak estrogen. Therefore, you have a lot of estrogen, and it’s coming at you at a constant rate.”

Other risk factors for the disease include family history, and not having children.

“The theory is that a person who has never had children has had a longer exposure to estrogen,” he said. “Her uterus is bathed in estrogen on a monthly basis. If a woman gets pregnant, there’s still a lot of estrogen around, but there are also other hormones, and if she nurses, that system is temporarily shut down until the child is weaned.”

Birth control pills can also lower the risk of contracting uterine cancer.

“Birth control pills still get a lot of bad press,” Dr. Hoogerland said, “but they’re somewhat protective.”

That’s because they’re comprised of synthetic estrogen and progesterone, and in addition to preventing pregnancy or helping women who have abnormally painful periods, birth control pills make the lining tissue of the uterus very thin. That enables the uterus to maintain a steady hormonal balance, making it impossible for extra estrogen to take hold.

“One of the best things you can do for a young obese person is to put her on the pill,” he said. Women with Polycystic Ovarian Syndrome (PCOS) can be treated with birth control pills, which reintroduces regular periods and reduces their risk of contracting uterine cancer.

Treatment
If a woman does have uterine cancer, the standard treatment is a hysterectomy. A post-operative examination of the uterus determines whether further treatment, such as radiation or chemotherapy, is needed.

If the patient is young, wants to have children and the tumor is well differentiated (clearly defined and easily detectable in comparison to healthy uterine tissue), Dr. Hoogerland said it can be treated with progesterone and the patient is monitored carefully. If there is an improvement within three months, he continues the treatment. If not, he performs a hysterectomy. “The usual case is that we find the disease when it’s reasonably early and well-differentiated. Then we perform a hysterectomy and the prospect for cure is extremely high,” he said.

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