What to Know Down Below™
Welcome to What to Know Down Below™ by Tina’s Wish! We’re here to empower you with the knowledge and tools you need to advocate for your own gynecologic health.
Knowledge is power, and we encourage everyone to join us in learning more about what you need to know, down below!
What to Know Down Below™
Understanding Uterine Cancer
Moderated by Jennifer Garam, ovarian cancer survivor & advocate and health journalist, and featuring Dr. Melissa Frey, Gynecologic Oncologist at Weill Cornell Medicine
Welcome to What To Know Down Below by Tina's Wish. We're here to empower you with the knowledge and tools you need to advocate for your own gynecologic health. Knowledge is power, and we encourage everyone to join us in learning more about what you need to know down below.
Speaker 2:Hi everyone. My name is Jennifer Garra , and I am an ovarian cancer survivor and advocate and health journalist. I'm thrilled to be your host for the next series of episodes focused on gynecologic cancers. In our last series, ovarian Cancer 1 0 1, we took a deep dive into ovarian cancer and its signs and symptoms, risk factors, and the need for an early detection test for ovarian cancer. Ovarian cancer is one of the five main types of gynecologic cancers. Today we will be kicking off our next three part series, A Guide to Gynecologic Cancers in which we will be discussing the other main types of gynecologic cancer, uterine cancer, cervical cancer, and vaginal and vulgar cancers. I am so excited to introduce our subject matter expert for this series, renowned gynecologic oncologist at Weill Cornell Medicine in New York City. Dr. Melissa Frey. Welcome Dr. Frey. And I would love for you to introduce yourself to our listeners.
Speaker 3:Uh , thank you so much for having me today. I am really excited to be here. My name is Melissa Frey . I'm a gynecologic oncologist at Weill Cornell Medicine, and my practice focuses on general gynecologic oncology, but I also have a special interest in hereditary cancer and genetic predisposition to cancer, identifying people who are at higher, who are at higher risk for cancer and taking steps to prevent cancer in that group.
Speaker 2:Great. Thank you so much. In today's episode, we will be talking about uterine cancer. So let's just start with the basics. What is gynecologic cancer in general and what is uterine cancer specifically?
Speaker 3:Gynecologic cancer in general is a cancer of one of the organs that are part of the female reproductive tract . Um, the uterus, which is a muscle in the pelvis , um, can have cancer and actually uterine cancer is the most common of the gynecologic cancers in the United States. In 2023, there are probably about 66,000 cases of uterine cancer.
Speaker 2:Great. And I often hear uterine and endometrial cancer referred to interchangeably. Is there a difference and , and if so, what is the difference between the two types of cancer ?
Speaker 3:There are several parts to the uterus. Um, so as I said, the uterus is a muscle , um, and the uterus has , uh, its muscular component, but it also has the lining of the uterus. This is the endometrial cavity is the center of the uterus, and there's a lining of that sort of cavity that's called the endometrium. And the most common , um, and most frequent , um, types of cancer of the uterus that we see are located at the endometrium, which is that lining. And that lining is what kind of gets thicker each month as a woman , um, goes through her normal menses. And then that that endometrial tissue is sort of shed at the end of a menstrual cycle. Um, there also can be cancers of the muscular layer , um, of the uterus, and that would be called a , an a uterine sarcoma. And so when we say uterine cancer, we're usually referring to endometrial cancer because that's the most common type, but there are other types of cancers of the uterus that we do see.
Speaker 2:Okay, great. So uterine cancer is the umbrella term and then there's different variations within that. Exactly. Um , so in terms of symptoms, when I had ovarian cancer, some of the main symptoms that I experienced were abdominal pain and like a persistent bloating that didn't go away. It was pretty constant. Um, what are typical symptoms or warning signs that someone might have uterine cancer?
Speaker 3:One of the key differences between , uh, uterine cancer and ovarian cancer is that people actually very often feel and appreciate symptoms at an early stage in the disease course. And that's because most women with , uh, uterine cancer start to have abnormal uterine bleeding. So for a woman who's still having menses, she may have increased bleeding amount or increased days of bleeding. And for a woman who has already gone through menopause, it's called postmenopausal bleeding or , um, a resurgence of bleeding after menopause. So that is the most common symptom of uterine cancer. And because this symptom is so common, we are often finding uterine cancers at an early stage because women present with this abnormal bleeding. Some there are other possible symptoms, so some women may have an abnormal PAP test. Um, the pap is, is really a cervical cancer screening test, and it's not meant to screen for a uterine cancer, but occasionally we can see abnormal cells on a pap test that indicate a uterine cancer. Um, and another common way that we find endometrial cancer is in incidentally. So if a , a woman is having , um, imaging for some other reason , um, whether it's for back pain or something else going on in her pelvis, we sometimes see a uterus with a very thickened lining or endometrial lining. And that can , um, sometimes be what tips us off to a , a uterine cancer diagnosis.
Speaker 2:And in terms of symptoms that a person would experience themselves. So you said the the bleeding of the abnormal bleeding. Are there any other symptoms , um, fatigue or anything like that, anything else that they would experience typically? And then what would be the difference between that and other benign conditions? Um, because for instance, fatigue is an ovarian cancer, you know, something people , uh, um, experience, but it's also could be attributed to any number of benign conditions as well.
Speaker 3:The reason why ovarian cancer often presents with fatigue or nausea or vomiting or , uh, changes in bowel function is because it's often diagnosed at an advanced stage, and that can happen with uterine cancer as well. So if the disease is more advanced , um, if the uterus is very large or if there is what we call metastatic disease or spread outside of the uterus, that can cause abdominal pain, pelvic pain, changes in appetite, changes in bowel or bladder function , um, fatigue. But usually thankfully , um, we catch this before those symptoms come on because , um, because a woman has postmenopausal bleeding or abnormal uterine bleeding, and so we actually find it before those symptoms. So it's less common with uterine cancer to have those general symptoms than it is with a disease like ovarian cancer.
Speaker 2:So if a person is experiencing this abnormal bleeding, at what point should someone go see their doctor?
Speaker 3:So I would recommend that anyone who is having abnormal or postmenopausal bleeding see their gynecologist right away. There are many benign things that can cause this . So we know that , um, there can be what's, what , you know, there can be , um, endometriosis or , um, um, pregnancy or, you know, there , there are many things that are benign, are totally normal that can cause changes in menstrual patterns. Um, but I think that the most important step is to check in with the gyno gynecologist to make sure that whatever's causing the abnormal bleeding is not something that needs to be further evaluated. And so often that would involve an exam with the gynecologist and often imaging in the form of a pelvic ultrasound to try to get the best view of the endometrial cavity.
Speaker 2:Um, and immediately, is that correct? Like as soon as you start to experience this, don't wait a month, two months? Um ,
Speaker 3:Absolutely, I think immediately.
Speaker 2:And would you say to advocate to get, I mean, sometimes if you call the doctor's office, they don't have an appointment for, you know, three months. So would you recommend saying when you call like, I have a concerning SY symptom, I need to get in right away?
Speaker 3:Absolutely. Um , for , for many, if not most women, it's going to turn out to be something non-cancerous. And so I'm, I'm not saying that to get people , uh, to make people feel nervous, but I just think that if someone is one of the , you know, one of the one of the women who does have a cancer, you want that evaluated right away. But that's not to scare people that everything is gonna be a cancer. It's more just that we should have prompt follow up so we can, we can rule out a cancer.
Speaker 2:Yeah, that's, especially because you said uterine has that chance of an early diagnosis, which is less likely in things like ovarian cancer. So you want to take advantage of that and really go in as soon as you start to experience Exactly . Symptoms. It sounds like , um, you touched on this, but I wanted to talk about how someone gets officially diagnosed with uterine cancer. Is, is there any early detect detection screening test at the, the doctor's office? You said a pap sometimes can detect it. Um, you know, like they , we have a pap smear for cervical cancer, mammogram for breast cancer. Is there anything like that or how do you get an official diagnosis?
Speaker 3:We don't routinely screen for uterine cancer. We really respond to symptoms. And, and , and so if a , if someone is having bleeding or having any new symptoms, or if on an exam a gynecologist , um, notices that the uterus feels larger than they would expect , um, for the woman's age and based on her history, then we would start the, the workup. And , and usually that involves , uh, a pelvic ultrasound or sonogram. That's the most common imaging that we use. And if there's any concern about the endometrial lining being , um, thicker than we would expect, or if there's any concern for cancer, then we usually do an endometrial sampling. This can be in a biopsy that's done in the office, or sometimes this is done in the operating room, and then it's called a dilation and curettage or DNC is their term.
Speaker 2:Okay. And you said a pap smear sometimes detects it, but that's what is , that's not something you can rely on, it sounds like. Right .
Speaker 3:So the pap is really meant to be a cervical cancer screening test. Occasionally , um, if a woman has endometrial cancer, some of the endometrial cancer cells will be shed from the uterus through the cervix and be picked up with a pap. But we do know that there can be , um, many, many women that have a normal pap who have endometrial cancer. And so we don't use it as a routine screening. It just sometimes , um, sort of comes up during, during , uh, a routine evaluation. And of course we'd follow it up.
Speaker 2:Great. Dr . Frey , what are some of the risk factors of things that may put you at higher risk for uterine cancer?
Speaker 3:So the, the most common risk factor for uterine cancer is obesity. We know that having increased adipose tissue results in increased levels of estrogen, and it's that estrogen that is driving a lot of the endometrial cancers that are diagnosed in this country. Along those same lines , um, taking extra estrogen. So taking hormone replacement therapy, especially if it's estrogen alone, which we do not recommend, we recommend taking estrogen and progesterone, but estrogen alone and any extra estrogen can also increase the risk of endometrial cancer. We do know that , um, patients who have , um, diabetes and high blood pressure seem to have a slightly higher risk for endometrial cancer, and this may be linked to , um, obesity or , or carrying extra weight. We know that people who have , um, um, more menses, so , um, more periods having earlier age of your first period and later onset of menopause can have increased risk just from a longer time being exposed to estrogen. Um, and then also for people who have , um, a lot of , uh, uterine cancer in their family, having relatives with uterine cancer can increase the , uh, risk of one developing uterine cancer, often due to some of the , um, uterine cancer related genetic syndromes.
Speaker 2:I just wanna touch on something you mentioned. I think you said HRT . Did you mention that this, I feel like, is , there's a lot of confusing information about this going through menopause. If you should be on HRT , if you should not, do you have a recommendation, like if it's individual, if people should really talk to their doctor and not get their information , information on social media? Like how, I mean, I just hear a lot of conflicting information about this.
Speaker 3:The topic of hormone replacement therapy is so complex, and I think sort of as a society, the pendulum has sort of swung back and forth. Um, as far as, you know, everyone should be on it, no one should be on it. And I think really it's, it's somewhere in the middle for the right person. Um, who's having symptoms after menopause, hormone replacement therapy can be great and is a great , um, a great medication for, for it . It's critical to also note that taking estrogen can increase the risk for , um, uterine cancer. And so it's very important that if someone's going to use hormone replacement therapy, it's prescribed and monitored by a clinician with experience because , um, one must take estro estrogen and progesterone because the progesterone actually is what protects the uterus for someone who's taking estrogen. And so what I would say is the , um, decision to be on hormone replacement therapy has to be an individualized decision with one's physician , where we very carefully weigh the risks and benefits, but for many women, it is the right decision.
Speaker 2:Great. Thank you for clarifying that. So I am BRCA one positive, which puts me at high risk for ovarian cancer and breast cancer, and I did develop ovarian cancer. Does BRCA status affect uterine cancer at all, or if not, is there any other genetic component at all? Um,
Speaker 3:There are genetic contributions or genetic risk factors to endometrial cancer. Um, there has been some evidence to suggest that people with a b RCA one mutation have a higher risk of an aggressive uterine cancer called a uterine serous cancer. The data are really limited. And so currently the standard guidelines would say that we should mention this to someone who has A-B-R-C-A one mutation, that she may be at higher risk for uterine cancer. And if a woman with A-B-R-C-A mutation is thinking about risk reducing surgery to prevent ovarian cancer, in addition to removing her ovaries, fallopian tubes, she can consider removing her uterus as well. We don't know enough to make an absolute recommendation that all women with BRCA one should have their uterus removed, but it is certainly something that a woman should discuss with her physician. We have not seen the same rates for BRCA two, but that's an area that's under investigation. There are other genetic syndromes that can increase the risk for uterine cancer. So one of the most common is called lynch syndrome. This is a syndrome that increases one's risk for , um, uterine cancer in addition to colon cancer, ovarian cancer, and some other cancers. And so for women who have Lynch syndrome, we do recommend , uh, surgical removal of the uterus to prevent a uterine cancer.
Speaker 2:And similar to other cancers, when you look at family history, is that something to consider too when you're evaluating a patient to see if they might be high risk ? You talk to 'em about if is there uterine cancer , um, history in your family?
Speaker 3:Absolutely. So any person who has a family history with , um, relatives that have uterine cancer and colon cancer, and actually ovarian cancer can be part of this syndrome that should , um, get a physician sort of thinking, this is a family that could have Lynch syndrome or that should get a person thinking, you know, is my family at risk. And, and the, the , um, genetic testing that we do now for syndromes like BRCA one and two, actually, it's usually a large panel and that covers lynch syndrome and there are several genes that can cause Lynch syndrome. So absolutely for any family that has these cancers, I would recommend genetic testing and so that we can determine who's at risk.
Speaker 2:That's, you know, great advice because I think that BRCA one or BICA one and two are kind of the most commonly known in terms of hereditary cancer, but there are so many other mutations that put people at risk for so many other types of cancers. So it's really good to know about Lynch syndrome and family history. Um, and then is there any way to reduce your risk?
Speaker 3:I think the , the best way to minimize risk of uterine cancer for someone at average risk is just to maintain a healthy weight , um, healthy diet exercise. And that that's really the best , um, of course to follow up with any symptoms. But then for people who have a significantly higher risk, so that would be an individual with Lynch syndrome where we can see the risk even exceed 50% over one's lifetime. We recommend preventative surgery to remove the uterus. Um, if someone is not ready for that surgery yet, or still in their childbearing years, or someone who's at very high risk, we do offer routine ultrasounds and also endometrial biopsies, but we really limit that to those women who are at highest risk.
Speaker 2:Um, that is a great point that you bring up , which is bring , if you have a family history or you're concerned you might be at higher risk, would you recommend like talking to your regular GYN and potentially being followed by a specialist such as yourself, a GYN oncologist?
Speaker 3:Absolutely. I think a lot of what a gynecologic oncologists do right now is cancer prevention and people who live at elevated risk. And so I think that is a , a very good idea for someone who's at higher risk.
Speaker 2:And two , it sounds like just see the specialist, and maybe you won't, it turns out you're not at high risk, but at least like a specialist, they see this all the time. They can more thoroughly evaluate you.
Speaker 3:Absolutely.
Speaker 2:And then , um, we touched on this, but what advice do you have? So you're experiencing these symptoms, you say co contact your doctor right away, get in right away. Um, are there other ways, you know, what recommendations you have for how to bring this up with your doctor? How to advocate for yourself? What if your doctor is not taking your concerns seriously? I, you know, hear a lot of women's health concerns brushed off, like, oh, it's just your period, or it's just this normal whatever, this or that. Like, what are your recommendations for getting taken seriously at your doctor and advocating for yourself?
Speaker 3:Um, I think unfortunately when that happens, it just falls on the woman, the patient, to be their own best advocate. And I think if you feel like your clinician is not listening to you, then you know, you may have to find another clinician because this is critical. And unfortunately, I think there is , um, often a delay because people think that , um, it's gonna resolve on its own, or abnormal bleeding is something that's uncomfortable , um, or embarrassing to talk to a clinician about. But this is what your doctor, especially your gynecologist is really there , therefore . And so I would say, you know, kind of be your best advocate. If you have symptoms, bring them to the attention of your clinician. And if you feel like you're not being listened to, then then find someone who is listening to you and taking this complaint seriously.
Speaker 2:Um, yeah , I just echo that it's so important to advocate for yourself. I was very lucky with being taken seriously , um, initially misdiagnosed and then correctly diagnosed within 18 hours. So very quickly, but I see a lot of people that that doesn't happen to, and they're dismissed for months. So just wanna , um, emphasize for the listeners the importance of advocating for yourself in your healthcare . Um, and that , um, there we have an episode about that as well on this podcast. So check out our past episode, how to advocate for yourself as a patient for more information and tips where we go into that , um, in more detail. Um, and before we wrap up, I just wanna go back to something that you said earlier that a very early onset of menopause or , uh, or of your period, onset of your period or going into menopause later could be risk factors. And I was wondering if you could just give like an age range, like what is considered an early onset of your period and what is considered a late menopause?
Speaker 3:Absolutely. So the average age of , um, first period in this country is about 12, I believe, although that that number is coming down and the average age that a woman goes through menopause is about 51. But we certainly see variation , um, earlier and later , um, for both of these. And I think it's important to know because , um, having more lifetime periods is a risk for uterine cancer. It's also a risk for ovarian cancer. And so I think that, you know, for women who have had more periods or have long histories of irregular menses or irregular periods, those are women who really wanna be cautious and, and be on top of this.
Speaker 2:Um, so it just sounds like these are all things to bring up to your doctor at your routine GYN exam, if you have to see a specialist to bring, just pay attention, know your normal , um, and, and note all the anything that may be out of the ordinary to talk to your doctor about. Um, is there anything else important that you want to add on this topic that we haven't uh, talked about yet today?
Speaker 3:No, I, I think I would echo what you say that it's very important to have a gynecologist. I think that a lot of women sort of might have an obstetrician if they had children, and then sort of after that they don't see a gynecologist as regularly or there's an assumption, you know, they've had a , a pap smear and so they're okay for five years, they don't need any follow up . And I would just say that having a gynecologist as part of your care team is critical. It's critical for routine care and preventative care. And then also, you know, if you have any complaint to have someone there who knows you and that the pap is , is very good as a cervical cancer screening, but that is, that is what it is meant for. It is not meant to screen for uterine or ovarian cancer. And so just to keep that in mind
Speaker 2:And how often in I ideal situations should someone be seeing their regular GYNI
Speaker 3:Think that it has to be very individualized. And so I, so I would kind of meet with a gynecologist and then based on your exam, based on, you know, your own meta personal and family history, you'd make that decision. But, you know, often it's every one to two years.
Speaker 2:Okay. Great. Well, thank you so much. Um, Dr. Faye , thank you so much for joining us today and a huge thank you to everyone out there listening. We hope that you walk away from today's episode, having learned something new and feeling more empowered in your health. Be sure to tune in for the rest of our three part series as we explore cervical cancer and vaginal and vulgar cancers.
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