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Women's Health

Endometrial Cancer

Endometrial cancer usually presents with abnormal uterine bleeding, especially postmenopausal bleeding; prompt referral, histological diagnosis, MMR and molecular assessment, and risk-adapted gynaecological oncology treatment are the key steps.

In a nutshell

Endometrial cancer commonly presents with postmenopausal bleeding, but persistent abnormal bleeding before menopause can also require assessment. Follow current NICE referral criteria, use transvaginal ultrasound and histological sampling, test all tumours for MMR or MSI, and manage by a gynaecological cancer MDT using stage, grade, histology and molecular risk.

Classic presentation

A postmenopausal patient with unexplained vaginal bleeding or spotting; transvaginal ultrasound may show a thickened endometrium, but tissue diagnosis is required.

Key points

  • Unexplained postmenopausal bleeding needs urgent assessment; use current NICE NG12 age and HRT criteria rather than assuming every case has the same referral route.
  • For postmenopausal bleeding, a double-layer endometrial thickness of 4 mm or more generally leads to endometrial sampling; recurrent bleeding needs further evaluation even with a thin endometrium.
  • Histology confirms the diagnosis, while grade, histology, stage, lymphovascular invasion and molecular results guide treatment.
  • All endometrial tumours should have MMR or MSI assessment to identify Lynch syndrome risk and inform systemic treatment options.
  • Operable disease is usually treated with hysterectomy and risk-adapted nodal staging; adjuvant radiotherapy or chemotherapy is not automatic.
  • Fertility-sparing progestogen treatment is only for highly selected low-grade, non-invasive disease with specialist counselling and close surveillance.

First-line investigation

Current NICE suspected-cancer referral followed by transvaginal ultrasound and endometrial histological sampling, with hysteroscopy for focal, inadequate or persistent disease.

Management

Refer abnormal bleeding through the current cancer pathway

  • Use NICE NG12 criteria for postmenopausal bleeding, HRT-related bleeding, age and associated symptoms, and re-refer recurrent bleeding after reassuring tests.1,3

Obtain tissue and molecular classification

  • Use transvaginal ultrasound and endometrial sampling, then ensure expert histology plus MMR or MSI assessment and appropriate molecular testing.2,4,5

Treat operable disease with risk-adapted surgery

  • Use minimally invasive hysterectomy-based surgery when suitable, with ovarian and sentinel-node decisions adapted to age, Lynch risk, histology, stage and molecular group.2

Use specialist fertility-sparing or systemic pathways

  • Reserve fertility-sparing progestogen treatment for selected non-invasive low-grade disease; use current NICE technology-appraisal eligibility for immunotherapy and systemic treatment in advanced or recurrent disease.2,6,7,9

Provide recurrence safety-netting and survivorship care

  • Give a treatment summary and direct access to the cancer team for recurrent bleeding, discharge, pain, cough, weight loss, bowel or bladder change and late treatment effects.2

Exam traps

  • Most postmenopausal bleeding is not cancer, but every unexplained episode requires the current urgent-assessment pathway.
  • A thin endometrium reduces risk but does not close the pathway when bleeding recurs.
  • Cervical screening does not diagnose endometrial cancer.
  • Do not use the old type 1/type 2 model alone; molecular classification, MMR, p53, POLE, grade, histology and stage can change risk.
  • Routine systematic lymphadenectomy is not required for low-risk disease; sentinel-node staging is risk-adapted.
  • Fertility-sparing progestogen treatment is not a general alternative to surgery and requires specialist pathology, MRI and close repeat sampling.

Illustrations

Endometrioid endometrial adenocarcinoma on histologyHigh-magnification H&E micrograph showing crowded malignant glands lined by atypical cells in endometrioid endometrial adenocarcinoma.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG12, Suspected cancer: recognition and referral (Current NICE suspected-cancer referral recommendations for endometrial cancer, last updated April 2026, including postmenopausal bleeding, age-specific criteria and unscheduled bleeding on HRT)Published 23 Jun 2015
  2. British Gynaecological Cancer Society, Uterine Cancer Guidelines: Recommendations for Practice, version 2.1 (UK specialist guideline published November 2021 covering presentation, ultrasound and biopsy, staging, molecular classification, surgery, adjuvant treatment, fertility preservation, recurrence and survivorship)Published 5 Nov 2021
  3. NHS, Post-menopausal bleeding (Current NHS patient information on causes, urgent assessment and the two-week specialist pathway)
  4. NICE HTG557, Testing strategies for Lynch syndrome in people with endometrial cancer (Current NICE diagnostic strategy for tumour MMR or MSI assessment, MLH1 promoter hypermethylation testing and referral for germline testing)Published 28 Oct 2020
  5. NHS England Genomics Education Programme, Presentation: Patient with endometrial cancer (Current NHS genomic-testing pathway, last reviewed July 2026, covering MMR/MSI, MLH1 hypermethylation, Lynch testing, POLE testing and advanced-disease genomic options)Published 22 Jul 2026
  6. NICE TA1092, Pembrolizumab with carboplatin and paclitaxel for untreated primary advanced or recurrent endometrial cancer (Current NICE technology appraisal for first-line pembrolizumab with platinum chemotherapy in eligible untreated primary advanced or recurrent endometrial cancer)Published 27 Aug 2025
  7. NICE TA1117, Dostarlimab with platinum-containing chemotherapy for primary advanced or recurrent endometrial cancer with MSS or MMRp disease (Current NICE routine-use appraisal published December 2025 for eligible adults whose systemic treatment is suitable, subject to the commercial arrangement)Published 16 Dec 2025
  8. BNF, current oncology and progestogen prescribing information (Current UK prescribing cross-check for progestogens, chemotherapy, immunotherapy, interactions, contraindications and monitoring; detailed BNF access is restricted in this environment)
  9. NICE TA963, Dostarlimab with platinum-based chemotherapy for advanced or recurrent dMMR or MSI-H endometrial cancer (NICE managed-access appraisal for eligible adults with primary advanced or recurrent high-MSI or MMR-deficient disease)Published 3 Apr 2024
  10. NICE TA779, Dostarlimab for previously treated advanced or recurrent dMMR or MSI-H endometrial cancer (NICE Cancer Drugs Fund appraisal for eligible adults with high-MSI or MMR-deficient disease after platinum-based chemotherapy)Published 16 Mar 2022
  11. NICE TA904, Pembrolizumab with lenvatinib for previously treated advanced or recurrent endometrial cancer (Current NICE appraisal for eligible previously treated advanced or recurrent disease; check the current recommendations and local oncology protocol before use)Published 26 Apr 2023

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.