Treatment for cancer of the uterus

Cancer of the uterus is usually treated with an operation that removes the uterus and cervix (total hysterectomy), along with both fallopian tubes and ovaries (bilateral salpingo-oophorectomy). If your ovaries appear normal, you don’t have any risk factors, and it is an early-stage, low-grade cancer, you may be able to keep your ovaries. If the cancer has spread beyond the cervix, the surgeon may also remove a small part of the upper vagina and the ligaments supporting the cervix.

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How the surgery is done

The surgery will be performed under a general anaesthetic. The hysterectomy can be done in different ways.

Laparoscopic hysterectomy (keyhole surgery) – This method uses a laparoscope, a thin tube with a light and camera. The surgeon inserts the laparoscope and instruments through 3–4 small cuts in the abdomen (belly). The uterus and other organs are removed through the vagina.

Robotic-assisted hysterectomy – This is a special form of laparoscopic hysterectomy. The instruments and camera are inserted through 4–5  small cuts and controlled by robotic arms guided by the surgeon, who sits next to the operating table.

Abdominal hysterectomy (open surgery or laparotomy) – The surgery is performed through the abdomen. A cut is usually made from the pubic area to the bellybutton. Sometimes the cut is made along the pubic line instead. The uterus and other organs are then removed.

Your surgeon will discuss the most appropriate surgery for you, and explain the risks and benefits. The type of hysterectomy you have will depend on a number of factors, such as your age and build; the size of your uterus; the tumour size; and the surgeon’s specialty and experience.

Treatment of lymph nodes

Cancer cells can spread from the uterus to the pelvic lymph nodes. If cancer is found in the lymph nodes, your doctor may recommend you have additional treatment, such as chemotherapy or radiation therapy.

Lymphadenectomy (lymph node dissection) – For more advanced or higher-grade tumours, the surgeon may remove some lymph nodes from the pelvic area to see if the cancer has spread beyond the uterus.

Sentinel lymph node biopsy – This test helps to identify the pelvic lymph node that the cancer is most likely to spread to first (the sentinel node).  While you are under anaesthetic, your doctor will inject a dye into the cervix. The dye will flow to the sentinel lymph node, which will be removed for testing. If it contains cancer cells, this will guide additional treatment, such as chemotherapy and radiation therapy. Sentinel lymph node biopsies are available only in some treatment centres.

What to expect after surgery

When you wake up after the operation, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be transferred to the ward.

Tubes and drips – You will have an intravenous drip in your arm to give you medicines and fluid, and a tube in your bladder (catheter) to collect urine (wee). These will usually be removed the day after the operation.

Length of stay – You will stay in hospital for about 1–4 days. How long you stay will depend on the type of surgery you have had and how quickly you recover. Most people who have laparoscopic surgery will be able to go home on the first or second day after the surgery (and occasionally on the day of surgery).

Pain – As with all major surgery, you will have some discomfort or pain. The level of pain will depend on the type of operation. After keyhole surgery, you will usually be given pain-relieving tablets. If you have open surgery, you may be given pain medicine in different ways:

• through a drip into a vein (intravenously)
• via a local anaesthetic injection into the abdomen (a transverse abdominis plane or TAP block)
• via a local anaesthetic injection into your back, either into spinal fluid (a spinal) or into the space around spinal nerves (an epidural)
• with a patient-controlled analgesia (PCA) system, a machine that allows you to press a button for a measured dose of pain relief.

While you are in hospital, let your doctor or nurse know if you are in pain so they can adjust your medicines to make you as comfortable as possible. Do not wait until the pain is severe. After you go home, you can continue taking pain-relieving tablets as needed.

Wound care – You can expect some light vaginal bleeding after the surgery, which should stop within two weeks. Your treatment team will talk to you about how you can keep the wound/s clean to prevent infection once you go home.

Blood clot prevention – You will be given a daily injection of a blood thinner to reduce the risk of blood clots. Depending on your risk of clotting, you may be taught to give this injection to yourself so you can continue it for a few weeks at home. You may also be advised to wear compression stockings for up to four weeks to help the blood in your legs to circulate well and avoid clots.

Constipation – The medicines used during and after surgery can cause constipation (difficulty having bowel movements). Talk to your treatment team about how to manage this – they may suggest medicines to help prevent or relieve constipation. Once your surgeon says you can get out of bed, walking around can also help.

Test results – Your doctor will have all the test results about a week after the operation. Whether additional treatment is necessary will depend on the type, stage and grade of the disease, and the amount of any remaining cancer. If the cancer is at a very early stage, you may not need further treatment.

Taking care of yourself at home after a hysterectomy

Your recovery time will depend on the type of surgery you had, your age and general health. In most cases, you will feel better within 1–2 weeks and should be able to fully return to your usual activities after 4–8 weeks.

If you don’t have support from family, friends or neighbours, ask your nurse or a social worker at the hospital whether it is possible to get help at home while you recover.

Rest up – When you get home from hospital, you will need to take things easy for the first week. Ask family or friends to help you with chores so you can rest as much as you need to.

Lifting – Avoid heavy lifting (more than 3–4 kg) for 4–6 weeks, depending on the advice of your surgeon. This will depend on the method of the surgery.

Work – Depending on the nature of your job, you will probably need 4–6 weeks of leave from work. People who have laparoscopic surgery and have office jobs that don’t require heavy lifting can often return to work after 2–4 weeks.

Driving – You will need to avoid driving after the surgery until pain in no way limits your ability to move freely. Discuss this issue with your doctor.  Check with your car insurer for any exclusions regarding major surgery and driving.

Bowel problems – It is important to avoid straining during bowel movements. Continue to manage constipation as advised by your treatment team.

Nutrition – To help your body recover from surgery, eat a well-balanced diet that includes a variety of foods. Include proteins such as lean meat, fish, eggs, milk, yoghurt, nuts, and legumes/beans.

Bathing – Your doctor may advise taking showers instead of baths for 4–5 weeks after surgery.

Exercise – Your treatment team will probably encourage you to walk the day of the surgery. Exercise has been shown to help people manage some treatment side effects and speed up a return to usual activities. Speak to your doctor about suitable exercise. To avoid infection, it’s best to avoid swimming for 4–5 weeks after surgery.

Sex – Sexual intercourse should be avoided for up to 8 weeks after surgery. Ask your doctor or nurse when you can have sex again, and explore other ways you and your partner can be intimate, such as massage.

Side effects after surgery

Menopause – If your ovaries are removed and you have not been through menopause, removal will cause sudden menopause.

Impact on sexuality – The changes you experience after surgery may affect how you feel about sex and how you respond sexually. You may notice changes such as vaginal dryness and loss of libido.

Lymphoedema – The removal of lymph nodes from the pelvis can stop lymph fluid from draining normally, causing swelling in the legs known as lymphoedema. The risk of developing lymphoedema is low following most operations for cancer of the uterus in Australia, but it is higher in women who had a full lymphadenectomy followed by external beam radiation therapy. Symptoms appear gradually, sometimes years after the treatment. Your treatment team will explain how to reduce your risk.

Vaginal vault prolapse – This is when the top of the vagina drops towards the vaginal opening because the structures that support it have weakened. Having a hysterectomy does not appear to increase the risk of vaginal vault prolapse in women without pelvic floor issues. Prolapse is more commonly caused by childbirth and weak pelvic floor muscles. To help prevent prolapse, it is important to do pelvic floor exercises several times a day. Most women can start these exercises 1–2 weeks after surgery. Your treatment team may explain how to do these exercises or you can see a women’s health physiotherapist.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill or damage cancer cells so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams. Treatment is carefully planned to limit damage to the surrounding healthy tissues.

For cancer of the uterus, radiation therapy is commonly used as an additional treatment after surgery to reduce the chance of the disease coming back. This is called adjuvant therapy.

In some cases, radiation therapy may be recommended as the main treatment if other health conditions mean you are not well enough for a major operation.

There are two main ways of delivering radiation therapy: internally or externally. Some people are treated with both types of radiation therapy. Your radiation oncologist will recommend the course of treatment most suitable for you.

Internal radiation therapy (brachytherapy)

Internal radiation therapy may be used after a hysterectomy to deliver radiation directly to the top of the vagina (vaginal vault) from inside your body. This is known as vaginal vault brachytherapy.

During each treatment session, a plastic cylinder (the applicator) is inserted into the vagina. The applicator is connected by plastic tubes to a machine that contains radioactive material in the form of a small metal seed. Next, this seed is moved from the machine through the tubes into your body. After a few minutes, the seed is returned to the machine. The applicator is taken out after each session.

This type of brachytherapy does not need any anaesthetic. Each treatment session usually takes only 20–30 minutes. You are likely to have 3–6 treatment sessions as an outpatient over 1–2 weeks.

If you are having radiation therapy as the main treatment and haven’t had a hysterectomy, the internal radiation therapy may involve placing an applicator inside the uterus. This is done under anaesthetic or sedation, and may require a short hospital stay.

External beam radiation therapy

External beam radiation therapy (EBRT) directs the radiation at the cancer and surrounding tissue from outside the body. For cancer of the uterus, the lower abdominal area and pelvis are treated, but if the cancer has spread (metastasised), other areas may also be treated.

Planning for EBRT may involve a number of visits to your doctor to have more tests, such as blood tests and scans. You will also be told about any special bladder or bowel preparations you have to take before each treatment.

Each EBRT session lasts about 30 minutes, with the treatment itself taking only a few minutes. You will lie on a treatment table under a large machine known as a linear accelerator, which delivers the radiation. The treatment is painless (like having an x-ray), but may cause side effects.

You will probably have EBRT as daily treatments, Monday to Friday, for 4–6 weeks as an outpatient. It’s very important that you attend all of your scheduled sessions to ensure you receive enough radiation to make the treatment effective.

Side effects of radiation therapy

The side effects you experience will vary depending on the type and dose of radiation, and the areas treated. Brachytherapy tends to have fewer side effects than EBRT. Side effects often get worse during treatment and just after the course of treatment has ended. They usually get better within  weeks, through some may continue for longer. Some side effects may not show up until many months or years after treatment. These are called late effects.

Short-term side effects

Fatigue – Your body uses a lot of energy to recover, and travelling to treatment can also be tiring. The fatigue may last for weeks after treatment ends. Exercise can help manage fatigue.

Bowel and bladder problems – Radiation therapy can cause inflammation and swelling of the bowel (radiation proctitis) and bladder (radiation  cystitis). Bowel movements may be more frequent, urgent or loose (diarrhoea), or you may pass more wind than normal. Less commonly, there may be blood in the faeces (poo or stools). You may also pass urine (wee) more often or with more urgency, or with a burning sensation. Your treatment team will prescribe medicines to reduce these side effects.

Nausea and vomiting – Because the radiation therapy is directed near your abdomen, you may feel sick (nauseous), with or without vomiting, for several hours after each treatment. Your doctor may prescribe anti-nausea medicine to help prevent this.

Vaginal discharge –  Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if the discharge smells bad or has blood in it. Do not wash inside the vagina with douches as this may cause infection.

Skin redness, soreness and swelling –  The vulva and the skin in the groin area may become sore and swollen. The area may look pink or red and feel itchy, and then peel, blister or weep. Your treatment team will recommend creams and pain relief to use. Wash the vulva with lukewarm water or weak salt baths, avoid perfumed products, and wear cotton underwear.

Long-term or late effects 

Hair loss –  You may lose your pubic hair. Sometimes, this can be permanent. Radiation therapy to the pelvis will not affect the hair on your head or other parts of your body.

Bowel and bladder changes –  Bowel changes, such as diarrhoea, wind or constipation, and bladder changes, such as frequent or painful urination, can also be late effects, appearing months or years after treatment. Bleeding from the bowel or bladder can also occur. In rare cases, there may be loss of bowel control (faecal incontinence) or blockage of the bowel. It is important to let your doctor know about any bleeding or if you have pain in the abdomen and difficulty opening your bowels.

Lymphoedema – Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly from the legs, making the legs swollen. This can occur months or years after radiation therapy. Look for early signs that you are developing lymphoedema to make treating it easier.

Narrowing of the vagina –  The vagina can become drier, shorter and narrower (vaginal stenosis), which may make sex and pelvic examinations uncomfortable or difficult. Your treatment team will suggest strategies to prevent this, such as using vaginal dilators.

Menopause – If you are premenopausal, radiation therapy to the pelvis can stop the ovaries producing hormones and this causes early menopause. Your periods will stop, you will no longer be able to become pregnant and you may have menopausal symptoms. Talk to your radiation oncologist about these issues. You may be able to visit a menopause clinic.

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells.

Chemotherapy may be used:

• for certain types of uterine cancer
• when cancer comes back after surgery or radiation therapy to try to control the cancer and to relieve symptoms
• if the cancer does not respond to hormone therapy
• if the cancer has spread beyond the pelvis when first diagnosed
• during radiation therapy (chemoradiation) or after radiation therapy.

Chemotherapy is usually given by injecting the drugs into a vein (intravenously). You will usually have several treatment sessions, with rest periods in between. Together, the session and rest period are called a cycle. You will have a number of treatments, sometimes up to six, every 3–4 weeks over several months. Talk to your doctor about how long your treatment will last.

Treatment is usually given to you during day visits to a hospital or clinic as an outpatient or, very rarely, you may need to stay in hospital overnight. Let your oncologist know if you are taking nutritional or herbal supplements as these can interact with chemotherapy and may affect how the drugs work.

Side effects of chemotherapy

The side effects of chemotherapy vary greatly and depend on the drugs you receive, how often you have the treatment, and your general fitness and health. Side effects may include:

• feeling sick (nausea)
• vomiting
• fatigue
• some thinning and loss of body and head hair
• numbness and tingling in the hands and feet (peripheral neuropathy).

Most side effects are temporary and steps can often be taken to prevent or reduce their severity.

Chemotherapy can affect your immune system, increasing the risk of infection. If you develop a temperature over 38°C, contact your doctor or go immediately to the emergency department at your nearest hospital.

Download our booklet ‘Understanding Chemotherapy’

High-risk endometrial cancer is often treated with EBRT in combination with chemotherapy to reduce the chance of the cancer coming back after treatment is over.

When radiation therapy is combined with chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

If you have chemoradiation, you will usually receive chemotherapy once a week a few hours before some radiation therapy sessions. Once the radiation therapy is over, you may have another four cycles of chemotherapy on its own.

Side effects of chemoradiation include fatigue; diarrhoea; needing to pass urine more often or in a hurry; cystitis; dry and itchy skin in the treatment area; numbness and tingling in the hands and feet (peripheral neuropathy); and low blood counts. Low numbers of blood cells may cause anaemia, infections or bleeding problems.

Talk to your treatment team about ways to manage any side effects.

Hormone therapy may also be called endocrine therapy or hormone-blocking therapy. Hormones such as oestrogen and progesterone are substances that are produced naturally in the body. They help control the growth and activity of cells. Some cancers of the uterus depend on oestrogen or progesterone to grow. These are known as hormone-dependent or hormone-sensitive cancers and can sometimes be treated with hormone therapy.

Hormone therapy may be recommended for uterine cancer that has spread or come back (recurred), particularly if it is a low-grade cancer. It is also sometimes offered as the first treatment if surgery has not been done (e.g. when a woman with early-stage, low-grade uterine cancer chooses not to have a hysterectomy because she wants to have children, or if a person is too unwell for surgery).

The main hormone therapy for hormone-dependent cancer of the uterus is progesterone that has been produced in a laboratory. High-dose progesterone is available in tablet form (usually medroxyprogesterone) or through a hormone-releasing intrauterine device (IUD) called a Mirena, which is placed into the uterus by your doctor (if you have not had a hysterectomy). Other hormone drugs may be available on clinical trials. Talk to your doctor about the risks and benefits of the different methods.

Side effects of hormone therapy

The common side effects of progesterone treatment include breast tenderness, headaches, tiredness, nausea, menstrual changes and bloating. In high doses, progesterone may increase appetite and cause weight gain. If you have an IUD, it may move out of place and need to be refitted by your doctor.

Some targeted therapy and immunotherapy drugs are being tested in clinical trials for people with endometrial cancer that has come back or not responded to treatment.

Targeted therapy is a drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. Your medical oncologist may discuss testing the tumour to see whether there are any suitable targeted therapy drugs available through clinical trials.

Immunotherapy is a type of cancer treatment that uses the body’s own immune system to fight cancer. It may be an option for some endometrial cancers that have a fault in the mismatch repair (MMR) genes.

Ask your doctor about recent developments in drugs for uterine cancer and whether a clinical trial may be an option for you.

Download our fact sheet ‘Understanding Targeted Therapy’

Download our fact sheet ‘Understanding Immunotherapy’

Palliative treatment helps to improve people’s quality of life by managing symptoms of cancer without trying to cure the disease. Many people think that palliative treatment is for people at the end of their life, but it can help at any stage of advanced uterine cancer. It is about living as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiation therapy, chemotherapy or hormone therapy. Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs. The team also supports families and carers.

Download our booklet ‘Understanding Palliative Care’