Cancer of the womb information centre

The womb

The womb, or uterus, is a muscular, pear-shaped organ at the top of the vagina. The lining of the womb is called the endometrium and is shed each month, as a period. These periods stop temporarily during pregnancy, but will normally continue until a woman has the menopause.

Cancer that starts in the womb lining is called endometrial cancer and this section is about this type of cancer.

Cancer that starts in the muscle layers of the womb is called uterine sarcoma; this type of cancer is discussed in our section about soft tissue sarcomas.

The position of the cervix in relation to the other female reproductive organs

The lower part of the womb is called the cervix, or sometimes 'the neck of the womb'. We have a separate information on cancer of the cervix.

Close to the womb there are collections of lymph nodes. These are small glands, about the size of a bean. The lymph nodes are part of the lymphatic system. This is a network of glands throughout the body, linked by fine ducts through which a colourless fluid, the lymph, passes and acts as a defence against disease.

Your feelings about having cancer of the womb

Most people feel overwhelmed when they are told that they have cancer. Many different emotions arise, which can cause confusion and frequent mood swings. You might not have all the feelings discussed below or experience them in the same order. These emotions are part of the process that many people go through in trying to come to terms with their illness. Partners, family members and friends often have similar feelings and may need as much support and guidance in coping with their feelings as you do.

Reactions differ from one person to another - there is no right or wrong way to feel. Some of the common emotional effects are mentioned below. However, reactions vary and people have different emotions at different times.

Our section on the emotional effects of cancer discusses the feelings and emotions that you may experience and has advice on how to cope with them.

• Shock and disbelief
• Fear and uncertainty
• Denial
• Anger
• Blame and guilt
• Resentment
• Withdrawal and isolation

Shock and disbelief

'I can't believe it' / 'It can't be true'

This is often the immediate reaction when cancer is diagnosed. You may feel numb and unable to believe what is happening or to express any emotion. You may find that you can take in only a small amount of information and so you have to keep asking the same questions again and again, or you need to be told the same bits of information repeatedly. This need for repetition is a common reaction to shock.

Some people may find that their feelings of disbelief make it difficult for them to talk about their illness with their family and friends. Other people may feel an overwhelming urge to discuss it with those around them.

You might find our section on talking about your cancer helpful.

Fear and uncertainty

'Am I going to die?'/ 'Will I be in pain?'

Cancer is a frightening word surrounded by fears and myths. One of the greatest fears expressed by almost all newly diagnosed cancer patients is `Am I going to die?'

In fact, many endometrial cancers are curable if found at an early stage. When a cancer is not completely curable, modern treatments often mean that it can be controlled for years and many patients can live an almost normal life.

`Will I be in pain?' and `Will any pain be unbearable?' are other common fears. In fact, many people with cancer have no pain at all. For those who do, there are many modern drugs and other techniques which are very successful at relieving pain or keeping it under control. Our information on controlling cancer pain, describes these methods.

Many people are anxious about their treatment: whether or not it will work and how to cope with possible side effects. It is best to discuss your individual treatment and possible outcomes in detail with your doctor. You might find it useful to make a list of any questions you may want to ask.

Some people are afraid of the hospital itself. It can be a frightening place, especially if you have never been in one before, but talk about your fears to your doctor or nurse. They should be able to reassure you.

You may find that doctors cannot answer your questions fully, or that their answers sound vague. For example, it is often impossible for them to say for certain that they have completely removed the tumour. Doctors know approximately how many people will benefit from a certain treatment, but cannot predict the future for a particular person. Many people find this uncertainty hard to live with.

Uncertainty about the future can cause a lot of tension, but fears may be worse than the reality. Gaining some knowledge about your illness can be reassuring. Discussing what you have found out with your family and friends can help to relieve some of the worry.

Denial

'There's nothing really wrong with me' / 'I haven't got cancer'

Many people cope with their illness by not wanting to know anything about it, or not wanting to talk about it. If that's the way you feel, then just say quite firmly to the people around you that you would prefer not to talk about your illness, at least for the time being.

Sometimes, however, it is the other way round. You may find that it is your family and friends who are denying your illness. They appear to ignore the fact that you have cancer, perhaps by playing down your anxieties and symptoms or deliberately changing the subject. If this upsets or hurts you because you want them to support you by sharing what you feel, try telling them. Start perhaps by reassuring them that you do know what is happening and that it will help you if you can talk to them about your illness.

Anger

'Why me of all people?' / 'And why right now?'

Anger can hide other feelings, such as fear or sadness. You may direct your anger at the people who are closest to you and at the doctors and nurses who are caring for you.

It is understandable that you may be deeply upset by many aspects of your illness and there is no need to feel guilty about your angry thoughts or irritable moods. However, relatives and friends may not always realise that your anger is really directed at your illness and not against them. If you can, it may be helpful to tell them this at a time when you are not feeling quite so angry. If you would find that difficult, perhaps you could show them this section of the website.

Blame and guilt

'If I hadn't . . . this would never have happened'

Sometimes people blame themselves or other people for their illness, trying to find reasons to explain why it should have happened to them. This may be because we often feel better if we know why something has happened. However, since in most cases it is impossible to know exactly what has caused a person’s cancer there is no reason for you to feel that you are to blame.

Resentment

'It's all right for you - you haven't got to put up with this'

Understandably, you may be feeling resentful and miserable because you have cancer while other people are well. Similar feelings of resentment may crop up from time to time during the course of your illness and treatment for a variety of reasons. Relatives too can sometimes resent the changes that the patient's illness makes to their lives.

It is usually helpful to bring these feelings out into the open so that they can be discussed. Keeping your resentment to yourself can make everyone feel angry and guilty.

Withdrawal and isolation

'Please leave me alone'

There may be times during your illness when you want to be left alone to sort out your thoughts and emotions. This can be hard for your family and friends who want to share this difficult time with you. It will make it easier for them to cope, however, if you reassure them that although you may not feel like discussing your illness at the moment, you will talk to them about it when you are ready.

Sometimes depression can stop you wanting to talk. If you or your family think you may be depressed, discuss this with your GP. They can prescribe antidepressant drugs for you, or refer you to a doctor or counsellor who specialises in the emotional problems of people with cancer.

Causes of cancer of the womb

Approximately 6000 women in the UK develop womb cancer each year. The exact cause of womb cancer is not yet known. It most commonly occurs in women between the ages of 50 and 64 and after the menopause. Womb cancer rarely affects women under 50. Being overweight increases the risk of developing womb cancer.

Women who are still having periods, and who take the contraceptive pill, are believed to have a lower risk of developing womb cancer. Women who have had their menopause and who take oestrogen-only HRT (hormone replacement therapy) for a long time may have a slightly increased risk of developing the disease. Women who have not had their womb removed and are taking HRT should make sure that they are taking a combination of the hormones oestrogen and progesterone, rather than oestrogen on its own. Taking combined oestrogen and progesterone HRT for up to five years does not increase the risk of developing womb cancer, but if it is taken for more than five years the risk may be slightly increased.

Detailed information on womb cancer, HRT and the pill is in our health professional section.

Taking tamoxifen (a hormonal therapy sometimes taken to treat breast cancer) over a long period of time also slightly increases the risk of developing cancer of the womb. However, this increase in risk is so slight that the benefits of taking tamoxifen to treat breast cancer are considered to outweigh the risk.

Although most womb cancers are not caused by an inherited faulty gene, in some women they may be. In a small number of families, a gene can be present that raises the risk of family members developing bowel or womb cancer. If you have several close family members who have bowel or womb cancer (especially if these were developed at a young age), this could be due to an inherited faulty gene. If you are worried that other family members may have an increased risk of cancer you can talk to your GP, who can refer you to a family cancer clinic if they think this is necessary.

Women who have very rare, inherited disorders, such as Cowden syndrome and Stein-Leventhal syndrome (cystic disease of the ovary), also have an increased risk of developing womb cancer.

Womb cancer, like other cancers, is not infectious and cannot be passed on to other people.

Symptoms of cancer of the womb

The most usual early symptom of cancer of the womb is abnormal vaginal bleeding. This may occur as:

• bleeding between periods
• heavier periods than normal (in pre-menopausal women)
• bleeding which starts after the menopause (in post-menopausal women)
• abnormal vaginal discharge

Abnormal vaginal bleeding may be due to many causes other than cancer, but you should always see your GP about it.

• Some women may notice pain in the lower abdomen (tummy), back or legs.
• Sometimes women may have pain or discomfort during sexual intercourse.

How cancer of the womb is diagnosed

Usually you begin by seeing your GP (family doctor) who will examine you and arrange for any tests or x-rays that may be necessary. Your GP may need to refer you to hospital for these tests, and for specialist gynaecological advice and treatment.

You may have one or more of the tests described here.

• Hysteroscopy
• Biopsy
• Dilatation and curettage (D&C)
• Vaginal ultrasound

Hysteroscopy

A thin, flexible tube with a light at the end may be used to look inside the uterus. This helps the gynaecologist to take accurate tissue samples (see Biopsy, below). After a hysteroscopy most women have period-type pains for a day or so, which can be controlled with painkillers.

Biopsy

A small sample of cells may be taken from the lining of the uterus by a gynaecologist or specialist nurse. This will be carried out in the outpatients department and you will not need an anaesthetic. A fine tube is passed into the uterus, and gentle suction is used to remove a sample of the lining. The sample is sent to the laboratory for examination under a microscope.

Dilatation and curettage (D&C)

You may have a procedure called dilatation and curettage (D&C), which is carried out under a general anaesthetic. The cervix is stretched so that the gynaecologist can insert an instrument to remove samples of tissue from the inner lining of the uterus. These samples can then be examined under a microscope. After a D&C most women have period-type pains for a day or so, which can be controlled with painkillers.

Vaginal ultrasound

Sound waves are used to make up a picture of the inside of the uterus. It will be done in the hospital scanning department.

A small device is gently put into your vagina. The device produces sound waves, which are then converted into a picture by a computer. This may be uncomfortable but should not be painful.

Further tests for cancer of the womb

If the tests show that you have womb cancer, your gynaecologist or surgeon will probably want to do further tests to see if the disease has spread. These tests help the doctor to decide on the best type of treatment for you. The tests may include any of those described below.

• Blood tests
• Chest x-ray
• CT (computerised tomography) scan
• MRI (magnetic resonance imaging) scan

Blood tests

Samples of your blood will be taken to check your general health, the number of cells in your blood (blood count), and to see how well your kidneys are working.

Chest x-ray

This is taken to check that your lungs and heart are healthy.

CT (computerised tomography) scan

A CT scanner takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes longer than an x-ray (from 10-30 minutes). It may be used to find the exact area and size of the cancer, or to check for any spread of the disease.

Most people who have a CT scan are given a drink or injection of iodine to allow particular areas to be seen more clearly. For a few minutes this may make you feel hot all over. If you are allergic to iodine or have asthma, it is important to tell your doctor and the person doing the test before you have the injection or drink. It is usually still possible to have the injection, but you will need to have steroid treatment on the day before, and the day of, the injection.

Having a CT scan

The CT scan is painless but it will mean lying still for about 10–30 minutes. You will probably be able to go home as soon as the scan is over.

MRI (magnetic resonance imaging) scan

This test is similar to a CT scan but uses magnetism instead of x-rays to build up cross-sectional pictures of your body. Some people are given an injection of dye into a vein in the arm to improve the image.

During the test you will be asked to lie very still on a couch, inside a long chamber, for up to an hour. This can be unpleasant if you don’t like enclosed spaces; if so, it may help to mention this to the radiographer. The MRI scanning process is also very noisy, but you will be given earplugs or headphones to wear, and many hospitals will play music for you during the scan. You can take in your own favourite music.

The scanner is a very powerful magnet, so before going into the room you should remove any metal items you may be wearing. People who have heart monitors, heart pacemakers, or certain types of surgical clips cannot have an MRI because of the magnetic fields.

It will probably take several days for the results of your tests to be ready, and this waiting time will obviously be an anxious time for you. It may help if you can find a close friend or relative to talk things over with.

Staging and grading cancer of the womb

Staging

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original area of the body. Knowing the extent of the cancer, and the grade, helps your specialist to decide on the most appropriate treatment for you.

The stages of endometrial cancer are:

• Stage 1 The tumour is contained within the endometrium (womb lining) or the muscle layers of the womb.

• Stage 2 The tumour has spread into the cervix.

• Stage 3 The tumour has spread into nearby tissues, such as the supporting membranes in the pelvic area, the vagina, or nearby lymph nodes.

• Stage 4 The tumour has spread beyond the womb into surrounding organs, such as the bladder or bowel, or to other parts of the body. If the cancer has spread to other parts of the body this is secondary (or metastatic) womb cancer.

Recurrent endometrial cancer is when the cancer comes back some time after initial treatment.

Grading

Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades:

• grade 1 (low-grade)
• grade 2 (moderate-grade)
• grade 3 (high-grade).

Low-grade cancer cells look very like normal endometrial cells. They are usually slow-growing and less likely to spread. In high-grade tumours, the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.

Treatment for cancer of the womb

• Types of treatment
• Multidisciplinary team
• Giving your consent
• Benefits and disadvantages of treatment
• Making decisions about treatment
• Second opinion

Types of treatment

Most womb cancers are discovered at an early stage (when they have not spread beyond the womb) and are cured by a hysterectomy (surgical removal of the womb). As this treatment is very successful for many women, further treatment is not normally necessary.

Radiotherapy may be given after the operation, if your surgeon feels that there is any risk of the cancer coming back. Radiotherapy may be used instead of surgery if the cancer cannot be removed surgically, or if you are not fit enough to have an operation. Radiotherapy may be used to shrink a tumour down before surgery, and may also be used if the cancer comes back (recurs) in the pelvic area at a later date.

If the cancer has spread to other parts of the body, treatment with a female hormone called progesterone may be able to shrink the cancer and control symptoms. Chemotherapy is also used sometimes in this situation, and can help to shrink the cancer and control its growth for a time.

Your treatment will depend on a number of factors, including:

• your age
• your general health
• the type of tumour you have
• the stage and the grade of the cancer.

Multidisciplinary team

If your tests show that you have womb cancer, you will be looked after by a multidisciplinary team. This is a team of staff who specialise in treating gynaecological cancer and in giving information and support. It will normally include:

• gynaecological surgeons
• specialist nurses who give information and support
• oncologists – doctors who have experience in gynaecological cancer treatment using chemotherapy, radiotherapy and (hormonal) therapy
• radiologists who help to analyse x-rays
• pathologists who advise on the type and extent of the cancer.

Other staff will also be available to help you if necessary, such as:

• physiotherapists
• counsellors and psychologists
• social workers.

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

• the type and extent of the treatment that you are advised to have
• the advantages and disadvantages of the treatment
• any possible other treatments that may be available
• any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can’t make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is important to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Some people ask what would happen if they did not have any treatment.

Although treatments such as radiotherapy can cause side effects, these can usually be well controlled with medicines.

Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage womb cancer

In women with early-stage endometrial cancer, surgery is usually done with the aim of curing the cancer and, in most cases, is successful. Sometimes additional treatments such as radiotherapy are given after the surgery to reduce the risks of the cancer coming back.

Advanced womb cancer

If the cancer is at a more advanced stage or has come back (recurred), treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. However, for some people in this situation, treatment will have no effect upon the cancer and they will get the side effects without any of the benefit.

Making decisions about treatment

If you have early-stage cancer and have been offered treatment that aims to cure it, deciding whether or not to accept the treatment may not be difficult. However, if you have more advanced cancer and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.

Second opinion

Some women find it reassuring to have another medical opinion to help them decide about their treatment. Most doctors will be pleased to refer you to another specialist for a second opinion, if you feel this will be helpful. However, a second medical opinion may take some time to arrange and may delay the start of your treatment, so you need to be sure that it will be helpful to you.

Treating cancer of the womb with surgery

The surgical treatment for womb cancer is the removal of the womb (hysterectomy) and is carried out by a gynaecological surgeon. Usually, both ovaries and the fallopian tubes will also be removed.

Sometimes the lymph nodes close to the womb will also be removed. This is known as a Wertheim’s hysterectomy. The reason for this extra surgery is to remove as much of the cancer as possible and to enable the pathologist to see if are any cancer cells in the lymph glands. Often it is possible for the gynaecologist to remove all the cancer at this operation so that no further treatment is necessary.

However, if the cancer cannot be completely removed your surgeon may recommend radiotherapy treatment to be given after the operation. Even if the whole tumour has been removed, radiotherapy is sometimes given to reduce the chance of the cancer coming back. If radiotherapy is necessary, your surgeon will refer you to a clinical oncologist (a doctor who specialises in radiotherapy treatment).

• Drips and drains
• Moving around
• Pain
• Going home
• Sex
• Physical activity
• Support

Drips and drains

When you get back to the ward you will have a drip (intravenous infusion) in a vein in your arm until you are able to eat and drink normally. You will probably have drainage tubes in the wound to stop any excess fluid collecting. These are taken out within a few days. Usually a small tube (catheter) is put into the bladder and urine is drained into a collecting bag.

Moving around

You will be encouraged to start moving about as soon as possible. This is an essential part of your recovery, and even if you have to stay in bed the nurses will encourage you to do regular leg movements to prevent blood clots in your legs. You will also be shown how to do deep breathing exercises to prevent chest infections. A physiotherapist will help you to do these exercises.

Pain

After your operation you may need regular painkillers, which are very effective in controlling any pain. If you still have pain it is important to let your nurses know as soon as possible, so that the painkillers can be changed until you find a type and dose that is effective.

Going home

Most women are ready to go home about 6–8 days after their operation, once their stitches or clips have been removed. If you think you might have problems when you go home – for example, if you live alone or have several flights of stairs to climb – let the ward nurses, or social worker, know as soon as possible so that help can be arranged.

Sex

Although you will no longer have your monthly periods or be able to become pregnant, you will, when you are ready, be able to be sexually active again. Your surgeon will probably advise you not to have sexual intercourse for at least six weeks after your operation, to allow the wound to heal properly. Many women need more time before they are ready to have a sexual relationship. If you have any questions about these issues, don’t be afraid to discuss them with your GP, surgeon, specialist nurse or one of our nurses.

You may find our section on sexuality and cancer helpful.

Physical activity

After a hysterectomy you will need to avoid strenuous physical activity, or heavy lifting, for about two months. Some women also find it uncomfortable to drive after their operation. It is a good idea to wait a few weeks before you start driving again. Some insurance companies have guidelines about this, and you may wish to contact your own company or the DVLA (Drivers and Vehicles Licensing Association) for advice.

Support

Some women take longer than others to recover from their operation. If you find you are having problems, it may be helpful to talk to someone who is not directly associated with your illness. Our nurses will always be happy to talk to you and they may be able to put you in touch with a counsellor or a support group in your area, so that you can talk to other women who have had similar problems.

Before you leave hospital, you will be given an appointment to attend an outpatient clinic for your post-operative check-up. This is a good time to discuss any problems that you may have had since your operation – but remember, you can ring your hospital doctor or the nurses on the ward at any time.

Treating cancer of the womb with radiotherapy

Radiotherapy treats cancer by using high-energy rays which destroy the cancer cells while doing as little harm as possible to normal cells.

• When is radiotherapy given?
• External radiotherapy
• Planning your treatment
• Treatment sessions
• Skin care
• Internal (intracavity) radiotherapy
• Side effects
• Possible long-term side effects

When is radiotherapy given?

Radiotherapy may be given after surgery, if your doctor feels that there is a risk of the cancer coming back. It may be used instead of surgery if the cancer has spread to the area surrounding the womb. Sometimes it is given to shrink a tumour before an operation. It may also be used if the cancer comes back in the pelvic area at a later date. Radiotherapy for womb cancer can be given externally or internally, and often as a combination of the two.

Your clinical oncologist, who plans your treatment, will be able to help you with any problems or concerns you may have.

External radiotherapy

This is given by directing high-energy rays at the area of the cancer. It is usually done at a hospital outpatient clinic each weekday, with a rest at the weekend. The type and length of your treatment will depend on the size and position of the cancer, but it may last a few weeks.

Planning your treatment

To make the radiotherapy as effective as possible, it has to be carefully planned. On your first few visits to the radiotherapy department you will be asked to lie under a large machine called a simulator, which takes x-rays of the area to be treated. A CT scan may be used instead.

Before the x-rays are taken, a tampon may be inserted into your vagina and a liquid which shows up on x-ray may be passed into the rectum. This is done to make sure that the clearest possible pictures are taken.

Planning may take a few visits. Marks will be made on your skin to show the radiographer, who gives you your treatment, where the rays are to be directed. Sometimes a few permanent marks may be made on the skin instead of pen marks. These marks are tiny and will be made only with your permission.

Treatment sessions

Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room but you will be able to talk to the radiographer, who will be watching you carefully from the next room. Radiographers are also sometimes called radiotherapists.

A radiographer watches on a monitor while treatment is given

Radiotherapy is not painful but you do have to be still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Skin care

Your skin may become sore in the area being treated. Perfumed soaps, creams or deodorants may irritate the skin and should not be used during the treatment. Your radiographer or nurse can advise you on skin care during this time.

Internal (intracavity) radiotherapy

Internal radiotherapy (sometimes called brachytherapy) may be used for women who cannot have surgery, or after surgery if there is a chance that the cancer may come back. It may be used on its own or combined with external radiotherapy.

With internal radiotherapy treatment an applicator, like a radioactive metal tampon, is inserted into the uterus or the top of the vagina. This is normally done under a general anaesthetic. Often, tubes may be used, into which a machine called a selectron feeds radioactive sources (small radioactive metal balls). They are usually left in place for one or two days.

Intracavity radiotherapy gives a high dose of radiation to the area close to the applicator, but only a low dose to tissues and organs more than a few centimetres away. As radioactive metal is used, you will probably be nursed in a separate room, apart from the main ward and often behind lead shields. If a selectron is being used, the radioactive sources can be withdrawn into the machine when people come into the room. This is to keep the dose of radioactivity to visitors and nurses as low as possible. Visitors are usually restricted and children are not encouraged to visit. You will be asked to stay in bed, while the applicator is in place, to make sure that it stays in the correct position. For the same reason, your urine will be drained away through a small tube, or catheter, which is put into the bladder.

The safety measures and visiting restrictions might make you feel very isolated, frightened and depressed at a time when you might want people around you. If you feel like this, you can let the staff looking after you know. It might also be helpful to take in plenty of reading material and things to keep you occupied whilst you are in isolation. The isolation only lasts while the applicator is in place. Once it is removed, the radioactivity disappears and it is perfectly safe for you to be with other people.

The applicator will be removed by one of the doctors or nurses on the ward and this can be uncomfortable. Painkillers will be given before the tubes are removed and sometimes sedation or gas and air (entonox) are also given to make the removal easier for you.

Sometimes, an implant containing a higher dose of radioactivity is used. This is only in place for a few hours, or sometimes a few minutes. These shorter treatments are given by a machine called a microselectron, and need to be repeated several times. They are given in the hospital outpatient department. A tube (catheter) into the bladder to drain urine is not needed with this treatment.

The shorter radiotherapy treatments and the longer treatments are equally effective.

Side effects

It is not unusual to have slight bleeding or discharge once radiotherapy treatment has finished. If it continues or becomes heavy, let your clinical oncologist or specialist nurse know.

Radiotherapy to the pelvic area can cause side effects such as tiredness, diarrhoea and a burning sensation when passing urine. These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of your treatment. Your radiotherapist, or specialist nurse, will be able to advise you what to expect.

Most of these side effects can be treated quite easily with tablets, and your radiotherapist can prescribe these. Any side effects should gradually disappear a few weeks after your treatment is over.

It is important to drink plenty of fluids and maintain a healthy diet during your treatment. You may feel slightly sick but this is not common. If you don’t feel like eating you can replace meals with nutritious, high-calorie drinks, which are available from most chemists and can be prescribed by your GP. Our information on eating well has some helpful hints on how to eat well when you are feeling ill.

During your treatment it is helpful to get as much rest as you can, especially if you have to travel a long way each day. Our information on coping with fatigue, has helpful tips on dealing with tiredness.

Sometimes radiotherapy causes a narrowing of the vagina, which can make sexual intercourse uncomfortable. Some women become less interested in sex and notice that their vagina is dry. See the section on the effects on your sex life and fertility.

Possible long-term side effects

Radiotherapy to the pelvic area can sometimes cause long-term side effects. However, improved planning and treatment techniques have made these long-term effects much less likely.

In a small number of people, the bowel or bladder may be permanently affected by the radiotherapy. If this happens, the increased bowel motions and diarrhoea may continue, or you may need to pass urine more often than before. The blood vessels in the bowel and bladder can become more fragile after radiotherapy treatment and this can make blood appear in the urine or bowel movements. This can take many months or years to happen. If you notice any bleeding, let your doctor know so that tests can be carried out and appropriate treatment given. Some people also find that the radiotherapy affects the lymph glands in the pelvic area and can cause swelling of the legs. This is known as lymphoedema and is an uncommon side effect.

There is more information about possible long-term side effects in our section on pelvic radiotherapy in women.

Treating cancer of the womb with hormonal treatment

In some situations, if there is a risk of the cancer coming back or if it comes back after surgery, your doctor may recommend hormonal treatment with progesterone. This treatment may reduce the chance of a cancer coming back. If a womb cancer is advanced, progesterone may shrink the cancer and control symptoms. Hormonal treatment may also be used for endometrial cancers that have already spread to other parts of the body when they are diagnosed.

Progesterone is a hormone that occurs naturally in women. Artificial progesterone is available as tablets, or by injection and can be given by your GP. The most common types are medroxyprogesterone acetate (Provera®) and megestrol (Megace®).

Side effects

Progesterone has very few side effects. Although some women may feel slightly sick, most women find that progesterone increases their appetite. This may make them put on some weight. Some women also notice slight muscle cramps.

Chemotherapy

Chemotherapy may be used if the cancer comes back, or has spread to other parts of the body, and does not respond to hormonal treatment. In some people, chemotherapy may help to shrink the cancer and relieve symptoms.

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.

How chemotherapy is given

The drugs are sometimes given as tablets or capsules or, more usually, by injection into a vein (intravenously).

Side effects

Chemotherapy drugs tend to temporarily reduce the number of normal cells in the blood. When your blood count is low you are more likely to get an infection and may tire easily. During chemotherapy your blood will be tested regularly and, if necessary, you will be given antibiotics to treat infection. Blood transfusions may be given if you are anaemic.

Other side effects may include tiredness, feeling sick (nausea), vomiting and hair loss. Nausea and vomiting can now be well controlled with anti-sickness medicines. Some chemotherapy drugs also make the mouth sore and cause small ulcers. Regular mouthwashes are important and the nurses will show you how to do these properly. If you don’t feel like eating meals, you can supplement your diet with nutritious drinks or soups. A wide range of these drinks are available and you can buy them at most chemists.

Occasionally, women may have an allergic reaction to a chemotherapy drug, which can be very frightening. Tell your doctor or nurse if you notice any skin rashes and itching, a high temperature, shivering, redness of the face, dizziness, headache, breathlessness, or anxiety and a need to pass urine. Treatment can be given to reduce allergic reactions.

Although these side effects may be hard to bear at the time, they disappear once your treatment is over and your hair will grow back within a few months of finishing chemotherapy.

Some people do not have many side effects. Your doctor will tell you what problems to expect from your treatment.

Effects of treatment for cancer of the womb on sex life and fertility

The treatments for womb cancer may affect your sex life, but many of these effects can be prevented or treated.

• Menopausal symptoms
• Narrowing of the vagina
• Sex after treatment
• Vaginal dilators
• Fertility

Menopausal symptoms

If you have had a hysterectomy and your ovaries have also been removed, or if you have had radiotherapy to the pelvis, you will have menopause symptoms (if you have not yet had the menopause). These can include:

• hot flushes
• dry skin
• dryness of the vagina
• feeling low and anxious
• being less interested in sex for a time.

Many of these symptoms can be eased by hormone creams or tablets, prescribed by your specialist. These replace the hormones that would have been produced by the ovaries. Some doctors do not like to prescribe these hormones due to a theoretical risk that they could cause the cancer to come back, but there is no evidence that the hormones increase the risk of recurrence.

If dryness of the vagina is a problem, your GP or specialist can prescribe creams or Vagifem® pessaries, or you can buy lubricating gels, such as K-Y Jelly® or Replens®, from the chemist. You, or your partner, can apply the gels or creams directly to the penis or vagina before or during sex.

Narrowing of the vagina

Radiotherapy to the pelvis can make the vagina become narrower and this can make sex difficult or uncomfortable. The key to overcoming this problem is to keep the muscles in the vagina as supple as possible. Hormone creams (available on prescription from your doctor) applied to your vagina can help, but regular sex, or use of a vaginal dilator, is often the easiest and most effective treatment.

Sex after treatment

Many women feel nervous about having sex soon after treatment for cancer, but it is perfectly safe. Sex won’t make cancer worse and your partner can’t catch cancer from you. Women often find they need to take more time over sex to help the vagina relax. It may also be easier if your partner is very gentle at first, so that your vagina can stretch slowly. Regular, gentle sex will help the vagina to become supple again and you should be able to go back to your usual sex life a few weeks after radiotherapy.

Vaginal dilators

Vaginal dilators are usually made of plastic and the nurses on the ward, your specialist nurse, or your specialist can give one to you. The dilator needs to be gently and regularly inserted into the vagina to stretch it gradually and prevent narrowing. The nurses, or your doctor, can show you how to use a dilator and can answer any questions. Try not to be embarrassed about asking for, or using, a dilator. Many women find them very useful to improve the suppleness of the vagina after radiotherapy, even if they have a regular partner. A dilator can be helpful for women who may have temporarily lost interest in sex due to menopausal symptoms, or who feel nervous of having sex soon after treatment, or who do not have a regular partner.

Fertility

Surgery and radiotherapy for womb cancer will prevent you from being able to have children in the future. Younger women, and those who were hoping to have children or complete their family, may be especially upset if they have needed a hysterectomy or had radiotherapy that has damaged their ovaries.

Women who have had their menopause may also feel a deep sense of loss after an operation for womb cancer. Some women feel that the removal of their womb takes away part of their womanhood and they feel less feminine. It can help if you give yourself plenty of time to grieve for children you might have had, or to mourn, as the loss of the womb can give many women a feeling of bereavement.

You may find it helpful to talk to a specialist gynaecological oncology nurse, or a counsellor, who is specially trained to listen and offer support. Our cancer support service can give you information and the Cancer Counselling Trust offer counselling to anyone affected by cancer.

Follow up after treatment for cancer of the womb

After your treatment is completed, you will have regular check-ups and blood tests, and possibly scans or x-rays. These will probably continue for several years. Many people find that they get very anxious for a while before the appointments. This is natural and it may help to get support from family, friends, or a support organisation.

If you have any problems, or notice any new symptoms in between these times, let your doctor know as soon as possible.

For people whose treatment is over apart from regular check-ups, our section on adjusting to life after cancer treatment, gives useful advice on how to keep healthy and adjust to life after cancer.

Research - clinical trials for cancer of the womb

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

• test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines
• look at new combinations of existing treatments, or change the way they are given, in order to make them more effective or to reduce side effects
• compare the effectiveness of drugs used for symptom control
• find out how cancer treatments work
• see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and the development of new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in trials.

Blood and tumour samples

Many blood samples and bone marrow or tumour biopsies may be taken to find out what is wrong with you. Most of these are needed to make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. Some samples may be frozen and stored for future use, when new research techniques become available.

The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.