What are the recommendations for screening for endometrial cancer?

Screening for Endometrial Cancer

Routine screening for endometrial cancer is not recommended for asymptomatic women at average or increased risk; instead, women should be educated about symptoms (particularly unexpected bleeding and spotting) at menopause onset and strongly encouraged to report these immediately. 1

Average and Increased Risk Women

No screening is indicated for the following groups 1:

• Women at average risk
• Women with increased risk factors including:
  • History of unopposed estrogen therapy 1
  • Tamoxifen therapy 1
  • Late menopause 1
  • Nulliparity 1
  • Infertility or failure to ovulate 1
  • Obesity 1
  • Diabetes mellitus 1
  • Hypertension 1

The rationale is straightforward: there is insufficient evidence that screening improves mortality or morbidity in these populations. 1

Critical Action for Average/Increased Risk Women

At menopause onset, inform these women about endometrial cancer risks and symptoms, emphasizing that unexpected bleeding or spotting requires immediate physician evaluation. 1

Very High Risk Women: Lynch Syndrome

Women at very high risk require annual screening beginning at age 35 years. 1 This applies to:

1. Known Lynch syndrome (HNPCC) genetic mutation carriers 1
2. Substantial likelihood of being a mutation carrier (mutation known in family) 1
3. Families with suspected autosomal dominant predisposition to colon cancer without genetic testing 1

Screening Method for High-Risk Women

Endometrial biopsy remains the standard for determining endometrial status. 1 The European guidelines suggest annual outpatient hysteroscopy with endometrial sampling (OHES) has high diagnostic accuracy for detecting endometrial cancer and atypical endometrial hyperplasia in Lynch syndrome patients. 1

Important Counseling Points

Inform high-risk women that screening recommendations are based on expert opinion rather than definitive scientific evidence, and discuss potential benefits, harms, and limitations of early detection testing. 1 The recommendation exists because these women face up to 60% lifetime risk of endometrial cancer, and early detection is potentially life-saving. 1, 2

Special Populations

Tamoxifen Users

Routine screening for endometrial cancer in asymptomatic tamoxifen users is not recommended. 1 However, postmenopausal women taking tamoxifen should be informed about symptoms of endometrial hyperplasia or cancer. 1

Women with Unopposed Estrogen

Unopposed estrogen treatment should not be started or should be discontinued in women with a uterus in situ. 1

Common Pitfalls to Avoid

• Do not perform routine surveillance in asymptomatic women with obesity, PCOS, diabetes mellitus, infertility, nulliparity, or late menopause 1—these are increased risk factors, not very high risk requiring screening
• Do not rely on transvaginal ultrasound alone for screening purposes 2, 3—only histological diagnosis can definitively exclude malignancy
• Do not delay evaluation of postmenopausal bleeding or unexpected bleeding in premenopausal women 2, 4—these symptoms require immediate diagnostic workup, not screening

Key Distinction: Screening vs. Diagnostic Evaluation

The guidelines address screening (testing asymptomatic women), not diagnostic evaluation of symptomatic women. Any woman presenting with abnormal uterine bleeding, especially postmenopausal bleeding, requires immediate diagnostic evaluation with transvaginal ultrasound or endometrial biopsy. 4, 5 This is diagnostic workup, not screening, and applies regardless of risk category.