Surgery

Cancer of the uterus is often diagnosed early, before it has spread. In many cases, surgery will be the only treatment needed. 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. 

The hysterectomy can be done in different ways, depending 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.

• 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 belly button. Sometimes the cut is made along the pubic line instead. The uterus and other organs are then removed. 
  
  

Side effects after surgery

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. You may experience some side effects and changes from surgery during this time, including:

• 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. 
• Vaginal vault prolapse – This is when the top of the vagina drops towards the vaginal opening because the structures that support it have weakened. To help prevent prolapse, it is important to do pelvic floor exercises several times a day.
     

Radiation therapy

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.

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 and 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. 

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. 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, and these are called late effects.

Short-term side effects can include:

• fatigue
• bowel and bladder problems 
• nausea and vomiting
• vaginal discharge
• skin redness, soreness and swelling.

Long-term or late effects can include:

• hair loss
• bowel and bladder changes
• lymphoedema
• narrowing of the vagina
• menopause.
  
  

Hormone therapy

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).

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.

Chemotherapy

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 may be treated as an outpatient or, very rarely, you may need to stay in hospital overnight. You will have a number of treatments, sometimes up to six, every 3–4 weeks over several months.

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, vomiting, fatigue, some thinning and loss of body and head hair, and 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.

Palliative treatment

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 cancer of the uterus. 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. It 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.