Does Hysteroscopy Worsen Endometrial Cancer?

Peter Kovacs, MD, PhD


August 02, 2012

The Risk of Diagnostic Hysteroscopy in Women With Endometrial Cancer

Soucie JE, Chu PA, Ross S, Snodgrass T, Wood SL
Am J Obstet Gynecol. 2012;207:71.e1-e5

Endometrial Cancer

Endometrial cancer is the fourth most common cancer among women. A woman has a 1:35-40 chance of being diagnosed with endometrial cancer in her lifetime. Survival depends on the histologic type and stage of the disease at the time of diagnosis. Disease that is confined to the uterus is associated with a relatively high (approximately 85%) 5-year survival rate. Stage III disease (disease that breaks through the serosa of the uterus or involves the vagina) is associated with a 30% lower survival rate. The endometrioid type of cancer is responsible for about 90% of cases.

Abnormal uterine bleeding is the most common presenting sign of endometrial cancer. Cancer, however, is not the sole reason for abnormal bleeding, which can also be associated with endocrine abnormalities, polyps, fibroid tumors, hyperplasia of the endometrium, and inflammation. It is important to establish the correct diagnosis before treatment. Imaging studies may be helpful to rule out anatomic problems, such as fibroid tumors or polyps. For histologic diagnosis, the endometrium needs to be sampled. This is usually done by means of a Pipelle biopsy, but dilatation and curettage and hysteroscopy with direct biopsy are both good alternatives.[1]

Concern has been raised, however, about the use of hysteroscopy in patients with endometrial cancer.[2,3,4] A high level of intrauterine pressure is used to improve visualization during this procedure, and the distending liquid can carry cancer cells through the Fallopian tubes into the abdominal cavity, worsening the stage of disease and the prognosis. Published studies addressing this problem have had conflicting results. This retrospective cohort study assessed the risk for malignant cell seeding during hysteroscopy in patients with endometrial cancer.

Study Summary

Soucie and colleagues identified 1972 patients with endometrial adenocarcinoma using a local cancer registry. One third of these patients had hysteroscopy before disease staging. Mean age and mean follow-up time of patients who had hysteroscopy and those who did not were similar. The rate of stage III endometrial cancer did not differ between the 2 groups (relative risk [RR], 1.16; 95% confidence interval [CI], 0.83-1.62). Cancer death rates were also not increased by the hysteroscopy procedure (RR, 0.87; 95% CI, 0.69-1.1). The investigators concluded that hysteroscopy in patients with endometrial cancer is not associated with poorer outcomes, as would be evidenced by more advanced stages of disease or higher mortality rates.


Endometrial cancer is relatively common in women, with a peak incidence in the menopausal years. It develops in the endometrium and spreads into the myometrium before progressing into the cervix or vagina, or through the uterine serosa into the peritoneal cavity and other distant sites. The prognosis is affected by the histologic type, differentiation, and stage of the disease. Local disease can be treated conservatively with high-dose progesterone, but in more advanced cases, proper staging involves removal of the uterus, adnexa, lymph nodes, and any involved area.

Abnormal bleeding is the typical presenting sign, but many other pathologic conditions cause bleeding. It is important to establish the correct diagnosis to be able to provide adequate care. Histologic sampling is an important part of the evaluation. Hysteroscopy is one option for obtaining this information and may detect other intrauterine findings (polyps, myoma) that could explain the clinical signs.

The concern that the high pressure used to distend the intrauterine cavity could spread the cancer and worsen the prognosis has been addressed in the literature. Most studies based their conclusions on relatively small samples. The benefit of the study by Soucie and colleagues is that it was adequately powered to answer the question. The lack of association between hysteroscopy and stage of disease is reassuring.

Hysteroscopy is an important tool to evaluate the uterine cavity and endometrium when intrauterine pathology is suspected. It can be used effectively even in cancer patients, and it seems not to be associated with adverse effects.



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