Who is at Risk?

Endometrial cancer is a disease that primarily affects postmenopausal women at an average age of 60 years at diagnosis. Risk factors include postmenopausal estrogen therapy, obesity, a high-fat diet, reproductive factors like nulliparity, early menarche and late menopause, polycystic ovarian syndrome, and tamoxifen use. Women with hereditary nonpolyposis colorectal cancer syndrome have a markedly increased risk of endometrial cancer compared with women in the general population.

Overview

Note: Separate PDQ summaries on Endometrial Cancer Screening; Endometrial Cancer Treatment; and Uterine Sarcoma Treatment are also available.

Intervention Associated With Decreased Risk

Oral contraceptives

Based on solid evidence, at least 1 year's use of oral contraceptives containing estrogen and progesterone decreases endometrial cancer risk, proportionate to duration of use. This benefit lasts at least 15 years after cessation.[1,2]

Magnitude of Effect: Use of oral contraceptives for 4 years reduced risk by 56%, 8 years by 67%, and 12 years by 72%.

Study Design: Case-control studies and prospective studies.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Harms

Based on solid evidence, current use of oral contraceptives is associated with an increased risk of blood clots, stroke, and myocardial infarction, especially among women who smoke cigarettes and who are older than 35 years.

Study Design: Randomized controlled clinical trials.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Physical activity

Based on solid evidence, increased physical exercise is associated with a decreased risk of endometrial cancer.[3,4,5]

Magnitude of Effect: Regular exercise may be associated with a 38% to 46% decrease in risk, although a trend in risk reduction with increasing duration or intensity has not been shown.

Study Design: Multiple cohort and case-control studies.

Internal Validity: Good.

Consistency: Fair.

External Validity: Good.

Factors Associated With Decreased Risk

Increasing parity and lactation

Based on solid evidence, increased parity and duration of lactation are associated with a decreased risk of endometrial cancer.[6,7]

Magnitude of Effect: Parous women have a 35% decreased risk of endometrial cancer (hazard ratio = 0.65; 95% confidence interval [CI], 0.54–0.77) compared with nulliparous women. Duration of breastfeeding has also been associated with a decreased risk, with a 23% risk reduction noted with breastfeeding more than 18 months. The risk reduction was attenuated when adjusted for parity.[8,9]

Study Design: Prospective cohort study.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Factors Associated With Increased Risk

Hormone therapy (HT)

Based on solid evidence, unopposed estrogen is associated with an increased risk of endometrial cancer.[10] This excess risk of endometrial cancer associated with postmenopausal unopposed estrogen therapy can be eliminated by adding progestin, but this is associated with an increased risk of breast cancer.[11,12]

Magnitude of Effect: The risk of endometrial cancer associated with unopposed estrogen use for 5 or more years is more than tenfold higher than nonhormone use. Addition of progesterone to estrogen negates this risk, but combined HT increases the risk of breast cancer, which is not observed with unopposed estrogen.

Study Design: Randomized controlled trials, cohort, and case-control studies.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Harms

Based on solid evidence, the combined use of estrogen and progestin are associated with an increased risk of breast cancer, heart disease, stroke, and thrombosis.[11,13,14] Based on solid evidence, unopposed estrogen is associated with an excess risk of stroke and thrombosis.[15]

Magnitude of Effect: Combined estrogen and progestin after a mean of 5 years of treatment: Approximately a 26% relative increase in incidence of invasive breast cancer; a 29% relative increase in cardiovascular heart disease; a 41% relative increase in stroke, associated with combined estrogen and progestin; and a 113% relative increase in pulmonary embolus.

Estrogen only after a mean follow-up of 6.8 years: Approximately a 39% relative increase in stroke and a 34% relative increase in pulmonary embolus. Risk of cardiovascular heart disease and breast cancer were nonstatistically significantly lower in the estrogen-treated group.

Study Design: Randomized placebo-controlled trials.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Selective estrogen receptor modifiers

Based on solid evidence, more than 2 years of tamoxifen use is associated with an increased risk of endometrial cancer.[16,17] A different selective estrogen receptor modifier, raloxifene, does not have this association.[18,19]

Magnitude of Effect: Women taking tamoxifen for more than 2 years have a 2.3-fold to 7.5-fold relative risk (RR) of endometrial cancer.

Study Design: Multiple randomized controlled trials.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Obesity

Based on solid evidence, being overweight or obese is associated with an increased risk of endometrial cancer.[20,21,22]

The risk of endometrial cancer increases 1.59-fold per 5 kg/m2 change in body mass.[23]

Study Design: Multiple randomized controlled trials.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

Interventions of Unproven or Disproven Effect

Weight loss

The evidence is insufficient to conclude whether weight loss is associated with a decreased incidence of endometrial cancer. Based on one study, self-reported intentional weight loss during 3 age periods was not associated with a decrease in endometrial cancer incidence.[24]

Magnitude of Effects: RR of endometrial cancer for women who intentionally lost at least 20 lbs was 0.93 (95% CI, 0.6–1.44).

Study Design: Cohort study with retrospectively self-reported data.

Internal Validity: Good.

Consistency: Good.

External Validity: Good.

References:

1.	Combination oral contraceptive use and the risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA 257 (6): 796-800, 1987.
2.	Weiderpass E, Adami HO, Baron JA, et al.: Use of oral contraceptives and endometrial cancer risk (Sweden). Cancer Causes Control 10 (4): 277-84, 1999.
3.	Moradi T, Weiderpass E, Signorello LB, et al.: Physical activity and postmenopausal endometrial cancer risk (Sweden). Cancer Causes Control 11 (9): 829-37, 2000.
4.	Schouten LJ, Goldbohm RA, van den Brandt PA: Anthropometry, physical activity, and endometrial cancer risk: results from the Netherlands Cohort Study. J Natl Cancer Inst 96 (21): 1635-8, 2004.
5.	Terry P, Baron JA, Weiderpass E, et al.: Lifestyle and endometrial cancer risk: a cohort study from the Swedish Twin Registry. Int J Cancer 82 (1): 38-42, 1999.
6.	Newcomb PA, Trentham-Dietz A: Breast feeding practices in relation to endometrial cancer risk, USA. Cancer Causes Control 11 (7): 663-7, 2000.
7.	Salazar-Martinez E, Lazcano-Ponce EC, Gonzalez Lira-Lira G, et al.: Reproductive factors of ovarian and endometrial cancer risk in a high fertility population in Mexico. Cancer Res 59 (15): 3658-62, 1999.
8.	Dossus L, Allen N, Kaaks R, et al.: Reproductive risk factors and endometrial cancer: the European Prospective Investigation into Cancer and Nutrition. Int J Cancer 127 (2): 442-51, 2010.
9.	Karageorgi S, Hankinson SE, Kraft P, et al.: Reproductive factors and postmenopausal hormone use in relation to endometrial cancer risk in the Nurses' Health Study cohort 1976-2004. Int J Cancer 126 (1): 208-16, 2010.
10.	Shapiro S, Kelly JP, Rosenberg L, et al.: Risk of localized and widespread endometrial cancer in relation to recent and discontinued use of conjugated estrogens. N Engl J Med 313 (16): 969-72, 1985.
11.	Anderson GL, Judd HL, Kaunitz AM, et al.: Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women's Health Initiative randomized trial. JAMA 290 (13): 1739-48, 2003.
12.	Effects of hormone replacement therapy on endometrial histology in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. JAMA 275 (5): 370-5, 1996.
13.	Writing Group for the Women's Health Initiative Investigators.: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 288 (3): 321-33, 2002.
14.	Persson I, Weiderpass E, Bergkvist L, et al.: Risks of breast and endometrial cancer after estrogen and estrogen-progestin replacement. Cancer Causes Control 10 (4): 253-60, 1999.
15.	Anderson GL, Limacher M, Assaf AR, et al.: Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA 291 (14): 1701-12, 2004.
16.	Fisher B, Costantino JP, Redmond CK, et al.: Endometrial cancer in tamoxifen-treated breast cancer patients: findings from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-14. J Natl Cancer Inst 86 (7): 527-37, 1994.
17.	Fornander T, Rutqvist LE, Cedermark B, et al.: Adjuvant tamoxifen in early breast cancer: occurrence of new primary cancers. Lancet 1 (8630): 117-20, 1989.
18.	DeMichele A, Troxel AB, Berlin JA, et al.: Impact of raloxifene or tamoxifen use on endometrial cancer risk: a population-based case-control study. J Clin Oncol 26 (25): 4151-9, 2008.
19.	Cummings SR, Eckert S, Krueger KA, et al.: The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation. JAMA 281 (23): 2189-97, 1999.
20.	Bergström A, Pisani P, Tenet V, et al.: Overweight as an avoidable cause of cancer in Europe. Int J Cancer 91 (3): 421-30, 2001.
21.	Weiderpass E, Persson I, Adami HO, et al.: Body size in different periods of life, diabetes mellitus, hypertension, and risk of postmenopausal endometrial cancer (Sweden). Cancer Causes Control 11 (2): 185-92, 2000.
22.	Olson SH, Trevisan M, Marshall JR, et al.: Body mass index, weight gain, and risk of endometrial cancer. Nutr Cancer 23 (2): 141-9, 1995.
23.	Renehan AG, Tyson M, Egger M, et al.: Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 371 (9612): 569-78, 2008.
24.	Parker ED, Folsom AR: Intentional weight loss and incidence of obesity-related cancers: the Iowa Women's Health Study. Int J Obes Relat Metab Disord 27 (12): 1447-52, 2003.

Description of Evidence

Background

Incidence and mortality

Endometrial cancer is the most common invasive gynecologic cancer in U.S. women, with an estimated 47,130 new cases expected to occur in 2012.[1] This disease primarily affects postmenopausal women at an average age of 60 years at diagnosis.[2] In the United States, it is estimated that approximately 8,010 women will die of endometrial cancer in 2012.[1] Incidence rates of endometrial cancer have been increasing by an average of 1.1% per year from 2004 to 2008.[3] Death rates from cancer of the uterine corpus have been increasing by an average of 0.3% per year from 1998 to 2007.[3]

In the mid-1970s, the diagnosis of approximately 15,000 cases of postmenopausal endometrial cancers in excess of those expected on the basis of the underlying secular trend, has been related to the use of postmenopausal estrogen therapy.[4] Additional risk factors may be related to estrogenic effects, including obesity, a high-fat diet, polycystic ovarian syndrome, tamoxifen use and reproductive factors such as nulliparity, early menarche, and late menopause.

Women with hereditary nonpolyposis colorectal cancer (HNPCC) syndrome have a markedly increased risk of endometrial cancer compared with women in the general population. Among women who are HNPCC mutation carriers, the estimated cumulative incidence of endometrial cancer ranges from 20% to 60%.[5,6]

Compared with white Americans, endometrial cancer incidence is lower in Japanese Americans (relative risk [RR] = 0.6; 95% confidence interval [CI], 0.46–0.83) and in Latinas (RR = 0.63; 95% CI, 0.46–0.87), but not in African Americans (RR = 0.76; 95% CI, 0.53–1.08) or in native Hawaiians (RR = 0.92; 95% CI, 0.58–1.46).[7] Higher mortality from endometrial cancer in African Americans is at least partly attributable to lower socioeconomic issues that impair access to care.[8]

Factors that have been associated with a decreased incidence of endometrial cancer include parity, lactation, use of combined oral contraceptives, a diet low in fat and high in plant foods, and physical activity.

Interventions Associated With Decreased Risk

Oral contraceptives

Use of combination oral contraceptives (COC) for at least 1 year reduces endometrial cancer risk by approximately 40%, as demonstrated by case-control studies and prospective cohort studies.[9,10,11] This decrease in risk persists for at least 15 years after discontinuation of COCs. A meta-analysis of ten case-control studies and one prospective study found an association between risk reduction and duration of use. Overall, 4 years of COC use was associated with a risk reduction of approximately 56%; 8 years, 67%; and 12 years, 72%. The single-prospective study did not show a duration response, but the risk was reduced by 80% after 9 years of follow-up.[12]

A Swedish population-based case-control study confirms these findings. Women who used any type of oral contraceptive had a 30% risk reduction (odds ratio [OR] = 0.7; 95% CI, 0.5–0.9) and women who used progestin-only pills had a 60% risk reduction (OR = 0.4; 95% CI, 0.2–1.4). Women who used COCs for at least 3 years had a 50% risk reduction (OR = 0.5; 95% CI, 0.3–0.7) and those who used COCs for at least 10 years had an 80% risk reduction (OR = 0.2; 95% CI, 0.1–0.4). Overall, risk decreased by 10% per year of COC use and was observed for atypical hyperplasias as well as all grades of invasive tumors.[13]

Physical activity

Several cohort [14,15] and case-control [16,17,18,19,20,21,22,23,24] studies of physical activity and endometrial cancer reveal a weak to moderate inverse relationship, despite varying methods of assessing physical activity levels. For postmenopausal women enrolled in The Netherlands Cohort Study on Diet and Cancer, a 46% reduction (RR = 0.54; 95% CI, 0.34–0.85; P = .002) in risk of endometrial cancer was reported in those women who were physically active 90 minutes or more per day compared with less than 30 minutes each day.[25] One case-control study of 822 endometrial cancer cases and 1,111 population controls showed that regular exercise was associated with a 38% decrease in risk (OR = 0.62; 95% CI, 0.51–0.76) without a trend for increasing duration or intensity of physical activity.[26] The Breast Cancer Detection Project Follow-up Study, using a prospective cohort, did not confirm an association between recent physical activity levels and risk.[27] It is unknown whether physical activity reduces endometrial cancer risk by reducing obesity, by reducing serum estrone levels, or by another mechanism.[28]

Factors Associated With Decreased Risk

Increasing parity and lactation

Decreased risk of endometrial cancer is associated with parity and lactation, perhaps by inhibiting ovulation. A case-control study conducted in Mexico City, among low-risk women, indicates a 58% to 72% reduction in risk of endometrial cancer associated with increasing duration of lactation. A significant trend was seen for duration of lactation and for the number of children breastfed.[29] A population-based case-control study, comparing Wisconsin women who breastfed for at least 2 weeks versus those who did not, was negative (OR = 0.90; 95% CI, 0.72–1.13). Increasing duration of lactation was not associated with a decrease in disease risk, but breastfeeding within the past three decades was associated with reduced risk (OR = 0.58; 95% CI, 0.36–0.96), as was the first breastfeeding after age 30 years (95% CI, 0.28–0.90).[30] The European Prospective Investigation into Cancer and Nutrition observed a decreased risk associated with parity compared with nulliparous women (hazard ratio = 0.65; 95% CI, 0.54–0.77) with a trend of decreasing risk with increasing number of full-term pregnancies (P < .0001). While breastfeeding for more than 18 months was associated with a decreased risk, the association attenuated and was no longer statistically significant after adjusting for the numbers of full-term pregnancies.[31]

Factors Associated With Increased Risk

Endogenous estrogen

Reproductive factors resulting in increased duration of exposure to endogenous estrogen, such as early menarche, nulliparity, and late menopause, are associated with an increased risk of endometrial cancer. Other factors associated with increased risk, such as obesity and polycystic ovary syndrome, may also be related to increased estrogen exposure.

The first prospective investigation of endogenous estrogens and the risk of endometrial cancer was a case-control study nested within the New York University Women's Health Study.[32] Results suggest an increased risk of endometrial cancer associated with postmenopausal levels of endogenous hormones including estradiol, percent-free estradiol, and estrone. Conversely, risk was decreased with higher levels of percent sex hormone-binding globulin (SHBG)-bound estradiol and SHBG. Analyses conducted prior to adjustment for hormone levels indicated a positive association with body mass index (BMI). After adjustment for estrone level, the positive association of BMI with risk of endometrial cancer was attenuated, suggesting that hormone levels may be an intermediate effect of body weight.[33]

Exogenous estrogen

Postmenopausal hormone therapy (HT)

An association between estrogen replacement therapy and endometrial cancer was reported in 1975 [34] and confirmed soon after.[35,36] In these three studies, the overall risk ratio ranged from 4.5 to 8.0. Further studies documented an association with duration of use (10-fold to 30-fold with 5 years or more of use),[37,38,39,40] and a persistent effect lasting more than 10 years after 1 year's use.[41] When these findings were publicized, prescriptions for estrogen declined sharply, followed rapidly by a drop in endometrial cancer incidence.[42]

Combination estrogen-progestin replacement therapy

Postmenopausal estrogen was long recognized to be associated with the risk of adenomatous hyperplasia, often a precursor of endometrial cancer.[43] In addition, progestational agents were known to be effective in the treatment of uterine neoplasms.[44,45,46] Consequently, improved postmenopausal HT was proposed, combining estrogen and progestin, so as to avoid the endometrial cancer risk associated with unopposed estrogen.[47,48]

The Postmenopausal Estrogen Progestin Interventions Trial [49] enrolled nearly 600 participants in a 3-year multicenter, double-blind, placebo-controlled trial. Five arms consisted of placebo, daily conjugated equine estrogen (CEE), CEE with progestin (medroxyprogesterone acetate [MPA] for 12 days of a 28-day cycle), CEE with micronized progesterone (MP) for 12 days of a 28-day cycle, or CEE with daily MP. Endometrial biopsies were obtained at baseline, annually, and as clinically indicated. Women on CEE had more pathologic abnormalities than women on placebo (simple hyperplasia: 27.7% vs. 0.8%, adenomatous hyperplasia: 22.7% vs. 0.8%, and atypical hyperplasia: 11.8% vs. 0%, respectively), but women on CEE with progestin did not.

A prospective cohort study was conducted among Swedish women for whom HTs were prescribed. For women using medium-potency unopposed estrogens for 6 years or more, the RR of invasive endometrial cancer was 4.2 (95% CI, 2.5–8.4) while the risk for women using a progestin-combined treatment for the same length of time was unaffected (RR = 1.4; 95% CI, 0.6–3.3).[50]

Selective estrogen receptor modulators (SERM): Tamoxifen and raloxifene

Tamoxifen and raloxifene are SERMs, drugs that have divergent estrogen agonist and antagonist effects in different target organs. The association between endometrial cancer and tamoxifen was first recognized in 1985, when three cases of endometrial cancer were described in women who had been treated with tamoxifen for breast cancer.[51] Since then, confirmation of the association has been provided by randomized clinical trials using tamoxifen for breast cancer treatment and prevention [52,53,54,55] and by case-control, observational, and laboratory studies.

The National Surgical Adjuvant Breast and Bowel Project, Breast Cancer Prevention Trial P-1 Study in women at high risk of invasive breast cancer demonstrated that tamoxifen decreased breast cancer incidence by 49%, but confirmed an increased incidence of endometrial cancer. The annual rate was 2.3 per 1,000 for women receiving tamoxifen versus 0.91 for those on placebo. Women older than 50 years experienced the largest effect. Of the 51 invasive cancers diagnosed in this trial, 50 were stage I.[56]

Raloxifene is a second-generation SERM approved for prophylaxis against postmenopausal osteoporosis. Unlike tamoxifen, it does not have an estrogenic effect on the uterus. The Multiple Outcomes of Raloxifene randomized trial, after 40 months of follow-up, showed that raloxifene reduced the risk of estrogen receptor–positive breast cancer, without increasing endometrial cancer (RR = 0.8; 95% CI, 0.2–2.7).[57] A population-based study of 547 women with endometrial cancer and 1,410 controls was done in Philadelphia, Pennsylvania. Of the cases, 18 (3.3%) had taken raloxifene and 34 (6.2%) had taken tamoxifen (OR = 3.0; 95% CI, 1.3–6.9).[58]

Obesity

Elevated BMI and obesity are associated with an increased risk of endometrial cancer. One of the possible mechanisms for the observed association is an increased level of serum estrone in obese women as a result of aromatization of androstenedione in adipose tissue, which increases the production of estrogen.[59] Alternatively, obesity has been associated with a reduction in levels of SHBG, which may protect against endometrial cancer by decreasing bioavailable estrogen.[60] Obesity has been associated with several factors known to increase the risk of endometrial cancer, including upper-body or central adiposity, polycystic ovarian syndrome, physical inactivity, and a diet high in saturated fat.[61]

Presumably, body weight is a modifiable risk factor, which accounts for a substantial proportion of endometrial cases worldwide. A study conducted among European countries estimated that between 26% and 47% of endometrial cancer cases can be attributed to overweight and obesity. The same group conducted a meta-analysis of 12 studies (5 cohort and 7 case-control), which examined the relationship between obesity and endometrial cancer. Eleven of the 12 studies concluded that there is a positive association between endometrial cancer and excess weight.[62]

RRs associated with obesity range from 2 to 10. Some studies show that upper-body and central weight confer a higher risk than peripheral body weight, even after consideration of BMI.[63,64,65] However, other studies have failed to confirm such an association. Several studies have observed a stronger association between endometrial cancer and obesity near the time of diagnosis compared with obesity earlier in life.[66,67,68,69]

Increasing age

Endometrial cancer primarily affects postmenopausal women, with a median age at diagnosis of 60 years.[2]

Genetic predisposition

Women with inherited conditions such as Lynch syndrome, Cowden syndrome, and polycystic ovary syndrome have an increased risk of endometrial cancer. (Refer to the PDQ summaries on Genetics of Breast and Ovarian Cancer and Genetics of Colorectal Cancer for more information.)

Interventions of Unproven or Disproven Effect on Risk

Weight loss

While it is known that obesity is associated with increased endometrial cancer risk, only one study examines the potential benefit of intentional weight loss. In the Iowa Women's Health Study of 21,707 postmenopausal women [70], participants completed a self-report questionnaire, about intentional weight loss between ages 18 and 39 years, between ages 40 and 54 years, and after age 55 years. Multivariate models adjusting for age, BMI, and BMI² found no association between endometrial cancer incidence and intentional weight loss of at least 20 lbs (RR = 0.93; 95% CI, 0.60–1.44). The obvious limitation of this study is the reliance on retrospective self-reported data.[70]

Fruits, vegetables, and vitamins

The association between dietary factors, particularly fruit and vegetable intake, and endometrial cancer has been evaluated primarily in case-control studies. A systematic review of the evidence was undertaken as part of the World Cancer Research Fund's Food, Nutrition, Physical Activity and Cancer: A Global Perspective (2006) report. A pooled OR from ten case-control studies for high versus low vegetable intake was 0.71 (95% CI, 0.55–0.91).[71] This association was similar to that reported previously in a report for the International Agency for Research on Cancer,[72] which was based on results from five case-control studies. Neither report observed evidence of an association between fruit intake and endometrial cancer.

There is case-control evidence suggesting that regular consumption of soy products reduces the risk of endometrial cancer.[73,74]

A consortium of seven prospective cohort studies examined the association between serum vitamin D levels and the development of endometrial cancer. After controlling for BMI, there was no evidence of an association between circulating vitamin D and risk of endometrial cancer.[75]

Multivitamin use has little or no influence on the risk of common cancers, including endometrial cancer, or on total mortality in postmenopausal women.[76]

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Changes to This Summary (01 / 25 / 2012)

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Description of the Evidence

Updated statistics with estimated new cases and deaths for 2012 (cited American Cancer Society as reference 1).

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This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about endometrial cancer prevention. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

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National Cancer Institute: PDQ® Endometrial Cancer Prevention. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/prevention/endometrial/HealthProfessional. Accessed <MM/DD/YYYY>.

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Last Revised: 2012-01-25