Uterine cancer predominantly endometrial carcinoma is among the most common gynecologic malignancies globally, particularly affecting women in mid-to-late adulthood. While developed nations have seen progress in early detection and declining mortality rates due to widespread screening and public education, many low- and middle-income countries, including India, continue to struggle with delayed diagnoses and suboptimal treatment outcomes. This is largely due to limited awareness, cultural taboos surrounding reproductive health and inadequate access to routine gynecologic care. Despite being treatable in its early stages, uterine cancer often goes undetected until it has progressed significantly, especially in settings where women are less likely to seek timely medical intervention for symptoms perceived as ‘normal’ or age-related [1-4]. 

In India, uterine cancer is slowly rising in prevalence, particularly in peri-urban and semi-rural regions where rapid lifestyle changes, obesity, diabetes and increasing life expectancy are converging to elevate risk. Symptoms such as abnormal vaginal bleeding, pelvic pain and postmenopausal discharge are often ignored or misattributed to hormonal changes or aging, thereby contributing to diagnostic delays. Furthermore, there exists a widespread misconception that gynecologic

cancers are limited to the cervix, leaving cancers of the uterus under-discussed and under-recognized. Compounding this issue is the lack of systematic screening programs specific to uterine cancer in India, where existing national initiatives often focus predominantly on cervical and breast cancers [5-8].

Shimla, the capital of Himachal Pradesh, offers a pertinent backdrop for evaluating uterine cancer awareness. With a mixed rural-urban population, varying education levels and constrained access to specialized gynecologic care especially in its hilly, remote areas Shimla typifies the barriers faced by many Indian women in semi-urban contexts. Socio-cultural inhibitions, low health literacy and limited reproductive health dialogue often discourage proactive health-seeking behavior. Women may delay reporting menstrual irregularities and even healthcare workers may prioritize other conditions over potential gynecologic malignancies due to low index of suspicion.

Given this context, the present study aims to assess awareness levels, perceptions and screening behaviors related to uterine cancer among adult women in Shimla. It seeks to examine how socio-demographic factors such as age, education, occupation and rural-urban residence influence knowledge and attitudes toward the disease. By identifying knowledge gaps and behavioral barriers, this research endeavors to inform the development of culturally sensitive, region-specific awareness programs and policy initiatives that promote early detection and improve health outcomes for women at risk of uterine cancer in underserved communities.

This study employed a descriptive, cross-sectional survey design to evaluate the level of awareness, knowledge and screening practices related to uterine cancer among adult women residing in Shimla, Himachal Pradesh. The primary aim was to assess understanding of uterine cancer symptoms, risk factors, preventive measures and existing screening behaviors, while exploring socio-demographic determinants that influence women’s health-seeking attitudes and practices. 

Study Area and Target Population

The study was conducted in Shimla, a hilly district in northern India characterized by its geographically diverse terrain, comprising both urban centers and remote rural settlements. Given its unique demographic structure and healthcare accessibility challenges, Shimla provided an ideal setting for assessing regional disparities in women’s gynecologic health awareness. The target population included women aged 18 years and above who were permanent residents of Shimla district, representing a wide spectrum of age groups, education levels, occupational backgrounds and socioeconomic strata

Study Duration

Data collection was carried out over a three-month period, from January to March 2025. This timeframe allowed for broad participant recruitment across seasons and ensured consistent access to both urban and rural populations despite the challenges of winter travel in high-altitude zones.

Sample Size and Sampling Technique

A total of 400 female participants were included in the study. The sample size was determined using a 95% confidence level, 5% margin of error and an estimated 50% prevalence of uterine cancer awareness in the absence of localized baseline data. Convenience sampling was employed to recruit participants from outpatient departments of government hospitals, women’s wellness camps, community centers, educational institutions and through digital platforms such as WhatsApp groups and local women’s forums.

Inclusion Criteria

• Women aged 18 years and above

• Permanent residents of Shimla district

• Able to comprehend and respond in Hindi or English

• Provided informed consent to participate in the study

Exclusion Criteria

• Women with a prior diagnosis of uterine cancer

• Respondents with incomplete or inconsistent questionnaire responses

• Participants who declined or withdrew consent

Research Instrument

Data were collected using a structured, bilingual (Hindi and English) questionnaire developed in consultation with gynecologists, oncologists and public health experts. The questionnaire was pilot-tested on a sample of 25 participants to ensure clarity, cultural sensitivity and relevance. It comprised three key sections:

Socio-Demographic Profile – age, marital status, education, occupation, income bracket and residential setting (urban/rural). 

Knowledge and Awareness Assessment

Only 20 multiple-choice questions designed to gauge participants’ understanding of uterine cancer risk factors (e.g., obesity, hormone therapy, late menopause), symptoms (e.g., abnormal bleeding, pelvic pain) and preventive/screening measures (e.g., pelvic exams, ultrasounds, Pap smears).

Attitudes and Practices

Questions exploring perceptions of personal risk, cultural beliefs, openness to gynecological exams and past experiences with screening or consultations for reproductive health concerns.

Scoring and Awareness Categorization

Each correct response in the knowledge section was awarded one point. Based on the cumulative score, respondents were categorized into four levels of awareness:

• Very Good Knowledge (≥80%)

• Good Knowledge (60–79%)

• Fair Knowledge (41–59%) Poor Knowledge (<40%)

• This classification facilitated comparative analysis across socio-demographic subgroups and enabled targeted interpretation of knowledge disparities.

Data Collection Procedure

Online surveys were shared via Google Forms, women’s groups on social media and educational institution networks. A brief overview of the study’s objectives and confidentiality assurances was provided before administering the questionnaire. Written or digital informed consent was obtained from all participants.

Data Analysis

All responses were anonymized, coded and entered into Microsoft Excel and analyzed using SPSS (Version 25.0). Descriptive statistics (frequencies, means and percentages) were used to summarize participant characteristics and knowledge levels. 

Ethical Considerations

The study was conducted in accordance with ethical standards for research involving human subjects. Participation was voluntary and participants were informed of their right to withdraw at any time without penalty. No identifying information was collected and data confidentiality was strictly maintained throughout the study.

Table 1 provides a comprehensive overview of the demographic profile of the 400 female participants included in the study. The age distribution skewed towards younger and middle-aged women, with 34.0% aged between 26–35 years and 27.0% in the 18–25 category, followed by 25.0% in the 36–45 bracket and 14.0% aged 46 and above. Educational attainment varied across the sample, with the highest proportion (27.0%) having undergraduate degrees, followed closely by those with secondary education (24.0%) and primary schooling (18.0%), while 17.0% reported having no formal education. Occupational representation was diverse, with homemakers comprising the largest group at 26.0%, followed by office workers and students (20.0% each), teachers (18.0%), healthcare professionals (9.0%) and other professions (7.0%). A significant majority 62.0% of participants were from rural settings, while 38.0% were urban residents. This demographic spread allowed for a balanced analysis of how age, education, occupation and residence influenced awareness and screening behavior related to uterine cancer.

Table 2 illustrates participants' responses to 20 knowledge-based questions designed to assess their understanding of uterine cancer and its screening. Awareness of basic definitions and primary symptoms was relatively high 68.0% correctly identified uterine cancer as a malignancy of the uterus and 70.0% recognized abnormal bleeding as a key symptom. Similarly, a solid proportion of women (66.0%) acknowledged obesity as a risk factor, while 65.0% understood the role of hormone therapy in increasing risk. Knowledge of diagnostic and treatment modalities showed moderate strength, with 68.0% familiar with endometrial biopsy and 67.0% aware that surgery is the typical treatment for early-stage cases. However, only 61.0% recognized that uterine cancer can be asymptomatic in its early stages and a mere 48.0% were aware of recurrence potential highlighting critical knowledge gaps. Awareness of screening tools such as transvaginal ultrasound (62.0%) and the role of early detection (63.0%) was promising but still leaves room for improvement. These findings underscore a need for more targeted education, especially regarding early and silent symptoms, recurrence and the value of regular screening.

Table 3 categorizes respondents based on their total knowledge scores, offering a summarized perspective on overall awareness levels. Of the 400 participants, 22.0% demonstrated “Very Good Knowledge” by answering 80% or more of the questions correctly, while the largest segment 34.0% fell under the “Good Knowledge” category (60–79% correct responses), reflecting a reasonably sound foundational understanding of uterine cancer and its screening practices. However, a substantial 33.0% were categorized as having “Fair Knowledge” (41–59%) and an additional 11.0% showed “Poor Knowledge” with less than 40% correct answers. These results signal that while nearly one in five women are well-informed, a concerning proportion either lacks adequate awareness or holds fragmented knowledge. This disparity further reinforces the need for community-based, accessible health literacy programs particularly in rural areas and among women with limited formal education to bridge these gaps and empower early detection and preventive care practices.

This study provides a timely and revealing snapshot of public awareness and screening practices regarding uterine cancer among women in Shimla a region emblematic of the broader socio-cultural and infrastructural challenges faced by women in semi-urban and rural India. With uterine cancer emerging as a growing gynecological concern amidst shifting lifestyle patterns, increased life expectancy and rising comorbidities such as obesity and diabetes, the findings of this study underscore both encouraging trends and areas requiring immediate attention.

The socio-demographic distribution of participants was notably balanced and reflective of Shimla’s diverse population. The predominance of younger and middle-aged women (61% under the age of 35) suggests an opportunity to leverage early adulthood as a window for health education and preventive care messaging. Furthermore, the participation of women across all educational levels and occupational categories including homemakers, office workers, teachers, students and healthcare professionals enriched the representativeness of the sample and allowed for nuanced insights into how

Table 1: Socio-Demographic Characteristics of Participants (Shimla)

Table 2: Public Knowledge and Awareness of Uterine Cancer and Its Screening

Table 3: Knowledge Score Classification on Uterine Cancer and Its Screening

knowledge levels vary across demographic lines. The rural-urban divide was especially significant, with 62% of respondents hailing from rural areas, reinforcing the need to bridge geographic gaps in access to information and gynecologic services.

In terms of knowledge and awareness, the findings reveal a mixed pattern. While a commendable 70% of participants could correctly identify abnormal uterine bleeding as a symptom and 68% understood the definition of uterine cancer, awareness of more nuanced or less visible aspects of the disease was notably weaker. Only 61% recognized that uterine cancer can be asymptomatic in early stages and a concerningly low 48% were aware of the potential for recurrence following treatment. These gaps are particularly critical, as asymptomatic onset and delayed follow-up care are major contributors to late-stage diagnoses and poor prognoses. Similarly, only moderate awareness was observed regarding the diagnostic value of transvaginal ultrasound (62%) and the influence of early detection on survival (63%), indicating the need for broader education about screening pathways beyond routine gynecologic exams.

The knowledge score classification further underscores these disparities. Although 22% of women demonstrated “Very Good Knowledge” and 34% fell into the “Good” category collectively forming a majority with relatively sound understanding one-third (33%) were classified under “Fair Knowledge,” and 11% showed “Poor Knowledge.” This means that nearly half of the study population is inadequately informed or misinformed about uterine cancer and its detection, a particularly troubling finding considering the disease’s treatability when identified early. These deficits likely correlate with lower education levels, rural residency and the lack of formalized uterine cancer screening campaigns within India’s current public health framework, which tends to focus more heavily on cervical and breast cancers.

Cultural stigma and societal silence around reproductive health emerge as key underlying barriers. In many parts of India, menstrual irregularities and gynecological symptoms are normalized or dismissed, especially by older women who attribute them to aging or “natural hormonal changes.” Such perceptions are often internalized due to long-standing taboos around discussing reproductive organs or undergoing pelvic examinations, which are still seen as invasive or shameful by some. These attitudes may deter women from seeking timely care or even acknowledging symptoms, exacerbating delays in diagnosis and treatment. Additionally, healthcare providers themselves may deprioritize uterine symptoms if they are not part of structured screening programs, further contributing to the cycle of under-recognition [9-11].

The study’s findings also highlight a need to better equip women with knowledge about non-traditional risk factors. While awareness about obesity (66%) and diabetes (64%) was encouraging, knowledge about the role of hormone therapy (65%) and the protective effects of early menopause (only 65% correct responses) requires further strengthening. These insights are crucial in light of changing reproductive trends, such as delayed childbirth and increased use of hormonal interventions, which are becoming more common in peri-urban areas like Shimla.

From a public health perspective, this study strongly advocates for the development of targeted, community-sensitive interventions aimed at raising awareness of uterine cancer, particularly among women in rural and underserved areas. Awareness campaigns should not only focus on symptoms and risk factors but also emphasize the value of routine gynecological checkups, demystify diagnostic tools like endometrial biopsy and ultrasound and challenge cultural taboos through trusted female health workers, local leaders and peer educators. School- and college-based reproductive health education programs can also play a crucial role in shaping informed attitudes early in life.

Importantly, uterine cancer awareness should be integrated into existing national frameworks such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) and reproductive health outreach under the National Health Mission. ASHA workers, ANMs and midwives who serve as primary health contacts in rural India must be trained not just to screen for cervical cancer via Pap smears but also to identify early uterine cancer symptoms and counsel women on the importance of reporting them. Simultaneously, efforts should be made to strengthen referral pathways and ensure timely access to gynecologic specialists for further evaluation and care.

The findings of this study illuminate both encouraging progress and significant gaps in uterine cancer awareness among women in Shimla, particularly in the context of evolving health risks and persistent socio-cultural barriers. While a fair proportion of participants demonstrated moderate to good knowledge of key symptoms, risk factors and treatment pathways, nearly half remained inadequately informed especially about asymptomatic onset, recurrence and the importance of early detection through regular screening. This disparity was more pronounced among rural residents and women with limited formal education, underscoring the urgent need for community-driven, culturally sensitive health education interventions. Addressing entrenched stigma around reproductive health, enhancing access to gynecologic care and expanding the role of frontline health workers in uterine cancer awareness initiatives are essential steps toward improving early diagnosis and reducing mortality. Ultimately, integrating uterine cancer literacy into broader public health programs can empower women in underserved regions like Shimla to take proactive control of their reproductive health, paving the way for timely intervention and improved outcomes.

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