Ultrasound pelvis

CT pelvis and

abdomen

Saline hysterography

Spinal and Chest X-ray

Full blood count

Pap smear ectocervix

Pap smear endocervix

Coagulation profile

Serum CA125

Renal function tests

Liver function tests

Blind endometrial

biopsy

Office hysteroscopy

TSH

Serum FSH

D&C uterus

None of the above

Ultrasound pelvis Rarely of much value because 75% of patients on Tamoxifen for >12m have abnormal endometrial echo

This is due to microcysticchange in the endometrium and proximal myometrium

However, 98% negative predictive value for Ca endometrium if the echo is < 5 mm

Ultrasound pelvis Rarely of much value because 75% of patients on Tamoxifen for >12m have abnormal endometrial echo

This is due to microcysticchange in the endometrium and proximal myometrium

However, 98% negative predictive value for Ca endometrium if the echo is < 5 mm

CT pelvis and

abdomen

Not unless you (or the patient or the radiologist)

are prepared to pay for it!

Rarely of much value because 75% of patients on Tamoxifen for >12m have abnormal endometrial echo

This is due to microcysticchange in the endometrium and proximal myometrium

However, 98% negative predictive value for Ca endometrium if the echo is < 5 mm

Saline hysterography Of some use in the evaluation of Tamoxifen-

affected endometrium

Of most use in the

delineation of polyps

Doppler flow in the stalk of

polyps also useful

Spinal and chest X-

ray

Only is there is some other reason to suspect breast

cancer secondaries

Full blood count Only if there has been substantial PV bleeding or

there is clinical evidence of

anaemia or blood

dyscrasia

Pap smear

ectocervix

Pap smear

endocervix

Should be done if not previously done or overdue

Because the

sqaumocolumnar junction

retreats into the cervical

canal postmenopause an

endocervical sample is

desirable

But this has poor diagnostic

value for endometrial

cancer

Coagulation profile No

Unless clinically indicated

for other reasons

Serum CA125 No

Unless clinically indicated

for other reasons

Renal function tests

Liver function tests

No

Unless clinically indicated

for other reasons

Blind endometrial

biopsy e.g. Pipelle

Tamoxifen is oestrogenic to the endometrium

And has a 0.2 – 4.0% risk of

causing endometrial

cancer

This is usually a diffuse

endometrial disease

And can be excluded with

>98% certainty by a blind

endometrial sampling

Outpatient

hysteroscopy

With or without directed biopsy is the procedure of

choice for this patient

Uterine D&C A 21st century gynaecologist would

favour ultrasound + Pipelle

sampling or office

hysteroscopy

TSH No

Unless clinically indicated

for other reasons

FSH No

No tests 5 – 10 % of patients with postmenopausal bleeding

have an endometrial

cancer

And this patient on

Tamoxifen is at increased

risk

She will not be happy if you

miss this, her second, brush

with cancer

Do nothing It is rare for the cervix to be “closed” when an

endometrial cancer is

present

If the endometrial echo

was <5 mm on ultrasound

this would be a reasonable

option

Uterine D&C with

general anaesthesia

A reasonable option to exclude endometrial

cancer

It is not 100% diagnostic

And re evaluation of the

patient is desirable if the

symptoms persist or

There are other grounds for

suspicion

Re attempt after:

Vagifem for 7 days

PV

Then 1000 ug

Misoprostol the night

before

A good option

Hysterectomy Unnecessarily aggressive

Unless there are other

grounds for suspicion