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 microcystic change 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!

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