Transcript Office Gynaecology

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 Tamoxifenaffected endometrium

Of most use in the
delineation of polyps

Doppler flow in the stalk of
polyps also useful

Spinal and chest Xray

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