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essay 363

essay 363 Posted by Shradha G.

Dear Paul,

I am not able to see marking of my essay 363.Your last post is of 26Feb,but in the essay only till 25 th Feb are visible.plz help.

Posted by PAUL A.

Your answer was marked in the order in which it was posted.

Posted by PAUL A.


Sorry, we did miss your answer and we have found it.



Post menopausal bleeding is associated with a 10% risk of endometrial carcinoma therefore I will tailor the history toward risk assessment. Symptoms of weight loss and anorexia are seen in malignancies (1) . A history of diabetes mellitus and hypertension are associated with endometrial carcinoma. Nulliparity, early menarche, late menopause and a prior history of polycystic ovarian syndrome are associated with endometrial carcinoma (1).  A family or personal history of breast, ovarian or colonic cancer is associated with the Lynch 2 syndrome (familial cancer). Use of tamoxifen, unopposed estrogen or sequential hormone replacement therapy (1) or phytoestrogens predispose to endometrial hyperplasia and carcinoma. A history of her cervical smears (1) would assess her risk of cervical cancer. Post coital bleeding suggests a cervical cause. Vaginal dryness suggests atrophic vaginitis. Vulval itching and soreness suggests a vulval cause(1). Surgical, anaesthetic and VTE risk assessment should also be done.

On examination measure her blood pressure and calculate her BMI (1). Palpate for supraclavicular and inguinal lymphadenopathy. Perform an abdominal examination for abdominal masses and ascites (1). Inspect vulva for ulcers. Perform a speculum vaginal examination. Cervical abnormalities or contact bleeding warrants colposcopy. Note vaginal epithelial atrophy. Perform a bimanual palpation for pelvic masses (1). Bleeding from the urethra or rectum may be mistaken for vaginal bleeding. Examine the urethra for local causes like a urethrocele. Perform a rectal examination to palpate possible pelvic metastases and diagnose rectal causes of bleeding like a rectal tumor.



Treatment will follow a multi-disciplinary team approach consisting of a gynaecological oncologist, anaesthesist, radiologist, pathologist, oncology nurses, psychiatrist and her general practitioner. Treatment depends on the stage of disease. Stage 1a requires a Total Abdominal Hysterectomy and Bi-Salpingo Oophrectomy (TAH/BSO) (1). Stage 1b requires a TAH/BSO with pelvic and para-aortic node sampling followed by adjuvant brachytherapy (1). Brachytherapy reduces the incidence of pelvic recurrence. Stage 2 disease requires a TAH/BSO with pelvic and para-aortic lymph node sampling and adjuvant radiotherapy(1). Bulky tumors may require neo-adjuvant radiotherapy prior to TAH/BSO and pelvic-para aortic lymph node sampling (1). Selected cases will benefit from a radical hysterectomy and pelvic lymphadenectomy (1). Stage 3 disease requires TAH/BSO and adjuvant radiotherapy (1). Disease spread to the pelvic side walls precludes primary surgery and is treated with intra-cavitary and external beam radiotherapy. Chemotherapy using doxorubicin and cis-platin with paclitaxel and granulocyte colony stimulating factor offers some benefit. Patients not suitable for surgery or radiotherapy may be offered progestogens (hydrodxyprogesterone, medroxyprogesterone or megestrol) (1). Stage 4 disease requires intracavitary and external beam therapy (1) for pelvic disease and progetogens for distant metastases. Discuss morbidity associated with radiotherapy. These include acute effects like vomiting, diarrhea and haematuria which may cause discontinuation of therapy. Late effects include rectal bleeding and fistulation. Morbidity of radiotherapy is increased with lymph node dissection (1). Ensure adequate analgesia adopting the WHO 3 step ladder. Offer psychiatric consult and discuss end of life care if appropriate.