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MRCOG PART 2 SBAs and EMQs

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MRCOG PART II ESSAY 372. PMB

answer to essay 372 Posted by lakshmi priya S.

(a) Majority of the patients with post menopausal bleeding are associated with benign pathology but needs careful assessment to rule ont genital tract malignancy. I'll take a detailed history amount the nature and amount of bleeding and precipitating factors like post coital bleeding which is highly suggestive of malignancy. Any associated abdominal pain,vaginal or vulval soreness and dyspareunia. I'll ask about the menstrual history-age of menarche,cycle length and regularity,age of menopause and also about parity as anovulation and nulliparity are associated with risk of endometrial carcinoma. Any past history of breast cancer and intake of drugs like tamoxifen. Medical conditions like diabetes and hypertension-risk factors for endometrial cancer. Recent cervical smear and its findings.History of intake of HRT and compliance. Any history of haematuria or rectal bleeding and anorexia, change in bowel habit and loss of weight.

On examining the patient i'll check the BP and BMI. I'll check for any abdominal mass or tenderness. By speculum examination i'll look for vaginal or vulval dryness, state of cervix, any mass or polyp, foul smelling discharge or bleeding, any contact bleeding. I'll do a Bimanual examination and see for size of uterus, any adnexal mass. If suspicious of malignancy i'll do a rectal examination also.

Investigations-FBC,U & E, LFT to know the general condition of patient.if cervical smear is due i'l do it and if its abnormal or any history of post coital bleeding i'll refer for colposcopy. I'll do a trans vaginal ultrasound to look for any polyp, fibroid and also endometrial thickness (sensitivity low to pick up malignancy). I'll do a hysteroscopy +/- biopsy.this has good sensitivity to identify an endometrial pathology. Further investigations are based on examination and pathology report.

(b) The diagnosis of endometrial adenocarcinoma is associated with emotional distress and the findings should be explained in a very sensitive manner. The report is disclosed to the woman in person. Counselling is done involving the oncologist, oncology specialist nurse and gynaecologist. I'll explain that its a cancer arising from the womb and it may spread and involve adjacent structures like urinary bladder and bowel and distant structures like liver, lungs etc. I'll explain the need for undergoing additional investigations like MRI/ CT, chest x ray to stage the disease. Hormonal status of the tumour should be assessed. After assessing the stage of the disease i'll counsel about the treatment options available and also about the prognosis.

I'll explain her the advantages and risks of undergoing surgical treatment and radiotherapy treatment. Stage 1 a cancers may need only simple hysterectomy and bilateral salpingo oopherectomy( removal of uterus and ovaries) and associated with good prognosis. stage 2 and 3 cancers need surgical removal of uterus and ovaries and lymph node dissection along with post operative radiotherapy for the better survival and also to prevent recurrence. Hormone positive tumours will respond to progesterone treatment. Surgery  will be associated with injury to bowel, bladder and ureters and thromboembolism. I'll explain her of the importance of compliance with the therapy. Will provide her written infiormation. Will give her follow up appointment and will also provide hospital contact details and contact numbers of the support groups.

 

ans 272 Posted by Sailaja C.

 

A 64 year old woman has been referred to the rapid access clinic with a 3 months history of blood-stained vaginal discharge. (a) Discuss your assessment [10 marks]. (b) She is found to have an endometrial adenocarcinoma. How would you counsel her? [10 marks].

 

I would enquire about the nature of the bleeding and its effect on her quality of life. I would ask her if the bleeding is after sexual intercourse as post coital bleeding suggests cervical pathology or atrophy. I would ask her about the previous menstrual periods including the age of menarche and last menstrual bleed as early menarche and late menopause are risk factors for endometrial cancer. 

I would ask her about recent cervical smear. History is taken if she is having menopausal symptoms like dryness of vagina which indicates atrophy.  I would ask her if she is taking HRT ( unopposed or sequential combined) or photo- oestrogen as they predispose to endometrial cancer. I would ask if she is diabetic or hypertensive as both the conditions are associated with the risk of endometrial cancer. I would as if she is having breast cancer as women with breast cancer have 2-3 fold increased risk of developing endometrial cancer. I would enquire if she is on Tamoxifen therapy which is associated with endometrial hyperplasia. While taking history I would try to exclude rectal and urethral bleeding as some women may misinterpret as vaginal bleeding. 

I would like know if there is any weight loss, change in bowel habit and anorexia as these features are indicative of malignancy. 

Examination includes recording of blood pressure and BMI as hypertension and obesity are risk factors for endometrial cancer. General examination is performed to assess surgical and anaesthetic fitness which consists of assessment of pallor, auscultation of chest and heart sounds. Abdominal examination is performed to detect palpable abdominal mass. Local examination is done to exclude  vulval and vaginal tumours or ulcer and atrophy.  Speculum examination is essential to identify cervical polyps, cervicitis, or carcinoma. Bimanual pelvic examination done to exclude abdomino- pelvic mass.

Cervical smear is taken if not taken before. Colposcopy is arranged in case of post coital bleeding and cervix is abnormal. Trans vaginal scan is performed to measure the endometrial thickness and more than 5 mm is abnormal. Sensitivity of 80-100% but has high false positive rate. TVS scan is helpful in identifying ovarian pathology as well. Out patient endometrial aspiration biopsy is beneficial in detecting endometrial carcinoma with sensitivity of 68-98%. It avoids complications associated with general anaesthesia and D&C but sampling cannot be done in 20% of the cases. Outpatient hysterscopy has similar efficacy as rigid hysteroscope under GA and is highly acceptable to the patient but polyps cannot be removed. Hysteroscopy with D&C is considered gold Standard for detecting endometrial carcinoma but associated with risk of perforation and haemorrhage. 

 

 

(b) She is found to have an endometrial adenocarcinoma. How would you counsel her? [10 marks].

 

As the diagnosis of endometrial adenocarcinoma creates considerable distress, the approach should be sensitive and supportive. counselling should be undertaken by multidisciplinary team consisting of gynaecological oncologist, nurse specialist and person experienced counsellor.  Counselling is preferably done in the presence of a relative. The diagnosis is explained that dancer is arising from the womb. She should be informed about the overall 5 year survival rate of endometrial cancer is about 73%. Prognosis depends upon the extent of the cancer is detected by performing further investigations like MRI. 

Explanation should be given about the treatment  for endometrial carcinoma is dependent upon the extent of the disease that is staging. Staging of endometrial cancer is explained with the help of diagrams and treatment options would be explained according to stage. 

The primary surgical management includes removal of the uterus and both the ovaries . Lymphnodes will be removed if the cancer is extended beyond st I a. The surgery can be undertaken through key hole surgery which is associated with short recovery and less haemorrhage with inherent risk of visceral injury. 

 

The treatment can be surgical only for Stage I a. Radiotherapy is required for the later satges. She should be informed that radiotherapy could be given before or after surgery. If the cancer is inoperable , the primary treatment would be radiotherapy or chemotherapy. If surgery or radiotherapy is not possible she may be treated with progestogens. 

 

The follow up plan consists of general examination , speculum and pelvic examination to identify recurrence which should be done every 3 to 6 months for the first 3 years and semi annually for next 2 years.

Important telephone numbers and written information  are provided.

Posted by Ana B.

 

 

History would include the nature of the bleeding and precipitating factors such as postcoital bleeding may suggest cervical pathology or vaginal atrophy, vaginal discharge may suggest infection. The menstrual history, for example,  late menopause or early menarche are recognized risk factors for endometrial cancer. Also polycystic ovaries syndrome, nulliparity, HRT, especially sequential combined, any unopposed estrogen therapy, hypertension, obesity, diabetes mellitus would increase suspicion for the endometrial cancer. The history of breast cancer; and well known that tamoxifen therapy increases the risk up to 3 fold.

It is important to ascertain the cervical smear history, weight loss and exclude urethral and rectal bleeding.

Examination would aim to exclude abdominal or pelvic masses, presence of ascites, genital tract atrophy, ulcerations, any cervical polyps, signs of infection.

Investigations are cervical smear if not up to date, colposcopy if necessary.

Aslo performing a transvaginal scan to identify any pelvic pathology, masses and measure the endometrial thickness. There are different cut offs  for endometrial thickness have been suggested: 3, 4 and 5 mm to increase suspicion for the cancer and decide on further investigations.

Endometrial thickness measurement has a good sensitivity but high false positive rate for endometrial cancer.

Outpatient hysteroscopy allows visualization of endometrial cavity, and taking a pipelle sample, it is cost effective at the same time. However if any polyps identified inpatient hysteroscopy and D&C would be better option with higher sensitivity;and to be considered a gold standard if endometrial cancer is suspected. Sonohysteroscopy is still not widely available but may give more information in comparison with TVS.

MRI and CT would be considered if more information required on the spread of the endometrial cancer.

2) Diagnosis of endometrial carcinoma would suggest an urgent referral to specialist tertiary centre for further management by multidisciplinary team.

The patient should be told the news in a very sensitive manner; time should be allowed for the consultation as it is breaking bad news. Desirably if someone close to the woman  could be with her during the counseling.

The prognosis would depend on the stage and histological type the cancer. Good prognosis if it is early stage of disease or well differentiated type.

Baseline tests should be arranged such as bloods and MRI while she is waiting for the appointment in tertiary center. Worth mentioning if she asks on the general management of the endometrial cancer the possibility of surgery, possibility radiotherapy as adjuvant, palliative care in advance disease and long term follow up. All of this will be decided by gynecological oncologists in conjoint decision with radiologists, histopathologists etc. and also specialist nurses.  Woman should be given the opportunity to ask questions and given the contact telephone number if any further questions arise

PMB Posted by Ghida R.

A 64 year old woman has been referred to the rapid access clinic with a 3 months history of blood-stained vaginal discharge. (a) Discuss your assessment [10 marks]. (b) She is found to have an endometrial adenocarcinoma. How would you counsel her? [10 marks].

Occurence of post menopausal bleeding is associated in 10-15% with endometrial adenocarcinoma. Bleeding from vulval or cervical neoplasia is among the differential diagnosis of postmenopausal bleeding and only be detected by clinical examination thus assessment should be undertaken to exclude the risk of malignancy. this is done by searching for the associated risk factors for endometrial cancer e.g time since menopause, whether the patient received HRT, and if so, whether she received progesterone or has omitted taking it, as this will lead to unopposed estrogen effect on the endometrium with resultant hyperplasia. Anovulation and low parity are also among risk factors for endometrial hyperplasia. I will also check for medical problems like hypertension, diabetes as these are associated with endometrial malignancy, and whether she has any liver disease which might lead to coagulation defect. I will check for her medication intake whether she received anticoagulation and thus is prone for vaginal bleeding , or if she is on tamoxifen which has positive estrogenic effect on endometrium and is associated with 3 to 6 fold increase in risk of endometrial cancer. I will check whether she is uptodate with her pap smears and whether she has had any abnormal smears in the past 10 yrs period. I will enquire about her family history of malignancies: colon, ovary, gastrointestinal as it might point out to a genetic predisposition as in HNPCC hereditary non polyposis colorectal cancer which is associated with higher risk of endometrial cancer. I will also check for Sexually transmitted infection by checking if she has recent change in partner or multiple sexual partners, painful intercourse as chlamydial infection might be the source to her bleedings.

Physical exam will include checking her BMI as obesity is associated with increased levels of circulating estrogens and their subsequent stimulatory effect on endometrium. Her blood pressure should be checked for hypertension. Abdominal exam is done to check for any masses. Pelvic exam is done by inspection for signs of vaginal atrophy, any lumps, reddness over the vulva to check for vulval neoplasia. speculum exam to check for any local causes of bleeding e.g trauma, cervical polyps, cervical masses.Also a bimanual exam will help detect any adnexal masses as there are some tumours associated with estrogen secretion as in granulosa cell tumours.

Blood test are sent to detect if there is anemia, high glucose level,  liver disturbances or bleeding tendencies. Pap smear can be taken if it is due or with suspicious looking cervix. 

Transvaginal ultrasonography is offered to detect any thickening in endometrial lining, as in menopause the endometrium should be thin <4mm and any thickness >4 mm might denote a pathology and thus requires endometrial sampling.

Endometrial sampling can be done using a pipelle which is an office based procedure and has high sensitivity to detect malignant changes.

Alternatively patient could be referred a hysteroscopy and endometrial sampling especially if inadequate amount of tissues was obtained by pipelle. Hysteroscopy is done as an outcase procedure under local anesthesia. If this was unsuccessful then it should be done as an inpatient procedure under adequate anesthesia.

 

B- the delivery of the results to the patient should be done face to face and never over the phone. I will ensure to allocate enough time to explain the results and to counsel the patient about subsequent management. The patient should preferably be accompanied by her partner or any close family member in order to support her. I will start by explaining that we were awaiting for the results of endometrial biopsy in order to detect whether there was any cancer cells. I will tell her that the results came back and that they are not good. Then I will tell her that the biopsy confirmed presence of cancer cells. I will then pause to allow the patient time to assimilate the news and to react. I will explain that this disease is usually detected in the womb at early stages thus allowing for cure. I will explain the staging of the disease which is to detect the spread of the disease outside of the womb, to lymph node and other pelvic organs, and that this is done through surgery to remove the womb and to sample lymph node and fluids from the pelvis. I will explain that these are usually done by a cancer specialist called gynaecologic oncologist in a specialised unit. There might be a need for a further treatment after surgery either by radiation or by medications and this will be determined by the oncologist after the results of pathology from the surgery. She will be cared by a team: surgeon, a cancer specialist, Mcmillan nurse.  I will be attentive to her concerns and if she prefers to have another meeting I will arrange for meeting with the team. I will offer a pamphlet about endometrial cancer along with phone number for support groups.

ASB-ASB Posted by ASB A.

(A) assessment 

Menstrual history should be obtained including age of menarche and age of menopause and asking whether her previous cycles were regular . Late menopause is a risk factor for endometrial cancer .Irregular cycles may be an indication of anovulatory cycles e.g polycystic ovarian syndrome which is a risk factor for endometrial cancer . Associated symptoms such as gastrointestinal symptoms ( e.g abdominal pain , bloating ) and postcoital bleeding should be asked about . obstetric history should be considered . Nulliparity is associated with increased risk of endometrial cancer . medical diseases such as diabetes and hypertension should be considered .Liver cirrhosis is a risk factor for endometrial malignancy . drug history should be obtained particularly for oestrogen only hormone replacement therapy and tamoxifen as they are risk factors for endometrial cancer .family history of breast , ovarian or colon cancer may be associated with increased risk of endometrial cancer .ask about previous cervical smears and their results . 

Examination should include measurement of blood pressure and calculation of body mass index (BMI) . General examination should include palpation of supraclavucular lymphnodes . Abdominal examination for abdominal masses . Inspection of the vulva for any suspicious lesions . speculum examination for cervical assessment . bimanual examination for adenexal massess , tenderness or cervical excitation .

(B) counselling 

counselling should include explanation of the diagnosis . there is malignancy of the lining of the uterine cavity . treatment should be discussed and the patient informed that removal of the uterus and both ovaries and adenexae are required through and abdominal incision ( laparotomy ) or laparoscopically . decision regarding postoperative adjuvant therapy will depend on the final stage of the disesae as well as the number of risk factors present ( e.g grade of the tumor , presence of lymphovascular space invasion ) . prognosis is generally good with early stage disease . after treatment , the patient is advised to have regular follow up for early detection of disease recurrence 

ans to essay 372 Posted by khalid M.

A] As most cases of pmb is due to bening pathology.  take a detail history.  History about blood stained discharge, duration , amount and associated factors such as itching , any foul smelling .  How it is affecting quality of life .  Menstrual history such as attainment of menopause, previous menstrual cycle, regularity, flow .  Obstretic history such as parity, last child birth, mode of delivery.  Sexual history, Is she still sexually active, any post coital bleeding.  Contraception history , any previous contraception in the form of  combined hormonal pills  as progesterone may protect the endometrium .  Cervical smear history , when was the last smear done and what are the results.  Medical history , any history of chronic diseases such as hypertension, diabetes mellitus.  Drug history such as use of HRT for menopausal symptoms  , either continious  or sequential,  or use of tamoxifene as this causes endometrial hyperplasia .  any previous history of breast cancer .  History of smoking, alcohol   and use of any recreational drugs.  History of weight loss , anorexia, bowel or bladder dysfuntion due to malignancy.

Examination  Temperature, pulse, BP, BMI

Per abdomen  Any palpable masses

Per speculum  Cervical status, any erosion , growth , cervical polyp, any vaginal growth.

Per vaginal examination  size of uterus, adnexal masses

Investigations  Blood - FBC, LFT, RFT, Blood glucose.

Urine for microscopy, culture and sensitivity.

TVS  for endometrial  thickness if  >5 mm , but this cannot detect endomerial growth such as polyp.

Out patient endometrial biopsy with vibra and pipelle capillary tube. this method might miss the malignant pathology.

out patient hysteroscopy and endometial biopsy . this is day case procedure  and gold standard method for endometrial pathology , easily acceptable by many women . no risk of GA . cost effective  but this method cannot remove polyps .

In patient hysteroscopy under GA and endometrial biopsy . and polypectomy can be done simultaneously

MRI to see extent of disease and lymphnode involvement.

Chest x-ray in case of metastasis and abdominal ultrasound for secondaries.

B] This is a very sensitive issue.   Approach towards her in a very emperical way .  Tell her the diagnosis in simple language that her lining of her womb is having carcinomatous  changes.  she needs treatment to prevent further spread  . the severity of the disease depends on the histological grading . 5 year survival depends on the stage of the disease .  Treatment should be by multidisciplinary approach involving gynecologist oncologist, anaesthetist, psychiatrist ,gp and specialist nurse .   in early stage and well differentiated    early treatment has a good prognosis.   Treatment depends on the stage of the disease, in early stage such as stage 1a surgery in the form of  TAH and BSO is done . It  can be done  either laproscopic or by  laparotomy.   in more advanced stage if lymphnodes are involved .  along with the above surgery we have to do selective lymphnode sampling  and post operative radiotherapy is needed  . Explain the risk and benefits of radiotherapy .  it may prevent the disease progression but has bowel and bladder compromise due to radiation effect .  In stage 2 disease  we may need pre operative radiotherapy in the form of intracavity and external beam radiotherapy ,  to debulk the tumour before surgery  . In more advanced stage chemotherapy in the form of cisplatin , doxorubicin with or without granulocyte stimulating factor is needed . In case of distant metastasis high dose progestrogens such as Medroxyprogesterone acetate is given . in this case the disease can still progress so regular follow up is needed .  Take the womens wishes into consideration .  Provide her information leaflet and contact Number of the support groups.  give her further appointment in case she wants to discuss more issues.

Ans essay 372,PMB Posted by Reena G.

a)This is a case of PMB so need to exclude benign and malignant cause. I will take her detailed history and will ask about her bleeding ,amount  and its impact on her life. Her LMP, cycles, regularity . Early menarche, late menopause and nulliparity will indicate about risk factors of endometrial carcinoma. Any  precipitating factors of bleeding like post coital bleeding , vaginal dryness, dyspareunia (indicate vaginal atrophy), vaginal discharge (indicate vaginal infection) to be asked. Any history of drug intake like HRT and tamoxifen  which predisposes to endometrial hyperplasia, any history of familial malignancy (breast, ovarian and colon) which increases her risk of cancer and any decrease in appetite and weight loss may point towards malignancy , any  bowel or urinary and chest complaint may indicate metastasis .medical co morbidities like diabetes and hypertension to be asked as it is associated with endometrial cancer. History  of last cervical smear  to be asked.

In examination  , her BMI and B.P. should be checked, any pallor or supraclavicular nodes to be checked.On abdominal examination any mass, ascites, tenderness to be noted, P/S examination amount of bleeding, any  vulval, vaginal and cervical  pathology(polyp or cancer) to be ruled out, Bimanual examination to be done to assess the mass,size , regularity, tenderness, mobility and adnexal pathology to be determined,P/R examination to be done if any complaint of bleeding PR.

In investigations , FBC, renal , liver and coagulation profile to be done, Transvaginal sonography to be done as it will show the increased endometrial thickness but there are various cut off s, >4mm raised the suspicion of Endometrial cancer and it will show if any ovarian pathology  but will not tell about Endometrial polyp. Sonohysterograpy if available gives valuable information about endometrial polyp.Endometrial biopsy to be done as outpatient by pipelle  or outpatient hysteroscopy or inpatient hysteroscopy and biopsy which is a gold standard. Tissue should be sent for histopathological assessment.

B) For patient counseling, I will  make sure she is with her partner or her close relative and will talk to her face to face using simple language  which she can understand using non jargons. The approach should be sensitive, sympathetic and empathetic . I will tell her that  unfortunatenately the report  shows  that she has cancer in her womb  and we need to know  how far it has spread , I’will give her time  to  come out  and will support  her  saying that overall  5 year survical  is 77%. and if early then prognosis is very good.

I will tell her that she should be treated in cancer centre  with a team of doctors, gynae cological oncologist, clinical oncologist, radiologist, mc.millan nurse, psychologist, radiotherapist.The plan of her treatment should be decided by MDT and she will be involved in all the decisions.

She may need to go for different imaging modalities like MRI, Ct scan, chest  xray  to know how far the cancer has reach and it will help to stage her disease and further treatment .

If she is stage 1 then simple removal of womb with both tubes and ovaries  will be enough as it is early stage and prognosis  for 5 yr survival is 85%.If she is Stage 2 and 3  then she need to go for extensive surgery  like removal of uterus, tubes, ovaries  and upper  part of vagina along with removal of glands in pelvis  and may require radiotherapy.Risk of surgery(injury to bowel,badder and vascular) and radiotherapy (rishk of abdominal wall oedema, leg edema)to be told and risks  will  be more if she is obese and has other co morbidities. If stage 4 and inoperable she may require radiotherapy, chemotherapy , or progesterone therapy.

Throughout her course of treatment she  will  be supported by specialist nurse. She should be well compliant to the follow up and can ask  questions  if any concerns. I will provide her leaflets and pamphlets  to support my verbal discussion and will provide her 24 hrs contact number of the hospital and will give information about support groups.

ans essay 372PMB posted by prija Posted by sowba B.

               The   woman should be told that postmenopusal bleeding is not always ominous but needs to be evaluated as there could be a chance of malignancy.she must be asked how long she is menopausal and how were her cycles previous cycles.the Amount of discharge should be asked so also frank bleeding if any.associated pain,feeling of mass should be asked as it may point to a pelvic pathology. A postcoital bleed may point to a cervical pathology –a benign polyp or a carcinoma. Her age at menarche must be noted as early menarche and late menopause are risk factors for endometrial cancer.other risk factors to be looked for are comorbids like diabetes,obesity and hypertension.any h/o unopposed estrogen,tamoxifen,rarely combined sequential HRT must be asked.family h/o breast,colorectal ,endometrial cancer may give clue to a familial LYNCH2 SYNDROME with a poorer prognosis.examination should include breasts,thyroid ,BMI,B.P .Any abdominopelvic mass.,signs of vaginal atrophy ,cervical polyp or growth.a cervical smear must be taken and colposcopy is done if indicated.a transvaginal usg is the first test to be done as its noninvasive ,widely available,cheap,helps in deciding histological sampling and also provides opportunistic screening of ovaries.sensitivity for ca is 70-80% benign only 33%.if endometrial thickness is >5mm an OP based endometrial sampling with pipelle or vibra aspirator is to be done.it is noninvasive ,but samples only 40 %of endometrium.efficacy can be improved if combined with a OP flexible office hysteroscope.hysteroscopy with a D&C is the gold standard.MRI is useful if sampling suggests a ca.other tests for surgical ,anaesthetic fitness include FBC,LFT,RFT,ECG,CXR,HIV,HbS Ag status

                     The woman should be reassured that majority of endometrial ca are early stage and if treated have a good prognosis.staging is always surgical and MRI is only an adjunct.stg 1 grade 1 tumors have a 95% 5yr survival ,while gr2 upto85%.prognosis depends on stage, type,grade,lymph node involvement,capillaryspace involvement,progesterone receptor status if >100 have a better prognosis,DNA ploidy status.a papillaryserous or clear cell type has a poor prognosis so also a familial cancer..surgery namely TAH with BSO is the treatment with selective pelvic,paraaortic node sampling. nodes are positive in only 3-5%of stage 1 tumors .ovaries are not conserved as involvement can be as high as30%.surgery can be done through laparosopy also survival matching the open route,advantages being,less hospital stay,early recovery but needs expertise.if nodes are positive post op radiotherapy is to be given.for stage4 with bowel or bladder involvement palliative surgery may help in improving quality of life or progesterone therpy can be tried for distant metastases.patient information leaflet must be provided and also contact numbers of support groups to enable her in making a choice of treatment.

              

 

ans essay 372 Posted by Mukta P.

Main goal is to rule out malignancy . Detailed history to find out risk factors for endometrial cancer. It'd include age of menarche and menopause as early menarche and late menopause is a risk factor for endometrial cancer. History of subfertility, anovulatory cycles,PCOS,nulliparity are all associated with unopposed estrogen exposure and hence risk factors for uterine cancer.History of HRT ( sequential or combined)  , history of Tamoxifen use for prophylaxis of breast cancer is associated with endometrial hyperplasia and cancer. History of previous surgery like hysterectomy-, may suggest the vaginal discharge could be from vault infection.History of prolapse and pessary use to rule out local cause of the vaginal discharge .Other causes like cervical cancer  and fallopian tube cancer should also be ruled out by asking about the last cervical smear result. I'd also ask about history of weight loss, reduced appetite,oliguria to find out about advanced disease and metastasis.I'd also ask about family history of breast cancer, uterine cancer  and colorectal cancer to find out about rare cases of familial cancer syndromes

I'd do a general examination to look specifically for pallor, BMI (obesity is an independent risk factor for uterine cancer), cervical lymphadenopathy for metastasis. Abdominal examination to look for any obvious pelvic mass. Speculum examination  to look for any local cause of blood stained vaginal discharge like pessary related ulcer, cervix. Vaginal examination to see the uterine size, mobility, any adnexal mass.

i'd ask for a transvaginal scan to look for endometrial thickness. If the endometrial echo is < 4mm, the risk of   endometrial cancer is very low, while if its > 4-5 mm, she'll need an office endometrial biopsy by pipelle to rule out cancer/hyperplasia. TVS will also look for any submucosal fibroid or polyp , and any adnexal mass.

B - i'd be empathetic and would ask her if she wants a relative to be called  to be with her when i discuss about the finding of endometrial cancer. I'd tell her about endometrial cancer, give her written information to read later on. I'd tell her that there will be a multidisciplinary team meeting to discuss her case with specialists to review and plan management which will then be discussed with her in detail. Most cases the treatment will be abdominal hysterectomy and bilateral oopherectomy, and the need for chemotherapy and radiotherapy will be based on the findings at surgery.I'll offer her contact numbers of support groups, I'll  ask regarding need for social service, ask to inform her GP so that local care can be arranged.

Posted by Im F.

A 64 year old woman has been referred to the rapid access clinic with a 3 months history of blood-stained vaginal discharge. (a) Discuss your assessment [10 marks]. (b) She is found to have an endometrial adenocarcinoma. How would you counsel her?

 A,Inquire about previous menstrual cycles, her last period’s duration of menopause post-menopausal bleeding, post coital bleeding, and pain in abdomen. Inquire about pressure symptoms such as increased frequency, urgency, difficulty in defecation, bleeding per rectum, and mass protruding from vagina.Use of HRT, TAMOXIFEN, CLOMIFENE and duration of use. .Also ask about the no of children. Family history of breast, ovarian, colon cancer should be included. Take the Pap smear history, her last smear and results. Contraception history, use of ocp duration. Past medical history DM and HPT and any previous abdominal surgeries.

 Examination to check B.P/BMI .Per speculum examination should be done to take swabs; smears exclude polyps and if appropriate refer for colposcopy.Vaginal examination and bimanual examination size of uterus, its mobility, consistency and any adnexal mass and lymph nodes palpation. Per rectal examination to exclude rectal patholo

Initial investigation should include FBC,renal profile and liver function test as baseline.pap smear if not done recently .endometrial sampling to rule out  endometrial hyperplasia. Tumor markers if findings suggestive of cancer eg CA125.Ultrasound scan to exclude pelvic mass CT/MRI if suggestive of cancer

b.Counseling should be done in a sensitive way and involve partner and family members. Explain to her the findings that there is an abnormal growth in her womb. Explain to her the stage of disease and that she will be looked after by multidisciplinary team oncologist, gynecologist ,specialist nurse.

Inform her regarding the treatment options according to the stage of disease which may include total abdominal hysterectomy ,bilateral salpingoophrectomy, lymhnode sampling with or without radiotherapy and /or chemotherapy. High dose progesterone therapy for distant metastasis. Respect her wishes to whatever treatment she opts for. Also inform her risk/ side effects of surgery such as injury to bowel, bladder and bleeding and that of radiotherapy.

Overall 5 yr.  prognosis is 78%.it depends upon tumor type its grade and stage of cancer.

Written information should be provided. Inform regarding support group.

Posted by amina  .

A 64 year old woman has been referred to the rapid access clinic with a 3 months history of blood-stained vaginal discharge. (a) Discuss your assessment [10 marks]. (b) She is found to have an endometrial adenocarcinoma. How would you counsel her? [10 marks]. 

postmenupausal woman with blood stained vaginal discharge should be seen and assessed urgently with aim to rule out malignancy .detailed history including age of menarche, last menstral period , previous menstral cycles and if any menstral irregularities ,should be asked. blood stained vaginal discharge could be due to cervical/ endometrial / vaginal/ fallopian tube cancer. benign causes will include vaginal atrophy and endo/cervical polyps .

we should ask about any associated features like weight loss, bowel/bladder dysfunction, any abd mass , bleeding per rectum.she should be inquired about medical disorders , diabetes ,htn , coagulopathies .other relevant details will be hx of PCO , personal/family hx of breast/bowel/ endo/ovarian cancer , use of medications, HRT , tamoxifen.

we should ask about previous hx of any surgeries , radiotherapy , chemotherapy , cervical smear , if any abnormal cervical smear in last 10 years ,

BP , BMI  should be recorded , she may be pallor , may have abd/pelvic  mass  . if abd/pelvic mass found , its location, consistancy , size should be recorded.it may be fixed/ mobile.

 detailed examination  of external genitalia for  any signs of vulval soreness , any mass/lesions , vaginal atrophy. speculum examination to see vaginal walls , cervix , any polyps , cervicitis, any suspcious  lesion/ growth may be visible.biopsy can be taken after patient ,s consent. bimannual examination for look for uterus ,size ,position , adnexal masses.

TVS is important , simple, easy , costeffective test that can help in further management. usually endometrium is thinner in postmenupausal women as compared to premenupausal.so keeping cutoff point as 5mm , TVS can help to pick high risk pts out of all. thin endometrium can be reassuring unless women continue to be symptomatic.if end thickness is more than 5mm , we should proceed with biopsy techniques like VABRA , PIPELLE  ,these outpaient techniques are acceptable to pt and safe her from risks of G A.hysterscopy can be performed , it has benefits of being diagnostic as well as therapuetic. outpatient hysterscopies with modern vaginoscopic approach are more better , easy and acceptable to women. written information is given before such procedures as these are not without risk.

endometrial polyps can be removed , biopsy can be taken, uterine cavity can be assessed for any predictors of malignancy .

2=   diagnosis of endometrial cancer is associated with significant psychological distress and  morbidity . breaking this news to woman can be very upsetting for her, she should be asked if she wants to call someone to be with her during consultation, sudden bombardment of information should be avoided and approach should be realistic but sensitive .all necessary information should be given in a way that include pauses .

we should tell her about diagnosis in simple way , your biopsy report came , i m not having good news for you , i m sorry to say , it shows  you have cancer arising from womb . she may need to ask questions , may cry , may deny , may become quite . enough time should be allocated to discuss and inform about dx.

she may need further appointments with MDT team including gynaecological oncologist , oncology specialist  nurse ,health counsellors , radiologists and general gynaecologists.she may have concerns about further treatments, their side effects , life time survival . these can be dealt with help of MDT and her GP. IF diabetes , htn , obesity are also complicating issues , she should be given information tailored to her case. obesity carries additional risks of surgical ,anesthetic complications,   difficulties in ultrasound assessments , additional risks of VTE .

INFORM HER we need to do other tests to know extent of cancer spread , its stage , its grade . she may need hysterectomy with/ with out lymphadenectomy. inform about survival rates of differant stages and their treatment.

she will be seen in cancer centre and further appointments will be given for counselling, surgery and radio/chemotherapy if needed.

 

essay 372 postmenopausal bleeding Posted by MONA V.

 

a)      Initial assessment includes detailed menstrual history of amount ,duration and type of bleeding .Last menstrual period is noted ,cycle length regularity and treatment for similar complaints in the past asked for. Early menarche and late menopause are risk factors for endometrial cancer. Ask for post coital bleeding ,vaginal infection,  dysparunia vaginal dryness if sexually active as atrophic vaginitis can cause bleeding  .  Previous cervical smear history is noted. History of risk factors for endometrial cancer like hypertension , diabetes , obesity is asked. Past history of breast cancer and tamoxifen use would need urgent evaluation for endometrial pathology. HRT use can also cause abnormal bleeding and is asked. Symptoms of malignancy like loss of weight , loss of appetite , rectal bleeding , hematuria would suggest malignancy

Examination done for blood pressure , BMI noted. Look for lymphadenopathy , hepatosplenomegaly due to malignancy. Abdominal examination for ascites , pelvic mass done . Speculum examination done for cervical polyp , cervical or vaginal growth due to malignancy. Pap smear is taken if scheduled as per screening programme. Vulval or vaginal pathology is noted. Pelvic examination done for uterine adnexal mass. The first line investigation is Transvaginal scan to determine endometrial thickness, endometrial polyp , ovarian status. Cut off for further invertigation is 5mm of endometeial thickness. Endometrial outpatient biopsy can be done by pipelle or vabra aspirator which has 90% sensitivity. Hysteroscopic guided biopsy is the gold standard for evaluation. Saline sonogram can also be done for endometrial pathology.

b)      The diagnosis is given in a sensitive way in the presence of family, carer if wished by the woman. She is seenby multispeciality team of gyneac oncologist, cancer nurse specialist, oncologist.MRI is done for myometrial assessment . Treatment depends on the stage of cancer , fitness for surgery and patient wishes. Stage 1a with endometrial and less than 50% myometrial involvement should be treated by Total abdominal hysterectomy with bilateralsalpingooophorectomy (TAHBSO) ,pelvic node sampling not indicated as per ASTEC trial. Laparoscopic assisted vaginal hysterectomy with removal of ovaries can be done in selected cases.  Stage 1b  need TAHBSO and selective  pelvic and para aortic node sampling. Stage 2 treated by TAHBSO ,pelvic node sampling ,followed by radiotherapy or radiotherapy followed by surgery and lymphadenectomy. Radical hysterectomy can also be done.Stage 3 treated by TAHBSO, radiotherapy(RT). If inoperable RT and chemotherapy given.

Stage 4 bulky disease needs RT whereas progesterone therapy can be used for distant metastatis.

She is given clear written information of good prognosis and 90% 5 year survival n early stage cancers . She is given contact of support groups like cancer .net.uk

MRCOG PART II ESSAY 372. PMB , Posted by A A.

 

 Ans : Approximately 10 % of women with postmenopausal bleeding (PMB) have endometrial cancer, other gynaecological cancers can also present with PMB . Aim of assessment is to rule out malignancy. I shall take detailed history regarding nature of PMB, (make sure that it is vaginal & not rectal or urethral bleed) any foul smell, associated pelvic/ abdominal pain ,since these increase the risk of cancer.I ll ask for other signs of malignancy, like weight loss , anorexia, per rectal bleeding or haematuria, ( metastatic or advanced disease). History of vaginal itching, dryness , sexual intercourse(( atrophic vaginitis /trauma). Drug history includes warfarin,  HRT( unopposed estrogen), tamoxifen for breast cancer. Personal and family history of malignancies should be asked, especially breast , colon and ovarian cancers. Belonging to family with HPNCC, Lynch II syndrome  increases risk of malignancy to 60% . Menstrual history of early menarche & late menopause, nulliparity & history of polycystic ovarian disease are all risk factors for endometrial cancer.  Medical history should include hypertension & diabetes mellitus,( although described have a weak association with endometrial malignancy).

Examination includes BMI, as obesity is a risk factor for endometrial cancer.Blood pressure,lymph nodes,  systemic examination must include chest examination, per abdominal examination to look for abdominal masses, ascities. Per speculum examination to look for signs of atrophic vaginitis, any cervical erosion, polyps etc. Cervical smear taken if previously not done. Bimanual pelvic examination for uterine size,postion , mobility & adenaxal masses etc.

 Transvaginal ultrasound done for endometrial thickness, Less than 4 mm reassuring, rules out malignancy. If more than 4 mm. outpatient endometrial sampling can be done with pippel or vibra but negative results don’t rule out malignancy. Hysteroscopy and biopsy is investigation of choice, as it can visualize endometrial pathology as well. DnC is no longer recommended as investigation for PMB.( SIGN guidelines)  Other investigation s will be according to the results of these preliminary investigations. She might have other comorbidities, which might be risk factors for treatment/anaesthesia.

b)Diagnosis of cancer causes anxiety and stress for the patient. I ll reassure her that more than 75 % of cases present in early stage and have good prognosis ,with 85 % 5 year survival in early low risk  disease. She needs to be told that staging is surgico pathological, but she needs to have TVS, MRI and Xray chest for pretreatment clinical staging, which will help in deciding management for her. She needs multidisciplinary management with gynaecologist, gynaecological onologist , specialist nurse, and psychologist. I ll tell her about the treatment options according to the stage of disease. TAH & BSO for early low risk disease is usually curative with low recurrence risks . For advanced/ high risk early disease, adjuvant radiotherapy or radiotherapy alone or chemotherapy according to circumstances in consultation with the oncologist.

Such patients are at risk of psycho sexual dysfunction, so ill reassure her that it is safe for her to have sexual intercourse. She needs social support. I ll give numbers of support groups. Written information leaflet provided. Hospital contact numbers , and next appointment date given. She is counseled for regular follow up and  for compliance with treatment.

essay 372 Posted by shazard S.

A) Regarding the history ask about the effect on her quality of life. Ask about constitutional symptoms of malignancy. These include weight loss and anorexia. Ask her parity. Decreasing orders of parity and nulliparity are risk factors for endometrial cancer. Ask her menstrual history. Ask about age of Menarche and menopause. Early menarche and late menopause are risk factors for endometrial cancer. Ask about a history of PCOS. PCOS and chronic anovulation are risk factors for endometrial cancer. Ask about results of previous cervical smears. Abnormal smears may increase her risk of cervical cancer. Ask about post coital bleeding. Post coital bleeding suggests a cervical cause(cervicitis, cervical polyp or malignancy). Post coital bleeding may also indicate vaginal atrophy. Obtain her past medical history. Ask about a history of Diabetes mellitus and hypertension. These conditions are risk factors for endometrial cancer. Ask about a personal history of breast cancer,. This increases the risk of developing endometrial cancer by 2-3 fold. Regarding her past drug history, ask about us of tamoxifen, unopposed estrogen, sequential combined HRT or phytoestrogens. These are risk factors for endometrial cancer. Ask about a malodourous vaginal discharge. This suggests a vaginal infection. Ask about a history of rectal bleeding or bleeding friom the urinary tract as these may be mistaken as vaginal bleeding. Regarding examination findings measure her blood pressure and calculate her BMI. Hypertension and obesity are risk factors for endometrial cancer. Inspect for signs of wasting. Wasting may be seen with malignancies. On abdominal examination palpate for masses. Perform a bi-manual examination for pelvic masses which may be of ovarian origin. Perform a speclum examination for cervical causes (cervicitis, polyps or malignancy). Inspect the vaginal mucosa for signs ulceration or atrophy. Regarding investigations take blood for full blood count and renal function. Use the values as a baseline. Perform a trans-vaginal ultrasound for endometrial thickness (ET). An ET>5mm is abnormally thick and has an 80% sensitivity for endometrial cancer. TVS has a poor sensitivity for benign endometrial pathology. Saline infusiion sonohysteroscopy increases sensitivity for benign endometrial pathology but is not widely available. If the endometrium is thickened endometrial biopsy is undertaken using hysteroscopy dilation and curettage ( gold standard for endometrial biopsy).

B) Recognise that the diagnosis will cause patient anxiety. Adopt a sensitive approach to counselling. Encourage the presence of a family member or friend of the patient. Explain the diagnosis in clear terms. Explain that malignant cells were discovered in the endometrial lining of the uterus. Regarding prognosis, explain that it is generally good with an overall 78% 5 year survival rate and 85% 5 year survival rate for stage 1 disease. Explain that prognosis depends primarily on the stage of disease. Explain that prognosis also depends on the histological grade with higher grades having poorer prognosis. Explain that prognosis is affected by histological type. Papillary and clear cell carcinomas have poorer prognosis. Explain that lymphatic spread is associated with poorer prognosis. Explain that larger tumor size has a poorer prognosis. Tumors < 2cm have a 5.7% rate of lymphatic spread. Tumors >2cm have a 21% risk of lymphatic spread. Explain that Progesterone recrptor levels also affect prognosis. Progesterone receptor levels >100 have a 93% 3year disease free survival rate. Levels <100 have a 36% 3year disease free survival rate for stage 1 and 2 disease. Regarding treatment options explain that this depends on the stage of disease. Stage 1a (invasion of <50% of the myometrium) requires TAH + BSO. Explain that the chances of lymphatic spread is sufficiently low to avoid lymph node sampling. Stage 1b disease ( invasion of >50% of the myometrium) requires TAH + BSO + pelvic lymph node sampling. Explain that adjuvant radiotherapy reduces local recurrence for stage 1 disease but does not improve survival rates. Explain that pelvic irradiation may cause morbidity which include radiation cystitis, radiation proctitis and radiation induced bowel injury. Explain that radiation induced morbidity is increased with pelivic lymph node dissection. Regarding stage 2 disease (spread to the cervical stroma). This may require neo-adjuvant pelvic irradiation(jntra-cavitary and external beam) with TAH BSO and para-aortic node sampling. TAH BSO with pelvic lymph node sampling and adjuvant pelvic irradiation may also be done. Selected patients with stage 2 disease will benefit from radical hysterectomy with pelvic lymphadenectomy. Regarding stage 3 disease ( regional spread) treatment is TAH BSO and adjuvant radiotherapy. Spread of disease to the pelvic side wall is inoperable and is treated with pelvic irradiation utilising intra-cavitary radiotherapy. Chemotherapy with doxorubicin and cis-platin is an alternative to radiotherapy. Patients who are not candidates for surgery, chemotherapy or radiotherapy may be treated with progestogens. Regarding stage 4 disease (bladder/bowel spread or distant spread) treatment depends on symptoms and sites of metastasis. Intracavitary and external beam pelvic radiotherapy may be used for bulky disease and progestogens for distant metastases. Regarding surgical mangement, explain that this may be by Laparotomy or Laparoscopy (LAVH or Total hysterectomy). Expalin the laparotomy and laparoscopy produce similar survival rates. Explain the intra-operative complication rates are similar. Regarding advantages of laparoscopy, explain that post -operative complications are reduced and that convalesence is better with laparoscopy. Disadvantages of laparoscopy include longer operating time, need for conversion to laparotomy (0-26%), 1/40 risk of portsite recurrence nad port site hernias. Laparoscopy also enetails risk of visceral injury and vault dehisence. Arrange referral to a gynaecological oncologist, oncology specialised nurses and inform her general practitioner. Offer the services of a counsellor. Offer her contact information to support groups like eyes on the prize.org and daily strength. Offer her written information such as brochures.

PMB Posted by saini K.

 

a) I will enquire about her LMP, age of menarche ,cycle length , regularity (anovulatory cycle,early menarche/late menopause risk factor for endometrial carcinoma). Presence of dysparoenia, vaginal dryness may suggest vaginal atrophy, vaginal discharge suggest infection, presence of post coital bleeding may suggest cervical lesion. I will further enquire about symptoms of malignancy like loss of weight/appetite, altered bowel habit. Medical problems like diabetes mellitus, hypertension, nuliparity,PCOS are high risk factor for endometrial malignancy. Personal history of breast carcinoma/ tamoxifen use, use of HRT and any family history of malignancy like colorectal carcinoma, ovarian carcinoma. I will ascertain when was last cervical smear done.

I will take her BP,BMI, examine for presence of any lymphadenopathy, abdominal examination for any mass, speculum examination for any cervical/vaginal mass/vaginal discharge and amount of bleeding, vaginal examination for uterine size as well adnexal mass.

I will take pap smear if needed, HVS if discharge. I will arrange for transvaginal scan for endometrial thickness. It has high sensitivity up to 80-100% but has high false positive rate. It also enables to assess ovaries. I will perform outpatient hysteroscopy with endometrial biopsy, it is most cost effective and avoid risk of GA and avoid hospital admission. However, polyp cannot be removed. Inpatient hysteroscopy and D&C if outpatient hysteroscopy and biopsy not possible. It is gold standard with sensitivity almost 100% but risk of GA and cost factor.Optimal mode of investigation controversial.

b)Need sensitive and empathetic approach to break news of newly diagnosed cancer, offer partner/family or friends to be around. I will explain her histological result of endometrial cancer. She needs multidisciplinary management including gynaeoncologist, medical oncologist, Mcmilan nurse.

Needs to do further investigation including MRI pelvis/CT abdomen to asses extend of disease. Explain her likely stage of disease but final staging depends after histological confirmation of extent of lesion, the possible treatment and prognosis depends on the stage. Explain treatment includes TAH/BSO and pelvic and paraaortic lymphadenectomy. She may need postop radiotherapy or adjuvant chemotherapy. Discuss the risk and complication of surgery , risk of anesthesia as well as risk/complication of postop radiotherapy or chemotherapy. I will discuss the impact of treatment on sexuality and sexual activity. I will provide her with written information leaflet and provide details of support groups. I will ensure psychologist support for her and family members if appropriate. Provide her follow up appointment

 


 

4/1/13 PMB essay Posted by D M.

Postmenopausal bleeding is endometrial cancer until proven otherwise,though i would start with history of any frank vaginal bleeding,associated symptoms like itching(vaginal atrophy),foul smelling discharge(infection),abdominal pain,bloatingweight loss,any urinary symptoms(urgency),bowel problems(change of bowel habit).I would then ask past medical history and risk factors of endometrialcancer such as diabetes,hypertension,history of cancer-breast,being on tamoxifen,history of PCOS,abnormal pap smears,any family history of cancer. I would also enquire obstetric history and any history of abdominal surgery. On examination I would note the BMI or any signs of cachexia. I would examine for any lymphadenopathy and palpate abdomen for any palpable masses or any tenderness. I would inspect the vulva for any lesions,masses or any signs of vaginal atrophy.On speculum visualising the cervix to exclude any fungated lesion that might be causing the PV loss and perform triple swabs(endocervical,high and low vaginal) if suspicion of discharge and infection.On digital examination I would look for any adnexal palpable masses,fullness in the pouch of douglas,uterine mobility or any cervical excitation and size of uterus. In terms of investigations I would organise a transvaginal scan for endometrial thickness or ovarian pathology.if ET is >5mm,pipelle biopsy is indicated and if unsuccessful as outpatient,then refer to outpatient hysteroscopy as histology from the endometrium is needed.

(b) Before counselling this patient,I wold ensure I have all the relevant information from either the MDT meeting if it had occured or the MRI report with the histology report,both reported by the radiologist and histopathologist consultants. In this way I would have as accurate understanding as possible for the staging,grade and hence be able to counsel regarding prognosis and plan of care. I would ensure the patient is with her partner/relative and leave plenty of time (double book) for consultation time. Also ensure to have the oncology specialist nurse and the gynae oncology consultant if needed.I would first start the consultation by asking the patient herself what she undestands from all the investigations that had been happening and the reason for those. In this way I can see what the patient's perception and insight is in general. Then I will ask what she thinks the result might be,in this way I can let her say the word 'cancer' if possible. otherwise I will clearly explain the diagnosis and that endometrial cancer is one of the few cancer with high cure rate, reaching 70% in 5 years if at stage one.(and most endometrial cancers are stage 1). I would then explain the immediate plan which is surgery needing to remove the womb,ovaries,tubes and cervix and send this to pathology,with waiting time for the results which will tell us exactly the staging.I would explain the skin incision,the aproximate hospital stay,need for catheter on first day and recovery time after going home with precise information on follow up and contact info of the oncology nurse in case she is worried at home. I would give leaflets on infomration regarding the procedure- total abdominal hysterectomy and bilateral oophorectomy. if appropriate expertise on laparoscopically performed then I would explain this as well. I will plenty of time for questions and either arrnage another appointment for the consent(where risks of operation will be discussed) or proceed at the same time. I would discuss the risk of bleeding(risk of blood transfusion),infection,injury to bowel/ureter,bladder in 1 in 200 risk,risk of thromboembolism hence need to be injected with blood thinners daily with possible 6 weeks duration. I would also mention that there are anesthetic risks( this is depending on any comorbitities). 

answer essay 372 -PMB Posted by Liza S.

 

By Liza.
(A)Aim is to identify or exclude endometrial pathology most notably endometrial carcinoma that if diagnosed early generally has a high cure rate. History of presenting complain can be elaborated by asking that the amount of discharge is mixed heavily with blood or it is a scanty blood mixed discharge ,any precipitating factors like post coital bleeding ,any associated pain are suggesting malignancy. Regarding her menstrual history I will ask the age of menarche and age of menopause as early menarche and late menopause have a 2-4 times increased risk of endometrial carcinoma .Obstetric history will include the parity, as in nulliparous women the risk of endometrial cancer is increased .Gene H/o will include the last cervical smear result whether it is done or if done what is result .Drug history will include whether she is on any HRT / Tamoxifen. Family history of any malignancy like hereditary non-polyposis colon cancer (HPCC) has an 80% life time risk of endometrial carcinoma. Medical history to be asked about diabetes or hypertension as they are the risk factors for endometrial ca. Features of malignancy like weight loss and anorexia should be asked. Any history of rectal bleeding or haematuria should be asked. Examination will include general examination like BMI  and BP as obesity has a 3-10 fold increase in risk of endometrial  carcinoma .P/A to exclude abdominal /pelvic  masses. S/E includes seeing any cervical erosion, polyp or any abnormal local lesions. P/v examination includes bimanual examination of uterus and adnexa. Investigation include biopsy of any valve lesion , Colposcopy /cervical smear –if cervix is found abnormal .TVUS for endometrial thickness  and  adnexa –in a postmenopausal women the endometrial  thickness is much thinner than in the premenopausal state and therefore more reliable in its use for predicting the presence of endometrial cancer, cut-off value used is 4-5 mm ,and  the chances of hyperplasia or cancer is very low when the endometrium is thinner  than  the  cut off  value . Hydrosonography use in the detection of focal lesion like polyp or fibroids can be enhanced with the use of saline or a contrast agent. Endometrium  biopsy  ,as aspiration biopsy  with the use of  pipella device and vebra device  is a very  sensitive  technique  which will be used if this patient have a increased endometrium thickness  than the  cut off values. Hysteroscopy guided biopsy under local anaesthesia/GA, offer the possibility of visualising macroscopically focal abnormalities and taking directed biopsies. 
(B)For delivering this bad news to the patient I will consider both the setting and the process, informing the patient on the telephone has to be avoided expect under unusual circumstances. I will choose a quiet, private setting that is comfortable and has ample seating and assure that there are no outside interruptions. The patient should have the option of having support person present. I will start  the discussion in a sensitive way  first  by summarizing  the patient presenting complaints and the components of  the evaluation  with a suitable warning words that I am so very sorry that your  histopathology report  showing  the endometrial  adenocarcinoma ,by allowing  the women to assimilate the information and recover her feeling  from this news , she then given  the information that this is the H/P report  but she has to have further investigation to find out the stage of her disease  and to be seen  by a MDT for her further care for proper staging , which is   a surgical staging .,and also discuss the treatment options  which is surgical ,adjuvant radiotherapy ,hormonal treatment  ,and  also explain the pros and coins of the care treatments ,  I will explain her that if she has an  early  stage  1 disease  it is a highly curable disease , if it detected early  which means that her tumour is confined to the uterus  and  if she  is low risk patient , i.e. no risk factors then surgical option  is total  (abdominal or/laparoscopy )hysterectomy +BSO i.e.  Removing her womb and bilateral removal of tubes and ovaries, I will identify the women main concern by asking her that do you have any other concern you want to discuss now, and I will also reassure her that she will be not be left to cope alone by saying that we will work through this together and I will involve the general practitioner or social worker in the next stages of the management plan. Good documentation is very important here that what information has been given to the women .This allow the seamless interaction with the MDT who may be involved with her care. Give her the written information leaflets  ,and I will give her the contact numbers  so that she can ask further questions , I will also suggest sources of support and websites  like voluntary organization like Macmillan cancer support website ,womb cancer support U.K 
 
essay 372 Posted by shereen S.

a)

Most common causes of postmenpausal bleeding are usually benign ,but there are 10% of patients  have endometrial carcinoma or other malignancies.The history will focus on risk factors for endometrial carcinoma.menstrual history such as late menpause and early menarche.family history of non polyposis colorectal carcinoma.drug history such as HRT and tamoxifen.medical history of DM and hypertnsion as it associated with increase risk of endometrial carcinoma.past history of previous irradiation as it will influence the treatment.i should also ask about other maliganacies such as the last cervical pap smear.any vulval symptoms as as sorness ,itching and dysparunia as it can refer to vaulval atrophy or vulval carcinoma.vaginal discharge to suspect infection.i will also ask about symptoms of metastasis such as cough and hymptosis.

General examination ofblood pressure and local examination measure BMI as obesity increase risk of endometrial carcinoma by 10 folds .local examination of vulva and vagina.pap smear if it  was not taken before.inspection of the cervix and colopscopy if suscpicous lesions are identified.bimanual examination to check adenxia,uterine size and mobility of the uterus.

investigations by first transvaginal u/s to triage the patient for next level of investigations .The cut off value is 0.4-0.5 cm of endometrial thickness.So if more the next step to take endometrial sample through outpatient pippelle or the gold satndared outpatient hysterscopy.if the patient can not tolerate pain so hysterscopy under general anasthesia can be offered.

B-

I should inform her face to face and by senstive and empathic way.councelling should be done without interruption.better to have family member with her but after her consent.Explaninig by simple language as  she has  cancer in her womb and this type of cancer has good prognosis  according to the stage of the disease.she needs further investigations to assess staging and spread of the disease such as chest X-ray and MRI to detect invasion of the disease to her uterus and to the para aortic and pelvic nodes.she will also preoperative investigations to check fittness for surgical treatments .
i will infrom her that surgical treatment in the form of total abdominal hysterctomy and bilateral salpingeooophrectomy is the main stay of the disease.But this also will depend on the stage and  her fittness for the  operation.Radiotherapy may be needed according to the stage, and according to the sample result of pelvic and paraaortic LN.if she unfit for operation radiotherapy can be used as the main stay o the treatment.iwill inform her about the risk of operation such as haemorrage , infection.injury to adjacent structures sucha as bladder ,ureter and intestine.the risk of lymphedema if lymphadectomy has done for her.

i will inform her that there are  hormonal and progestogen treatment but with no proven efficacy.,and it well depend on estrogenic and progestogenic receptor in the tumour.

i will ask her if she understand all the information i give her,and if she has any questions.i will inform her she will not be alone in this  situation there will be registered nurse wil assist her. i will inform her about support group .iwill give her written information about the disease and give her time to digest the information  i told her.i will inform her that she may need another appointement to discuss any concern about her disese.

she should know also she will be followed by MDT consists of obstertcian ,oncologist and pathologist. 

after councelling all information that were given to her will be documented and attached to her file.

Support groups Posted by S S.
Tell us about support groups for endometrial pts, please.
Posted by amina  .

eyes on the prize.org.uk