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essay-PMB-4/1/13 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).

Posted by Farrukh G.

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