PV Bleeding on Tamoxifen

1. PV Bleeding on Tamoxifen Max Brinsmead PhD FRANZCOG May 2015

2. Which of the following tests are required for a 61 year-old woman using Tamoxifen after breast cancer surgery and who experiences some vaginal bleeding?

3. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

4. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

5. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • CT pelvis and abdomen • Not unless you (or the patient or the radiologist) are prepared to pay for it!

6. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

7. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • Spinal and chest X-ray • Only is there is some other reason to suspect breast cancer secondaries

8. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • Full blood count • Only if there has been substantial PV bleeding or there is clinical evidence of anaemia or blood dyscrasia

9. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

10. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer Coagulation profile • No • Unless clinically indicated for other reasons

11. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer Serum CA125 • No • Unless clinically indicated for other reasons

12. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • Renal function tests • Liver function tests • No • Unless clinically indicated for other reasons

13. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

14. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • Outpatient hysteroscopy • With or without directed biopsy is the procedure of choice for this patient

15. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • Uterine D&C • A 21st century gynaecologist would favour ultrasound + Pipelle sampling or office hysteroscopy

16. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • TSH • No • Unless clinically indicated for other reasons

17. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • FSH • No

18. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer • 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

19. Office hysteroscopy is planned for the 61 year-old woman using Tamoxifen with postmenopausal bleeding but it fails because the cervical canal is too tight. What are the options?

20. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer -failed hysteroscopy • 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

21. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer -failed hysteroscopy • 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

22. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer -failed hysteroscopy • Re attempt after: • Vagifem for 7 days PV • Then 1000 ug Misoprostol the night before • A good option

23. A 61 year-old patient with postmenopausal bleeding on Tamoxifen after breast cancer -failed hysteroscopy • Hysterectomy • Unnecessarily aggressive • Unless there are other grounds for suspicion