Endometrial Cancer. Part 3
The history that is compatible with endometrial cancer is number one, postmenopausal bleeding. I think that is fairly obvious for most gynecologists who have a patient present in their office who say, I am bleeding. There are other causes for postmenopausal bleeding, but the first flag in your head should be, this may be coming from her uterus, therefore we should get an endometrial biopsy. Certainly, there are other sources of postmenopausal bleeding that can be coming from the bladder, the rectum, vagina, atrophy and those sources need to be worked up. Abnormal menses is a much more difficult diagnosis to make, and you have to be very astute to your patient’s menstrual history and really listen, my periods are increasing, they are coming twice a month, I’m spotting in between the month, this is a group of patient’s that you really have to be on the ball to pick up, because this is the group that gets missed, the 25% that are before menopausal or perimenopausal frequently get diagnosed in a later stage of disease, simply because they were told they are perimenopausal, they have been put on progesterone therapy, oral contraceptions and not undergone an endometrial sampling or even a pelvic ultrasound to diagnose whether there is a thickened endometrial stripe or even a suspicious stripe.
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Only 20% of patient’s who present with postmenopausal bleeding will ultimately have a malignancy, however, the older the patient that presents with postmenopausal bleeding, the more likely she is to have an endometrial cancer. The diagnosis of endometrial cancer is simple, we need to get a specimen of the endometrial cavity, the gold standard is a fractional D&C, most of the fractional D&Cs can be avoided by the office biopsy. I tend to use a Randall curette which is the exact same diameter as a Pipel, except it’s metal, so it doesn’t bend, so as far as the discomfort, because of the cervical dilatation, it’s exactly the same as the Pipel, but sometimes in the postmenopausal woman, it’s a little more difficult to get into the cervical os so I find that the Randall Pipel without the teeth works very well. In addition, if you use the Randall Pipel because it’s metal, you can actually sound the uterus and decide how large it is, you can actually feel where you are with your endometrial sample.
The last diagnosis of endometrial cancer is occasionally picked up on an asymptomatic woman which again is very rare to have a patient who has endometrial cancer who is asymptomatic, but it does occur, to pick it up on a Pap smear. If you have 100 patient’s that have endometrial cancer and you took Pap smears from those patient’s, only 20 would have an abnormal Pap smear. Of the 20 that have an abnormal Pap smear, about 80% would be AGUS, meaning atypical glandular cells of undetermined significance, not ASCUS, atypical squamous cells of undetermined significance, if you ever have a patient in your practice that has atypical glandular cells, those patient’s really need to be worked up thoroughly with an endocervical curettage plus an endometrial curettage, but the Pap smear is not designed to pick up endometrial cancer, it designed to pick up precancerous lesions and does a very poor job for screening for endometrial cancer. The office biopsy is 90% accurate, meaning if you can gain access to the endometrial cavity and you have a patient that has endometrial cancer, 90% of the time it will give you the answer that you have a cancer, 10% of the patient’s who truly do have a cancer that you have done the office Pipel or Randall curette, whatever your choice, 10% of those patient’s will be missed. So therefore, it is imperative that patient’s who have abnormal uterine bleeding that you strongly suspect need to be worked up to rule out an endometrial cancer in your office, biopsy comes back negative. For those small percentage of patient’s, the 10%, they really should undergo a formal procedure, a D&C if that’s medically possible. There are other ways of diagnosing endometrial cancer, one of the new advances has been hysteroscopy which is used on conjunction with D&C and I think this is a very nice technique, it can pick up polyps which you can miss on your D&C, you can also look at the endocervical canal, occasionally you can be working somebody up for an endometrial cancer and find out that indeed they had adenocarcinoma of the endocervix and it not from the endometrium, so I think that hysteroscopy does add t the D&C, it’s not absolutely necessary for complete workup of endometrial cancer, it’s just a diagnostic tool. Hysteroscopy is very infrequently used, it’s used in conjunction with ultrasound. It’s a technique where they look with the ultrasound machine at the uterine strip, and they place saline in to see if this is a cancer. If you’re going to go to that extreme, at some point you are still going to have to sample the patient with either an office biopsy or fractional D&C so I’m not sure that the added expense of this test is always indicated.