3.  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.  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.  CT pelvis and abdomen  Not unless you (or the patient or the radiologist) are prepared to pay for it!

6.  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.  Spinal and chest X- ray  Only is there is some other reason to suspect breast cancer secondaries

8.  Full blood count  Only if there has been substantial PV bleeding or there is clinical evidence of anaemia or blood dyscrasia

9.  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. Coagulation profile  No  Unless clinically indicated for other reasons

11. Serum CA125  No  Unless clinically indicated for other reasons

12.  Renal function tests  Liver function tests  No  Unless clinically indicated for other reasons

13.  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.  Outpatient hysteroscopy  With or without directed biopsy is the procedure of choice for this patient

15.  Uterine D&C  A 21 st century gynaecologist would favour ultrasound + Pipelle sampling or office hysteroscopy

16.  TSH  No  Unless clinically indicated for other reasons

17.  FSH  No

18.  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

20.  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.  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.  Re attempt after:  Vagifem for 7 days PV  Then 1000 ug Misoprostol the night before  A good option

23.  Hysterectomy  Unnecessarily aggressive  Unless there are other grounds for suspicion