Question of the week # 51

A 75 year old woman was diagnosed with Stage II breast cancer one year ago. The patient received chemotherapy, underwent modified radical mastectomy and radiation. . The cancer was ER+, PR+ and Her2-neu negative. The patient has been receiving Tamoxifen for the past few months. She reports that she has been experiencing vaginal spotting and intermittent mild vaginal bleeding over the past few months. She has also been experiencing intermittent hot flashes after starting Tamoxifen therapy. On physical examination, her vitals are with in normal limits. Pelvic examination does not reveal any gross pathology. Next step in managing this patient:
A. Stop Tamoxifen
B. Start oral progesterone
C. Obtain endometrial biopsy
D. Do a hysterosalpingogram
E. Recommend Hysterectomy with bilateral oophorectomy

3 Responses

  1. Obtain Endometrial Biopsy

    Tamoxifen is a selective Estrogen Receptor Modulator. It acts as an antagonist on the breast but acts like an agonist on the endometrium. Hence, Tamoxifen is used in breast cancer therapy but it also, increases the risk of endometrial hyperplasia and endometrial cancer.

    Vaginal bleeding is a less common adverse effect with Tamoxifen and is usually, benign. However, when a post menopausal patient on Tamoxifen develops vaginal bleeding, endometrial biopsy ( Ans. C) must be performed at least initially to exclude malignancy.

    Stopping Tamoxifen ( Ans.A) may stop bleeding if it is tamoxifen related adverse effect but it will not clarify whether the cause of the bleeding in benign or malignant.

    Oral progesterone ( Ans.B) is the treatment for benign endometrial hyperplasia and will help prevent vaginal bleeding from benign hyperplasia. It is not yet clear if this patient’s vaginal bleed is secondary to benign hyperplasia until a biopsy is performed.

    Hysterosalpingogram (Ans.D) may reveal the pathology such uterine masses but will not provide tissue diagnosis.

    Hysterectomy with bilateral salpingo-oophorectomy ( Ans.E) is too aggressive measure at this time. It can be recommended if the patient has biopsy proven early stage endometrial cancer.

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