The controversy related to the incidence of endometrial cancer due to tamoxifen treatment has led to the monitoring of patients and the systematization of a protocol for their control and treatment.
The objective of this protocol is the early diagnosis and treatment of endometrial cancer and precursor lesions.
Two groups of patients must be distinguished:
- Asymptomatic: Those who do not present metrorrhagia.
- Symptomatic: Those patients who have genital bleeding.
Protocol for asymptomatic patients
In the case of patients who are asymptomatic, the action protocol is as follows:
- Annual gynecological examination
- Clinical history with risk factors
- Adjuvant treatment, dose and period of treatment with tamoxifen.
- Cervico-vaginal cytology
- Colposcopy
- Transvaginal ultrasonography with endometrial and ovarian assessment and Doppler.
The pattern of normality will be given by the endometrial thickness, which varies according to the menopausal state:
- Premenopausal:
- proliferative phase 4-10 mm
- secretory phase -8-14 mm
- Postmenopausal: regular endometrial pattern maximum 4mmm.
The ultrasound study and its pathological endometrial pattern will condition the specialists in Gynecology to perform the following study, which is the diagnostic hysteroscopy, which will be performed with directed biopsy.
Diagnostic hysteroscopy is usually performed without general anesthesia, with a 5.5 mm hysteroscope, biopsy channel and ClN pump perfusion, at pressures not exceeding 100mmHg. If the state of the cervix requires it, either because of its atrophy (menopausal patients), it is prepared with local estrogens or percutaneously (50mg patches) three days before the procedure.
According to the result of the biopsy:
- Non-pathological result: new ultrasound control in 6 months, clinical assessment and endometrial thickness.
- Pathological result: referral to the gynecology oncology unit for procedure and complete study and treatment.
- The transvaginal ultrasound study also assesses the adnexal status, as well as the Doppler function.
When the characteristics are suspicious, the patient is referred to the gynecologic oncology unit for study and procedure.
Protocol for symptomatic patients
In the case of symptomatic patients, an immediate hysteroscopy is performed if the bleeding is very abundant, endometrial aspirate and application of treatment for dysfunctional bleeding.
Depending on the biopsy result, if it is negative and does not require a surgical procedure, it is included in the follow-up protocol for asymptomatic patients. If the result is positive, the patient is referred to the gynecologic oncology unit.
Follow-up protocol for asymptomatic patients
The follow-up to be performed for asymptomatic patients will be:
- Cytology-cervicovaginal
- Transvaginal ultrasound: assessing endometrial thickness. If this has not experienced any increase, annual control will be performed, unless metrorrhagia appears, in which case hysteroscopy and or endometrial aspirate.