Endometrial cancer is the most prevalent gynecologic malignancy in the Unites States. Even though the cancer occurs most frequently in postmenopauasal women, 5% of the total number cases are found in women 40 years and younger. These women usually have specific risk factors such as morbid obesity, chronic anovulation, and hereditary syndromes (Schuiling & Likis, 2013). As future providers, it will be vital to know and understand the risk factors for endometrial cancer and the signs and symptoms of the disease so prompt diagnosis and treatment can happen for the patient.
Subjective Data Ms. C. G is a very pleasant 23 year old Caucasian female who was referred to the office by a local physician for endometrial cancer. Her mother is here with her at the visit. The patient was seen by another physician on 9/8/15 as a new patient referred by the local ER for epigastric abdominal pain and endometrial thickening. She had an ultrasound done 9/5/15 in the ER that showed a normal size uterus with 25 mm thickened endometrial lining with area of cystic changes. The referral doctor took the patient to the OR on 10/15/15 for a diagnostic hysteroscopy, sharp uterine curettage and myosure polypectomy.
The pathology ended up showing endometroid adenocarcinoma, FIGO grade I. The patient has not had much vaginal bleeding since her surgery, but prior to the surgery her periods were very irregular and unpredictable. The patient does have a pretty interesting past medical history of Bardet-Bidel Syndrome, which led to congenital blindness. Vision loss is one of the major features of the syndrome, and so is obesity. Her current weight is 350 and her BMI is 47. 5. She denies any new or different pelvic or abdominal pain and issues with her bowels and bladder.
Past Medical History and Surgical History C. G. is a pretty healthy young lady besides having an unfortunate genetic disorder called Bardet-Biedl Syndrome. This syndrome is known to cause congenital blindness, obesity, extra fingers and toes, learning problems, impaired speech, and abnormities of the genitalia (“Bardet-Biedl syndrome,” 2013). The syndrome has led to blindness, obesity, and an extra toe for the patient. Her only other past medial history is hypothyroidism that is well controlled with medication. Her past surgical history includes a diagnostic hysteroscopy, sharp uterine curettage and myosure polypectomy on 10/14/5015, tonsillectomy and adenoidectomy, cholecystectomy, and toe removal.
Overall, the patient feels likes she is healthy and doing well. ROS General- Admits to weight gain, denies fatigue, fever, chills, night sweats Skin- Denies delayed healing rashes, bruising, bleeding or skin discoloration Eyes- Admits to partial blindness in bilateral eyes Ears- Denies ear pain, hearing loss, ringing in the ears, or discharge Nose/Mouth/Throat- Denies sinus problems, dysphagia, nose bleeds or discharge Breast- Denies lumps, bumps, pain or changes Heme/Lymph/Endo- Denies HIV history, blood transfusions, night sweats, swollen glands, increase thirst or hunger Cardiovascular- Denies chest pain, palpations, PND, orthopnea, edema Respiratory- Denies a cough, wheezing, hemoptysis, and dyspnea Gastrointestinal- Denies abdominal pain, denies N/VD, constipation, hepatitis, hemorrhoids, eating disorder, ulcers, black tarry stools Genitourinary/Gynecological- Denies urgency, frequency, burning, changes in color of urine. Denies sexual activity at this time, STDs, pain, or pregnancy history.
Admits to occasional vaginal spotting Musculoskeletal- Denies back pain, joint swelling, stiffness or pain Neurological- Denies syncope, seizures, weakness Psychiatric- Denies anxiety, depression, sleeping difficulties, suicidal ideations/attempts Initial Differential Diagnoses Endometrial cancer (C54. 0) Endometrial polyp (N84. 0) Endometrial hyperplasia (N85. 00) Differential diagnoses are developed to help the provider narrow down possible diagnoses to rule out options to finalize a diagnosis for the patient. Before the pathology report was known, the patient’s abnormal bleeding and pelvic pain in the ER lead to an ultrasound that showed a thickened endometrium.
From that report, initial differential diagnoses were developed. Objective Data Vitals Weight: 350 lbs. , Height: 6”0’, BMI: 47. 5, BP: 154/95, Pulse: 75, Temperature: 97. 6 Examination General appearing- Healthy appearing adult female in no acute distress. Alert and oriented, answers questions appropriately Skin- Skin is warm, dry, clean and intact. No lesions or rashes noted HEENT- Normcephalic, no conjunctival or scleral injection. ears are patient and clear bilaterally, neck is supple no thyromegaly or nodules, oral mucosa is pink and moist Cardiovascular- S1, S2 with regular rate and rhythm.
NO extra sounds, clicks, rubs or murmurs, No edema Respiratory- Symmetric chest wall. Respirations regular and easy. Lungs clear to auscultation bilaterally Gastrointestinal- Abdomen obese, BS active in all 4 quadrants, abdomen soft and non-tender Breast- Free of masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration Genitourinary- Bladder is non distended; no CVA tenderness. External genitalia no lesions. Vagina no lesions, no discharge or blood. Cervix nulliparous, small. Adnexa not tender or enlarged. No perineum/anal lesions. Lab Tests
A basic metabolic panel and complete blood count with differential was ordered to rule out an infectious process, anemia, electrolyte abnormalities or any other condition that could make the patient not a surgical candidate. Also, a prolactin level was ordered to rule out a possible prolactin-secreting tumor. Assessment and Diagnosis Due to the pathology report, the final diagnosis is adenocarcinoma of the endometrium (C54. 1). Due to her history, the diagnosis of Bardet-Biedl Syndrome ( Q87. 89) was given, as well. The nursing diagnosis for the patient is fear/anxiety related to a diagnosis of cancer.
Plan and Implementation The patient and her mother were told all about the findings from the report and her diagnosis. They were informed that although the exact cause of her cancer is unknown, it is highly likely from her obesity and an excess of endogenous estrogen unopposed by progesterone (Schuiling & Likis, 2013). Unfortunately, her obesity was affected by her Bardet-Biedl Syndrome so it was not avoidable. The patient and the mother were made aware that the recommend surgery for the cancer is a total abdominal hysterectomy (Creasman, 2014).
Due to the patient’s age, her fertility goals will need to be known because once a hysterectomy is performed, she will not be able to bear children. The option of surgery was discussed with the family, and as of now, her future fertility goals are uncertain. The patient was encouraged to talk with her family and to really think about her future fertility goals and if childbearing is something that she is interested in before she makes a final decision. She was told to follow-up in the office in two weeks to discuss her decision on whether or not to go forward with the surgery or wait for a later date.
She was informed that if she decides not to have the surgery at this time, she will need a hysterectomy in the near future to remove her cancer. The patient and her mother express understanding and agree with the plan. Until the patient decides if surgery is what she wants to pursue, she is prescribed Provera 10 mg, 4 tablets PO daily for thirty days, 120 tablets, refill one. She was told that she will need to take hormone therapy to help decrease the amount of estrogen in her body. The patient was educated on the medication and all the possible side effects.
After the teaching, she expressed understanding. She was told to call the office with any heavy bleeding or with any questions or concerns that she may have. Conclusion Endometrial cancer, if caught in an early stage, is usually low grade and has a favorable prognosis. With any cancer diagnosis, there is always a fear and anxiety of future life plans and what obstacles the patient may face. As providers, it will vital to really listen to the patient and education them on their cancer diagnosis so the patient has a good understanding of their condition and treatment options.