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MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 226 - PMB

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		Posted by Shatha A. Fri Feb 9, 2007 03:58 am
(a) Post menopausal bleeding (PMB) can be the presenting symptom of endometrial cancer. It has been shown that 8-10% of patients with PMB have an underlying endometrial cancer. However; conditions like vulval, vaginal atrophy, trauma or carcinoma can be the cause of PMB. Cervical pathology can be a cause specially if the bleeding mainly post coital. Therefore history of the nature of the bleeding, any precipitating factor is helpful. History of loss of appetite or weight , recent change in bowel habit should be taken. Clinical examination should be directed to exclude abdomino-pelvic mass in case of oestrogen secreting tumour. Vaginal examination to exclude any vulval, vaginal or cervical pathology together with bimanual examination to assess uterine size, mobility and the presence of adnexal mass. (b) There is no agreed protocol on the investigation of PMB. The use of transvaginal ultrasound scan for measurement of endometrial thickness is widely acceptable as it has high sensitivity approaching 100% in detecting endometrial malignancies in addition its cheep, available and not invasive, however; it?s sensitivity in detecting benign pathology like endometrial is not as high and has been shown to be around 30%. Out patient endometrial sample is an acceptable method of investigation as it can sample between 68-98% of endometrium and its safe, cheep but can be cause pain or discomfort for patients. The use of hysteroscopy and endometrial biopsy is considered as the gold standard. It can be done as an out patient procedure with the use of fibrooptic hysteroscope. A paracervical block with local anaesthetic may be required. The procedure has a wide patient acceptability, avoid the use of general anaesthesia and considered to be cost effective. In patient hysteroscopy under general anaesthesia can be an alternative in patient who are not suitable for outpatient due to patient preference, or when difficulty in manipulating the cervix is anticipated for example previous cone biopsy. The use of Magnatic resonance imaging (MRI) in the investigation of PMB is not justified but it is of great value in staging of endometrial cancer. (c) Atypical endometrial hyperplasia is a histological term which describe some changes in the endometrial cells which is abnormal but not typical of cancer. However; some times its impossible to differentiate between the atypical hyperplasia and endometrial cancer. In addition there is a substantial interobserver variability in the diagnosis. There is a risk of underlying endometrial cancer in 10-20%. It is considered to be a premalignant condition with a risk of progression to endometrial cancer in up to 50%. For this reason and the fact that the patient is healthy 65 year old, surgical treatment in the form of total abdominal hysterectomy and bilateral salpingo oophorectomy is the ideal treatment which will guarantee cure. The procedure should have low risk of complication in the hand of skilled surgeon, however there are risks of primary haemorrhage, bladder, bowel ureteric injury, blood transfusion, infection and thromboembolism. The patient should be aware that medical management with systemic progestogens like megestrol or the use of levonorgestre containing intra uterine system is another option, but this require long term follow up with endometrial samples, and there is no long term data about the outcome of such therapy in the management of atypical hyperplasia and no agreed protocol on the duration of therapy.
		Posted by neera B. Fri Feb 9, 2007 04:19 am
This women with postmenopausal bleeding needs careful review since 10% cases are associated with genital tract malignancy. a) I shall enquire about predisposing factors for endometrial hyperplasia and cancer endometrium such as early menarche , late menopause, intake of sequential HRT , nulliparity, tamoxifen intake, intake of unopposed estrogens . To ascertain familial cancer syndromes, enquire about cancer ovary, endometrium, colon in family. For extrauterine causes, I will ask about vulval ulcer, dry vagina, postcoital bleeding , cervical smear history and lump abdomen . Finally I will ask about extragenital causes like blood in urine or faeces. I will examine abdomen for lump and tenderness. Vulval lesion and urethral caruncle will be inspected . Speculum examination will be done to look for atrophic vagina, foreign body like forgotten pessary or IUCD , UV prolapse, vaginal and cervical lesion . Vaginal examination is aimed to assess uterine size, adnexal mass and mass in POD. b) Transvaginal scan is a cheap, effective , easily available, noninvasive screening method for endometrial thickness and adnexal masses. If ET is lesser than 5 mm, the patient should be reassured . But if ET exceeds 5mm, endometrial biopsy is indicated . Outpatient EB by Pipelle is cheap, easily available , does not require hospital admission and is usually painless. If it shows endometrial hyperplasia or carcinoma, further treatment can be planned . However it samples only 4% of endometrial cavity. Vabra aspirator is also an outpatient procedure without anaesthesia but maybe more painful. It samples 40% of the endometrial cavity. Outpatient hysteroscopy is done as a day case without anaesthesia. Direct visualization of endometrial cavity is possible and directed biopsies can be taken. Thus it has higher sensitivity than above methods. But unlike inpatient hysteroscopy which is done under GA, removal of submucous fibroids and polyps cannot be done in out-patient hysteroscopy. In patient hysteroscopy is gold standard for diagnosing endometrial pathology. D & C and HycoSy are not routine methods for endometrial evaluation. If pelvic mass is seen on TVS and its nature is uncertain, MRI is helpful. If cervical smear is due , it should be taken . Biopsy of a visible lesion on vulva, vagina or cervix should be offered under local or general anaestheia to rule out malignancy. If urinary/ gastrointestinal lesion is suspected, urine microscopic examination , MSU for culture , proctoscopy for haemorrhoids and sigmoidoscopy should be discussed. c) I will tell her that 22-25% cases of atypical hyperplasia progress to cancer endometrium. Thus , a hysterectomy will be offered soon. There is virtually no place of expectant management with this risk of cancer. Routes of hysterectomy will be discussed . Vaginal hysterectomy is quicker and less costly, but removal of ovaries and evaluation of pelvis can be technically difficult. Abdominal hysterectomy enables removal of ovaries as well as lymphnode assessment. Laproscopic hystrerectomy requires key hole insertion , is associated with lesser blood loss quicker recovery and shorter hospital stay, but evaluation of lymph nodes may not be complete. Both body of the womb and neck of womb should be removed ( Total Hysterectomy) because cervical involvement occurs early in case of endometrial cancer. The procedure of hysterectomy will be told . Benefit of hysterectomy is that , it prevents progression of atypical hyperplasia to cancer. If underlying early stage cancer endometrium is present, it may be adequately dealt with by total abdominal hysterectomy with removal of both tubes and ovaries. However common risks such as bleeding and urinary or wound infection can occur . Rarely , bladder , ureteric or bowel injury may occur. Serious risks are venous thromboembolism and rarely deathin 1:10000 cases. Additional procedures like blood transfusion , repair of urinary or bowel injury and removal of both tubes and ovaries will be discussed. Ovarian removal does not eliminate the risk of future cancer ovary , since ovarian cancer may develop from peritoneum. Leaflets will be given to enable her to make an informed decision. Discussion will be documented and a consent form filled.
		Posted by Sarwat F. Fri Feb 9, 2007 05:46 am
About 80% cases of postmenopausal bleeding are due to benign diseases which include atrophic vaginitis. Important condition to exclude in this case is endometrial carcinoma or atypical hyperplasia. It is therefore important to take history regarding risk factors for endometrial carcinoma which include age at menopause, parity of patient, coexisting medical diseases like diabetes mellitus and hypertension, any previous surgeries including hysterectomy, use of HRT, duration and type of HRT used, any history of recent weight loss. History is also taken regarding her cervical smears. Examination is done to check for any abdominal masses or lumps as ovarian malignancies can also cause endometrial hyperplasia. Vaginal examination to assess the state of vaginal atrophy is done. Options for subsequent investigations include a vaginal ultrasound to assess endometrial thickness, pipelle endometrial sampling and hysteroscopy. The likelihood of endometrial carcinoma is very low if endometrial thickness is less than 3 mm in women not taking HRT. There is no reliable cutoff level for endometrial thickness on ultrasound for women on HRT. Ultrasound will also assess the state of ovaries to see if there are any ultrasound evidence of malignancies like multiloculated cysts, solid areas, and evidence of ascites. A gentle speculum examination can be done to assess the state of cervix and if there is any abnormal vaginal discharge, a high vaginal swab can be taken. Pipelle endometrial sampling can be done to obtain a sample for histological examination. Its sensitivity is about 80% however specificity is quite low. Its advantages include avoidance of need for anaesthesia and outpatient procedure. However it can lead to significant discomfort if cervix is tightly closed and may lead to inadequate sample for assessment. Hysteroscopy is the next step in such cases which can be done under general anaesthesia. Its advantages includes assessment of uterine cavity and sampling of abnormal areas in endometrial lining. However its disadvantages include need for general anaesthesia and hospitalization even as a daycase procedure. It can be done as an outpatient procedure as well. Other disadvantages includes uterine perforation, haemorrhage and infection. Atypical hyperplasia of endometrium has a risk of progression to endometrial carcinoma of about 25 to 50%. Women should be informed of this risk and hysterectomy should be offered. Advantages and disadvantages of hysterectomy are discussed. It is needed to prevent the risk of progression to endometrial carcinoma. However it needs hospitalization and its complications include anaesthetic, operative complications like risk of haemorrhage, damage to bladder, ureter, bowel, need for blood transfusion, return to theatre for additional stitches and postoperative complications like urinary retention and urinary tract infection. Removal of ovaries is also discussed preoperatively especially if there is a positive family history. In cases where surgical treatment is not suitable either because of anaesthetic fitness or coexisting diseases one option is to offer progesterone like megestrol acetate and repeat endometrial sampling in six months. Long term followup is necessary in such cases.
		Posted by Dr Saibal S. Fri Feb 9, 2007 12:10 pm
A. Post menopausal bleeding is associated with risk of endometrial cancer in 8-10% of women,which increases with age so prompt assessment is essential. 90% women will be idiopathic or have benign causes like vulval and vaginal atrophy, trauma or erosions. Cervical polyps or trauma,vaginal foreign body like a forgotten pessary can be causal.These conditions may be likely with a history of vulval pain and soreness,recent trauma or pessary fitting.Smear history will help to rule out cervical cancer. History of early menarche before 12 years and late menopause after 50 will indicate excessive estrogen influence with increased risk as will a history of nulliparity and unopposed estrogen replacement or possible sequential combined HRT. Weight loss,lethargy may point to a sinister cause.BMI should be calculated as obesity increases risk. Some women may not have any significant history. General examination to rule out anaemia and undetected hypertension should be done. Abdominal examination to rule out tenderness or pelvic mass. Vulval examination to exclude erosions or trauma , urethral caruncle, perineal exam to rule out haemorrhoids . Speculum exam for cervical smear if never done in the past or abnormal in the past with inspection for polyps, trauma , foreign body like pessary, signs of estrogenisation/atrophy. Bimanual palpation for uterine and adnexal pathology is essential. B. Subsequent examination ideally in a dedicated postmenopausal bleed clinic. Transvaginal ultrasound is highly effective in detecting endometrial cancer if endometrial thickness >4 mm,irregular outline or fluid in the uterus.If none of these found women can be assured and discharged as risk of malignancy in very low without the anxiety of additional investigations.TVS is the 1st mode of screening. Can also detect other pathology like ovarian cysts. , adnexal mass ruling out causes like the rare granulosa tumour or fallopian tube tumour. If any abnormality detected as above outpatient biopsy with pipelle(samples 5% endometrium ) or vabra curette can be done.But sensitivity is low and malignancy can be missed. Also misses other pathology like polps .D/C is not recommended for outpATIENT diagnosis. Outpatient hysteroscopy with fibrooptic hysteroscope can be done under pudental block and highly acceptable to patients. Directed biopsies can be taken , Small polyps can be avulsed and highly sensitive.Problems may be faced in a small no. of women due to cervical stenosis, or pain. MRI may be used for clinical staging in case of malignancy as highly sensitive in assessing nodal involvement and depth of uterine and cervical involvement. Full blood count to rule out anaemia, LFT and KFT to ensure adequate liver and renal function and ECG for cardiovascular status. C. The woman should be told that there a thickening of the womb lining which is the cause of bleeding.Most of the changes regress over time but in her case a complex thickening can cause cancer of the womb in 20% cases. She should be explained that the optimum treatment is the removal of the womb along with the ovaries at her age as it will prevent cancer, and as the ovaries are no longer functional. Alternative treatment discussed should be use of progesterone treatment to decrease the hyperplasia which is done in younger [patients who wish to retain the womb and fertility,require regular scans abd biopsies with the risk of cancer developing in 20%. She should have a followup appointment with the consultant gynaecologist to discuss treatment and information about endometrial hyperplasia and printed information on TAH BSO. Website information on atypical hyperplasia from Cancer help uk will also be helpful for information about cause and treatment. Treatment should be according her preference and consent should be taken after explaining risks and benefits, postoperative care and recovery of TAHBSO.
		Posted by Dr Saibal S. Fri Feb 9, 2007 12:23 pm
[:eek:] Forgot to mention the risks of TAH BSO, its what this question wants. Vaginal hysterectomy appropriate unless previous adhesions and difficult removal.Laparoscopy assisted hysterectomy also possible, 2 out of 100 women will have the given risks lin abdominal procedures like 0.7 % bladder and ureteric damage,1.5% chance of bleeding ,0.04% risk of damage to bowel.
		Posted by SWATI M. Fri Feb 9, 2007 01:14 pm
Further evaluation is needed urgently as risk of having endometrial cancer is 10%. Details of symptoms such as pus like discharge, foul smell,fever, abdominal lump which may suggest pyometra should be enquired.Identify risk factors for endometrial cancer nulliparity, early menarche ,late menopause, family history of colorectal cancer. Postcoital bleeding suggest cervical pathology and ask details of last pap smear. Associated symptoms such as anorexia, recent weight loss are suggestive of malignancy. Clinical examination performed for any abdomino-pelvic mass ,hepatomegaly. Speculum examination done for any lesion/ growth at cervix, note if vaginal atrophy , which may be cause.Note uterine size , mass, tenderness on vaginal examination. b) Transvaginal ultrasound to estimate endometrial thickness has sensitivity of 80 ?100 % to detect endometrial cancer,minimally invasive ,acceptable to most women,but different cut off levels- 3,4,5 mm -are used ,have high false positive rate and not sensitive to detect polyps. Additional information ovarian pathology, presence of ascitis can be obtained. Endometrial sampling by pipelle,vabra aspirator for histological assessment is a simple, outpatient procedure, has high sensitivity , causes minimal discomfort. It may be difficult/ unsuccessful due to cervical stenosis , is a blind technique, likely to miss focal pathology and endometrial polyps. Vabra aspirator is more painful than pipelle. Hysteroscopy and biopsy can be performed as outpatient with flexible hysteroscope, avoids admission, need for GA, acceptable to most women and cost effective but only small biopsy can be obtained. Inpatient hysteroscopy and biopsy is useful as less likely to miss endometrial polyps and focal lesions. Complications such as uterine perforation , infection can occur. Hysteroscopies are invasive procedures, need expertise and necessary instruments. Cervical smear is taken if due for it. If history /above investigations suggest malignancy ,further investigations are needed. FBC for Hb estimation as may need surgical intervention.WCC, CRP if pyometra is suspected. LFT?s ,Chest X ray to rule out metastasis, U & E as a baseline. MRI is sensitive to determine myometrial invasion to plan extend of surgery. c) Atypical hyperplasia is cellular abnormality in endometrium which may progress to endometrial cancer in 25-50% or may coexist in some.Hysterectomy is recommended treatment.Fate of ovaries should be discussed. At her age ovaries are not functional, removal will reduce risk of ovarian cancer but not primary peritoneal malignancies. Oophorectomy is not must to treat present condition unless has coexistent endometrial cancer. Abdominal, vaginal, laparoscopy( key hole) routes for hysterectomy ,benefits, risks should be discussed.Vaginal and laparoscopic route are associated with less morbidity and early recovery. With abdominal route oophorectomy can be easily performed, surgery can be extended if malignancy is detected intraop but associated with more morbidity ? haemorrhage, infection, bowel/ bladder injuries. If surgery has been declined it may progress to malignancy.Alternative option is to use high dose progestogens but the disease may still progress and need prolong follow up with endosampling / hysteroscopy. Provide follow up appointment and provide related information leaflets. She will need prolong follow up if endometrial cancer is detected in histology specimen of hysterectomy.
		Posted by Srivas P. Fri Feb 9, 2007 06:32 pm
a)About 12% of PMB is due to malignancy, of which 8 % could be due to endometrial Cancer. Cervical, ovarian, vaginal, fallopian tube malignancies can also present with PMB and very rarely extra genital causes like bladder, rectal ,and colon cancers present like this .A larger 88% cases are due to benign cause?benign polyps, atrophic endometrium, endometrial hyperplasia, urethral caruncle, vaginal candidiasis, prolapse uterus. History should look for risk factors?nulliparity, obesity, early menarche, late menopause, family history of endometrial cancer, any treatment with sequential HRT?all these increase her chances of endometrial cancer. History of COC for more than 3years in the past, decrease her risk of ovarian and endometrial cancer by almost 50%-This effect lasts almost 15 years after stopping COC. Post coital bleeding should be asked as may indicate cervical cancer. Her cervical screening history should be taken. BMI, Abdominal examination for pelvic masses, vaginal, vulval and cervical examination to rule out obvious pathology and pelvic examination for adnexal masses and uterine size should be done. Rectal examination is helpful to rule out anal fissure and haemohoids. b)TVS measurement of endometrial thickness is very effective in detecting endometrial pathology, is simple, less expensive and non invasive. A higher cut off of 5 mm on endometrial thickness is taken if she is on Sequential HRT. A cut off of < 3mm on USG on woman who has never taken HRT or is on Combined HRT reduces the likelihood of endometrial cancer to less than 0.6-0.8%. Such woman can be reassured and followed up with hysteroscopy and biopsy if there is recurrence of symptoms. USG can also detect ovarian tumors undetected by clinical examination. A saline Sonohysterography improves detection of endometrial polyps and sub mucous fibroids. Hysteroscopy with endometrial sampling by pipelle or vabra aspirator are the gold standard for investigation of PMB especially indicated if endometrial thickness is higher than cut off described for USG. This procedure misses malignancy only in 3% cases. Can be done as OPD procedure, it reduces anxiety and costs to the patient. Blind endometrial aspirate without hysteroscopy can also detect endometrial hyperplasia and cancers but misses lesions like polyps hence it is best combined with hysteroscopy. She may need GA and inpatient procedure if she is anxious, has vaginal narrowing or has cervical stenosis. Cervical smear is not indicated in a well screened woman with no pathology based on cervical screening program. Other investigations like three dimentional USG and color flow Doppler are not cost effective and are under evaluation before routine use. Similarly D & C is no longer the first line investigation for PMB as it misses pathology in 10% cases. c) I will tell her that atypical endometrial hyperplasia is a premalignant condition of the uterus and in 10-20% cases may be associated with underlying endometrial carcinoma and it may progress to invasive carcinoma in 50% cases. TAH and BSO is the best option for her. Ovaries are the site for metastasis if underlying carcinoma is present and they are best removed. If she is not willing for surgery or is unfit the only other option is high dose progesterone like Megesterol 2o mg per day for 6 months and she has to on regular 3-6 monthly follow up with endometrial sampling and hysteroscopy. I will take informed consent if she is willing for surgery and explain to her that hysterectomy can be done by abdominal-total or sub total, vaginal or laparoscopic route, under regional or GA. She will have consultation with anesthetist before the procedure to discuss anesthesia. Her BMI, cervical smear history and well screened normal cervix where subtotal hysterectomy is possible, presence of prolapse favoring vaginal hysterectomy and most importantly the choice of the patient, influence decision on type of surgery, type on incision, choice of anesthesia. Advantage and disadvantages of various procedures will be discussed. I will discuss possible but rare risk of damage to the bladder (0.1%), the ureter (0.7%), damage to the bowel (0.04%) and risk of long term bladder dysfunction. Complications like wound infection, UTI, fever are commoner and can be avoided by antibiotics. Risk of death is possible due to major complications but is around 1 in every 4000. Risk of VTE will be minimized with early mobilization, good hydration, TED stockings and use of heparin depending on her risk for VTE. She may need Blood transfusion and occasionally additional procedures in case of injury to internal structures. I will explain that normally period of stay in hospital will be 5 days and she would need to avoid straining and lifting weights for 3 months. I will give her information booklets.
		Posted by Misbah W. Fri Feb 9, 2007 11:19 pm
b]Different investigation are available forPMB in outpatient and inpatient setup but no agreed protocolhas been set up.Trans-vaginal scan[tvs]i s used to measure endometrial thickness as 3,4,5mm.Sensivity to detect endometrial malinency is 80-100%but high false positive rate.End. polyps can be detected but sensivity is low.Adnexal pathology can be seen also.Easy,non-invasive andhigh patients acceptability.Cost effective ,can be done in outpaiient.Hystero-contrast sonography is more sensitive but not readily available. Endometrial aspiration biopy can be done in out patient withdifferent deviceslike vubra and pipeiie de cournier.Have lower dedection rate for endometrial cancer And cant sample whole cavity.Samle cant be possible in some woman due to atrohic changes. Out-patienthysteroscopy and biopsy is done by using fibrre-optic scope.A cervical smear if required,and endometrial biopsy can be taken under direct vision but polyp cant be removed.Very cost effective with high patient accetance.May requir analgesia . D&c under G/A is no longer recomended due to complications. Hysteroscopy and D&C is highly recomended in patient out patient procedure is difficult or refused.Hysteroscopy should be performed before D&C otherwise may miss end. pathology .End.polyp can be removed at same time.Risk of utrine perforation is 6-13 in 1000.haemorrhage.,infection and unintended mojor operation can be overcome by trained person and antibiotics. c]Atypical endometrial hyperplasia is associated with high risk of progression to endometrial carcinama if untreated and in about 25-50% cases it co-exist with it.So she should be counselled to have surgeryas hysterectomy with ophrectomy which is treatmenr of choice .Abdominal/vaginal hysterectoy depend on patient choice and clinicians experties.It is amojor surgery and associated with risk of mortalityand morbidity withhaemorrhage,infection and thromboembolismFollow up biopsy report willhelp to decide about further management if end. carcinama is found.If she is taking exogenic stimulus she should stop that immedatly.If she is reluctant for surgery and she stops exogenc source she can be prescribed local progestrogen and follow up after 6 month with hysteroscopy. women should be provided with leaflets and discussion should be documentd Whole discussion should b
		Posted by Fahima A. Sat Feb 10, 2007 05:27 am
a) This is a case of post menopausal bleeding ( PMB), the cause of which is mostly benign but about 10% cases it is associated with endometrial carcinoma. The aim of my assessment is to find out the causes and to rule out any malignacy. First of all I will take a history whether she is on HRT or not as PMB commonly associated with HRT. History of soreness of vulva & vagina may lead to the diagnosis of atrophic vaginitis. Any personal or family history of breast ovarian or colonic carcinoma will give rise to the suspicion of familial cancer and thereby endometrial carcinoma. To rule out the risk factors of endometrial carcinoma I will make an especial enquiry about parity, early menarchae, late menopause, diabetes mellitus, hypertension & Tamoxifen therapy. History of her previous smear report & any post coital bleeding is important to detect cervical malignancy. During examination I will calculate her BMI as obesity has an association with endometrial pathology. Abdominal examination may reveal an ovarian mass & hormone secreting ovarian tumour will be detected. I will do vaginal examination to detect atrophic vulvitis & vaginitis and per speculum examination to detect cervical polyp, cervicities or carcinoma. Bimanual examination is needed to detect size of uterus & any adenaexal pathology. b) Trans Vaginal Sonogram (TVS) should be done to measure endometrial thickness (ET) & to exclude any ovarian tumour. If ET is more than 5 mm suspicion of endometrial carcinoma will arise. Sensitivity is almost 80-100% but it has high false positive rate. Saline sonohysterography may detect polyp or submucous fibroid but it depends on available expertise.Out patient endometrial biopsy simple easy & cost effective and has a sensitivity of 67-97%. Pipelle biopsy represents 4% of endometrium but easy whereas Vabra represents 40% of endometrium but painful & therefore has a less acceptability. Outpatient hysteroscopy gives an opportunity to visualize uterine cavity as well as to take biopsy. It does not require inpatient stay, so cost effective and without the risk of anaesthesia. However there may be failure to introduce canula in some cases which may lead to hysteroscopy and D&C . Blind D&C has no role in PMB. However optimal mode of investigation is unknown, usually either combination of TVS with outpatient endometrial biopsy or hysteroscopy done for the diagnosis of PMB. c)Atypical endometrial hyperplasia may give rise to endometrial carcinoma in about 25-30% cases even it may be associated with carcinoma in some cases.. The ideal treatment for her is total abdominal hysterectomy with bilateral salpingo-oophorectomy. However it is associated with anaesthetic risk, haemorrhage, injury to other organ like bladder bowel& ureter ,DVT. But if she is medically unfit for surgery or declines to do it she can be treated conservatively after excluding carcinoma. Usually oral medroxy progesterone acetate 100mg/day given for 6 months or Mirena IUS given. In either case follow up with hysteroscopic biopsy is done 3 months after cessation of treatment to confirmed that hyperplasia has regressed. Long term follow up is indicated in these cases. Patient should be given information & leaflet about the risk of conservative treatment & importance of follow up.
		Posted by sailaja devi K. Sun Feb 11, 2007 12:49 pm
At 65 yrs age the cause for blood stained vaginal discharge is benign or malignant condition of the genital tract. Clinical assessment to identify cause of blood stained discharge ,to exclude genital tract malignancy. History to identify any risk factors for endometrial cancer.Establish nature of bleeding,any precipitating factors like post coital which suggest cervical pathology or atrophy.History of weight loss,cange in bowel habit,anorexia.History of cervical smears. Enquire about age of menarche ,parity & age of menopause .Early menarche nulliparity,late menopause are risk factors for endometrial cancer.Use of oral contraceptives is protective for endometrial cancer.History of infertility ,use of unopposed estrogens in the past.Any past diagnosis of PCOS.History of breast cancer,women with breast cancer has 2-3 fold risk of endometrial cancer.History of drug use like tomaxifen.History of hormonal replacement therapy possible sequential use.History of hypertension & diabetes ,these are risk factors for endometrial cancer. General Examination of women for surgical & anaesthetic fitness.Perabdomen examination to identify mass arising from pelvis, to exclude any metastatic masses & ascites.Perspeculum examination to exclude genital tract atrophy ,vaginal tumours /ulceration & cervical poyps,cervicitis,carcinoma.Bimanual pelvic assessment to identify size of the uterus ,exclude adenexal mass & exclude abdomino pelvic mass. b) Cevical smear ,consider colposcopy if post-coital bleeding.Trans ? vaginal ultrasound is non-invasive , relatively cheap& can visualize pelvis as a whole. Endometrial thickness is an indicator of endometrial pathology.Cut-off of 5 mm ,double layer endometrial thickness has a pick up rate of 80-86 %.Sensitivity to detect endometrial malignancy is 80-100%,to detect benign endometrial polyps is 33 %.False positive rate is 25 % . Hysteroscopy & endometrial biopsy is the gold standard test to investigate postmenopausal bleeding.It allows visual inspection ,sample suspicious area directly & less likely to miss pathology.Hysteroscopy can be done as outpatient / inpatient procedure.Out patient procedure is cost effective ,acceptable,uses flexible fibre optic hystoroscope & has similar efficacy to rigid hysteroscope.It requires local anaesthesia ,avoids complications of general anaesthesia.In patient hysteroscopy has cost implications, done under general anaesthesia.Hysteroscopy is associated with complications like uterine perforation 6 in 1000,infection 3-5 in 1000,haemorrhage 4 in 1000& unintended major operation. Dilatation & curettage without visualization of the endometrial cavity is no longer considered acceptable method. Out patient endometrial aspiration biopsy be done by vibra aspirator & Pipelle.Pipelle is most acceped ,tolerated method & complications are uncommon.It is possible to miss pathology as as it is done with out visualization.It samples small portion of endometrium,picks up 70-95% of endometrial carcinoma. Other methods are MRI & markers .MRI is expensive than ultrasound,useful in staging cancer. There is no agreed protocol for investigating post-menopausal bleeding but hysteroscopy with endometrial sampling is gold standard & should be performed as an out-patient procedure where possible.TVS may be used to select women for endometrial biopsy . I will counsel that atypical hyperplasia means abnormality in lining of the womb.Carcinoma may exists in 25-50 % of cases. The risk of progression to endometrial carcinoma range from 22 ? 33 % .So offer her surgical treatment ,she will be better of with hysterectomy & bilateral salpingo-oophorectomy.Counsel her about procedure & potential unwanted outcomes.Hysterectomy with bilateral oophorectomy through the abdominal route or laproscopic approach will be better os it allows visualization of adenexa.Hysterectomy requires approximate 7 days hospital stay,can return to activities in 4-8 wks.Hysterectomy is associated with common unwanted effect like infection , less common effects like intraoperative haemorrhage,damage to other organs like urinary tract/bowel & urinary dysfunction like frequent passing of urine, urinary incontinence.Rare unwanted effect with hysterectomy is thrombosis.Death is very rare. She should know that medical treatment is not curative.The best medical available treatment is with high dose progestogens .It is safe to use for 8-12 wks as there is no evidence of optimal duration of use.She should know that long term follow up is needed as recurrences may not appear for many years.This verbal counseling should be supported with appropriate written information & proper documentation..
		Posted by Randa E. Mon Feb 12, 2007 05:09 am
a) It is important to exclude causes like endometrial, cervical, vulval and vaginal malignancies in patients who present with postmenopausal bleeding or spotting. A history including the regularity of the bleeding and association with lower abdominal pain or cramps. Postcoital bleeding might point to a cervical cause. Risk factors for endometrial cancer, like the age at menarche, at menopause and parity should be ascertained. Use of HRT, type, dose and length of time used should be known. History of weight loss and GI symptoms like nausea must be included. Any change in bowel habits must also be ascertained for all these are associated with carcinoma. Previous smear history and family history of endometrial cancer are important. Physical examination should include the BMI. Abdominal examination should be performed to exclude tenderness, masses and lymph nodes. Speculum examination should be done and might reveal blood coming through the cervical os. It might also reveal the prescence of secondary metastisis at the lower end of the vagina . Bimanual examination of the uterus for size and mobility and adenexial masses should be performed. b) Trans Vaginal ultrasonography can be used to triage cases for further investigation but is limited by endometrial thickening (cut-off point 5mm) and cystic atrophy, which will produce misleading appearances. The sensitivity for detecting endometrial malignancy is 80%-100% with a high false positive rate. Sensitivity for benign endometrial conditions like polyps is poor, around 33%. It is relatively cheap, available and non-invasive. Outpatient endometrial aspiration biopsy is relatively cheap and can be performed in an outpatient setting without anaesthesia. The Vebra devise samples 41.6% of the endometrium and the Papell de Cournier samples only 4.2%.Sensitivity of endometrium sampled is 68%-98%. A negative biopsy will still require further investigation. Also outpatient hysteroscopy and biopsy is an alternative. It is cost-effective and has a high degree of patient acceptability. Direct visualisation of endometrial cavity is possible and directed biopsies can be obtained. Sometimes procedures may require paracervical block for pain or discomfort. Hysteroscopy and D&C is considered to be the gold standard investigation. It is performed under anaesthesia. It has a high sensitivity for detecting endometrial carcinoma and benign endometrial polyps.Unfortunately the procedure is associated with risks like uterine perforation, infection and haemorrhage. An informed consent is required before the procedure. c) She should be told that this is a condition that occurs when the lining of the uterus(endometrium) grows too much. This is due to endometrial glands lined by enlarged cells with increased nuclear:cytoplasmic ratios. These hyperplasias are generally considered pre-malignant with a risk to progression to cancer in up to 29% of cases. She should know that at her age total hysterectomy and bilateral salpingo-oophorectomy (removal of the tubes) either vaginally or abdominally, would be the recommended form of treatment.Advantages and disadvantages of both procedures should be discussed. She should also be told that surgery results in survivals >95% at 5 years time. Hysterectomy is sometimes associated with serious risks e.g.injury to the bladder/ureter or bowel, haemorrhage requiring transfusion and pelvic abscess/infection. She should also be told about more frequent risks e.g.wound infection and delayed healing or the need for extra procedures e.g. repair of damaged organs. This information should be given with courtesy and respect and any uncertainties promptly discussed. She should be given enough time to make her decision and her wishes respected. Written information including details of support groups and contact should also be provided.
		Posted by kiria O. Mon Feb 12, 2007 11:30 am
Postmenopausal bleeding( PMB) mostly caused by genital tract atrophy and other causes such as polyps, cervicites and trauma. Only 10% of cases of PMB caused by endometrial cancer. Detailed history should be taken, any post coital bleeding, presence of offensive vaginal discharge, pain and weight loss. Also, drug history such as HRT and tamoxifen, both associated with increased risk of endomtrial hyperplasia and cancer. Her medical history is important as diabetes and hypertension are risk factors for endometrial cancer. In addition, her obstetric history should be acertained. General examination should include blood pressure and BMI as both hypertension and obesity is associated with increased risk of endometrial cancer. Abdominal examination for abdominopelvic masses and ascites or hepatomegaly. Pelvic examination should include speculum exam to exclude local causes such as polyps,vaginites,cervicites and vaginal and cervical atrophy. Bimanual examination to look for pelvic mass and uterine size. The main aim of investigation is to exclude endometrial cancer. Ultrasound scan for endometrial thickness is very usefull although, the cut off point is contraversial, endometrial thickness more than 3-6mm is considred highly suspecious and endometrial sampling is essential to exclude endometrial cancer. Pipple endometrial sampling is of a great value as it performed in out pateint clinic,easy to do with very good sensitivity 89% in detecting endometrial cancer however, corneal pathology maybe missed as sampling is blindly performed and many women find it painfull. Out pateint hystroscopy and endometrial sampling is of agreat value as direct visulization of endometrial cavity and any suspecious area is sampled under direct vision. the problem with this model is that, it is not avilable inall out pateint clinics and can not take large biobsy or remove polyps. In pateint hystroscopy and endometrial biobsy only performed if out pateint investigation is failed because of stenosed cervix or difficulty in obtaining sample, it needs general anasthesia and some forms of treatment such as polyp removal is possible. I would explain the diagnosis of endometrial hyperplasia to her(abnormal growth in the lining of the womb but it is not a cancer) Pateint should know that, the condition is potentially precancerous and may chang to cancer in 25 out of 100 women. Also,she should be counseled regarding need for treatment and the best option is hysterectomy to eleminate the risk of endometrial cancer. Endometrial ablation is used in some places for treatment of endometrial hyperplasia but still contravercial issue. If she refuse surgery should be counsled regrding option of tratment with very high doses of progestagens with long duration and need for follow up by regular endometrial sampling.
		Posted by Shyamaly S. Tue Feb 13, 2007 07:28 am
A healthy 65year old woman has been referred to the gynaecology clinic because of a 3 months history of blood-stained vaginal discharge. (a) Justify your clinical assessment [5 marks]. (b) Clinical examination shows a blood-stained vaginal discharge but no other abnormalities. Evaluate the options for subsequent investigation [8 marks]. (c) A diagnosis of atypical endometrial hyperplasia is made. How would you counsel her? [7 marks]. A) This patient has postmenopausal bleeding (PMB). It is imperative that she was referred on the 2-week wait system to ensure rapid investigation. PMB is associated with 10% risk of gynaecological malignancy, of which 80% are endometrial cancer, and the rest are cervical cancer, vaginal and vulval cancers. A history of nulliparity, late menopause, use of unopposed oestrogens would alert to endometrial cancer. Previous abnormal smears or postcoital bleeding may suggest cervical pathology. History of urethral or rectal bleeding should be sought- these are often confused with vaginal bleeding or may suggest rectal or bladder invasion. A family history of endometrial, ovarian or colonic cancer may suggest the Lynch syndrome and an increased risk of endometrial cancer. Cachexia or weightloss would also increase the suspicion of malignancy. Raised BMI would increase the risk of endometrial cancer. Abdominal and bimanual examinations would assess for any ovarian tumours secreting oestrogen, an enlarged or fixed uterus suggesting invasive malignancy. Cervical and groin lymphadenopathy should be noted. Speculum examination would assess the cervix for malignancy or polyps and for atrophic vaginitis. B) A smear test should be performed to detect dyskaryotic. Endocervical and High vaginal swabs may be performed to exclude genital tract. This is important if she exhibits high-risk sexual activity. Transvaginal ultrasonography and endometrial biopsy together have a high sensitivity for endometrial cancer. Using 5mm as a cut off for endometrial thickness, TVUSS has a 90%sensitivity to detect endometrial pathology. It also enables ovarian assessment and ascites detection. It is well tolerated by patients and can be performed quickly as an outpatient. Endometrial sampling can be performed using a Pipelle, which samples 4% of the endometrial surface and has a sensitivity of up to 97% for endometrial cancer. This maybe performed as an outpatient. It is uncomfortable but is well tolerated. The Vabra sampler utilises electronic suction. It can be performed as an outpatient and samples 40%of the endometrium, but is more painful than the pipelle. Outpatient flexible hysteroscopy enables the uterine cavity to be visualized and directed biopsies can be taken. It is well tolerated by patients. If these outpatient procedures are not possible or the patient declines, hysteroscopy and curettage can be organised under regional or general anaesthetic. This is the gold standard. It enables visualisation of the cavity, extensive biopsying and treatments for benign disease but is associated with significant anaesthetic risks. This is one of the reasons why curettage alone under GA is no longer recommended. Inpatient hysteroscopy is also associated with higher costs. C) I would explain that abnormal cells have been found with an overgrowth of the lining of the womb. No cancer cells were seen, but there is a 25-50% chance that this may develop into a cancer and there is also a significant risk that there may already be a coexisting cancer that has not been sampled. I would recommend Total Abdominal Hysterectomy and Bilateral Salpingoophorectomy as the treatment of choice. The benefits are that it gives a cure for endometrial hyperplasia so that long-term follow-up is unnecessary. It enables a full histological diagnosis to be made- if endometrial cancer is found 10 year follow-up will be organised. If there is evidence of invasion further treatment with radiotherapy maybe necessary. Removing the ovaries also reduce the risk of ovarian cancer. This is major surgery, which would require a 5-day hospital stay and a prolonged recovery period at home. The operation itself involves a risk of bleeding, infection, damage to the bladder, ureters and bowels and thrombo embolic disease and anaesthetic risks. Laparoscopic Vaginal hysterectomy with bilateral salpingoophrectomy is an approach available for the treatment of women with endometrial hyperplasia if the appropriate skills are available. The alternatives if she refuses surgery are medical treatment with progesterone and repeat hysteroscopy and curettage in 6 months, or no treatment, but this would not be recommended as there is a high risk of developing invasive cancer. I would give her leaflets to support this discussion.
		Posted by Abi T. Tue Feb 13, 2007 09:57 pm
a)PMB should prompt quick diagnosis and exclusion of endometrial CA in the first instance, ideally within 2 weeks of presentation to clinic.The majority of patients with PMB have benign pathology. Other genital malignancies which may present similarly are vulval, vaginal and cervical Ca. A good history should be obtained to ascertain risk factors for endometrial CA such as nulliparity, early menarche, late menopause, exogenous estrogens in the form of HRT and a family history of endometrial CA,ovarian and colon CA(or HNPCC). Smear history should be obtained to ensure they are uptodate and normal. A history of postcoital bleeding may suggest cervical pathology. A history of dyspareunia and irritative bladder symptoms may indicate atrophic vaginitis. Rectal bleeding and hematuria may suggest bowel and bladder pathology respectively, as bleeding from these areas can be confused with vaginal bleeding.a Abdominal examination would be to detect any pelvic masses the vulva and vagina inspected to detect atrophic changes and any suspicious lesions. speculum examintaion should be done to detect any cervical lesions such as polyps. A bimanual examination is done to detect and adnexal masses suggesting ovarian pathology. A large, irregular, fixed uterus is suspicious of malignancy. b) A TVS should be done initially as it has a 90-100% sensitivity for detecting endometrial pathology. It is well tolerated.If a cut off point of 5mm is used for endometrial thickness, there is low likelihood of CA and the patient can be reassured. It also has the advantage of ovarian assesement and for presence of ascites. CA125 should be done if ovarian cysts are present. Endometrial sampling can be done in the outpatient setting using either a Pipelle or the Vabra aspirator. The Pipelle is usually better tolerated. The Vabra aspirator samples more than 40% of the endometrium but is more painful. Hysteroscopy and endometrial biopsy is the gold standard investigation. This can be done in the outpatient setting which avoids the risks of GA and inpatient stay. The entire endometrial cavity can be visualized and any polyps can be removed as well as opportunity to do targetted biopsies of suspicious areas. If outpatient procedures are unsuccesful or patient does not accept , then inpatient hysteroscopy is warranted. This is done under regional or general anaesthetic and has the advantage of being able to do a proper EUA as well. c)I would explain the diagnosis and implications to her in a sensitive manner. This is an overgrowth of the lining of the womb with some abnormal changes in the cells. This is a premalignant condition with 25-50% coexistent CA already present. 10-20% of women may progress to CA. There is no place for expectant management. The treatment of choice is a TAH and BSO. This allows for adequate inspection of the pelvis and removal of the ovaries is necessary to eradicate any potential source of estrogen. This would be curative if histology subsequently confirms CA.(up to Stage 1b) However this involves GA and the risks of the procedure must be discussed, eg bleeding, infection, thrombosis, bowel, bladder, ureteric damamge and the risks of GA. This also necessitates inpatient stay. If she refuses surgery, she should be aware that regular follow up is necessary with repeat endometrial sampling. The sampling may not always be accurate as small foci can be missed. High dose oral progesterone with medroxyprogesterone for 6 months may be an option, but there is no clear consensus as to the duration and regularity of followup as endometrial CA may present even after many years after cessation of progesterone treatment. The LNG IUS may not be suitable as the irregular bleeding may be confusing and repetituous endometrial sampling may be required. A leaflet supporting the above information would be provided and her wishes taken into account.