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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 253 - PMB
ESSAY 253 - PMB Posted by PAUL A.
Sat Jan 12, 2008 05:23 am
A healthy 55 year old woman is referred to the gynaecology clinic because of a 3 months history of vaginal bleeding 5 years after her last menstrual period. (a) What additional information would you obtain from the history ? [7 marks] (b) How would you investigate her symptoms? [6 marks] (c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].
Posted by S M.
Sat Jan 12, 2008 06:55 am
(a) What additional information would you obtain from the history ? [7 marks]

I will take a detailed history starting with her presentic complaint, and then going on to her obstetric, medical and family history.

I will start with asking her about the nature of the bleed and whether or not the bleed was associated with intercourse or accompanied with foul discharge. I will ask the lady if she suffers from vaginal dryness and other menopausal symptoms. I will ensure that she has not sustained any trauma in the perineum and is not using pessaries for uterovaginal prolapse. I will enqire about her menarche and also find out is she has any children. I will take a smear history.
I will find out if she suffers from diabetes, hypertension, polycystic ovarian syndrome or bleeding diasthesis. I will also enquire about past history of breast cancer. I will ask her if she is on any medication like HRT, Tamoxifen or Anticoagulants.
I will find out if she smokes or not
And last but not the least, I would enquire about family history(esp first degree relatives) of cancers like breast, ovarian and endometrial cancer.

(b) How would you investigate her symptoms? [6 marks]

Since 10% of patients with post menopausal bleed have endometrial cancer, PMB warrants urgent and detailed investigations.
I will arrange for an FBC to be done if the lady complains of heavy bleeding.I will also take a smear and arrange for an urgent USS (ideally TVS) for endometrial thickness. If the endometrial thickness is greater than 5, if there is a polyp seen on scan or if the lady is at a high risk of developing endomerial cancer I will proceed with hysteroscopy.Hysteroscopy can be performed in outpatient setting or under GA. Out patient hysterteroscopy has the advantage of being immediate and cost effective.

Another procedure that I can performin low risk women in an outpatient setting is a pipelle biopsy but it will not be able to sample the whole of the endometrium and can miss the pathology. Moreover some women can find it uncomfortable.

Facilities for Sonohysteroscopy are also available in some centers.

If the diagnosis of endometrial cancer is established by hysteroscopy, further investigations for determing the extent of disease will need to be performed.

(c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].

Treatment of patient with atypical endometrial hyperplasia should be individualized and ideally started after consultation with Gynae oncologist.

Simple atypical hyperplasia has a 8% and Complex atypical Hyperplasia has a 30% risk of developing into adenocarcinoma of endometrium.

The conventional treatment for atypical hyperplasia is total abdominal hysterectomy with bilateral salphingo oopherectomy. The advantages are that it definitively sorts out the problem at hand and decreases the hassle of follow up. However it is a major surgery and is associated with risks of infection, bleeding, injury to internal organs and pulmunary and thromboembolism. The risks are more pronounced in women who are obese or have coexising chronic medical problems.

In these women, TCRE (trans cervial resection of endometium) is thought to be an option. However, this too is not without its share of risks and would require follow up.

Mirena coil and oral prgestagens can be considered if the patient declines or is not suitable for either of the previous two options. This option would warrant careful follow up and patient cooperation with treatment.

In any case, the patient should be given detailed verbal and written information and allowed to make a decesion for herself.
Posted by Anna A.
Sat Jan 12, 2008 12:28 pm
1.This patient has post menopausal bleeding, therefore possibility of endometrial cancer should be ruled out. The significant of post menopausal bleeding (PMB) should be determine by asking the number of pads used and the presence of blood clots. Question should be asked if it was associated with post coital bleeding. The duration of last cervical cytology and the result should be obtained. Presence of diabetes mellitus and hypertension, early menarche are the risk factor to develop endometrial cancer. History of breast cancer with Tamoxifen treatment should be asked. The use of hormone replacement therapy is associated with withdrawal bleeding. Smoking is a protective factor toward endometrial cancer but nulliparous and family history of gynaecological cancer is associated with higher risk of endometrial cancer. Constitutional symptoms like loss of weight or appetite with bowel symptom are useful information. The posibility of rectal bleeding or haematuria should be determined.
2.Cervical smear or colposcopy if any abnormality on the cervix should be performed. If there is presence of suspicious growth, punch biopsy is justified to role out cervical cancer. Transvaginal scan should be done to lmeasure for endometrial thickness and it has 80-100% sensitivity to detect endometrial cancer. Presence of adnexal masses with PMB may be suggestive of oestrogen secreting tumor. Pipelle or Vibra is acceptable method for assessment of PMB but it can miss endometrial polyps. Outpatient hysteroscopy and biopsy has similar effectiveness in detecting endometrial pathology but large polyps can not be removed. Hysteroscopy with D&C is a gold standard for investigating PMB but it is associated with complication like uterine perforation, bleeding, infection and haemorrhage. Rectoscopy or cystoscopy is required if clincially indcated.
3.Atypical hyperplasia has 50-75% risk to develop endometrial cancer and 25% of them may have an early stage of well differentiated endometrial cancer. Therefore, a conservative treatment is associated with higher risk of endometrial cancer. Medical treatment with high dose progestogen to revert atypical endometrial hyperplasia is not a good option if the patient is having concurrent breast cancer. Hysterectomy and bilateral salpingectomy is the best option of management for atypical hyperplasia in a menopause patient as there is no issue of fertility anymore. In this patient, vaginal route would be the most appropriate as it is associated with less morbidity and mortality as compared to abdominal route. The patient should be given thorough information and discussions to enable inform decision. Follow up and written information leaflet should be given to the patient.
Posted by Sahathevan S.
Sat Jan 12, 2008 06:04 pm
(a)What additional information would you obtain from the history? [7 marks]
Post menopausal bleeding (PMB) is the most common presenting symptom of endometrial carcinoma. I will ask detailed history to asses the risk for endometrial carcinoma and also information related to other differential diagnosis of cervical,vuval and vaginal malignancies. Also ask nature of the bleeding whether it is cyclical any association with sexual intercourse. I will also inquire whether she is nulliparous. History of HRT in more detail duration of its use and type of HRT will benefit to assess her risk. History of GI symptoms such as change of bowel habit and weight loss may suggest malignancy.Cerviac smear history and any cervical atrophy may be useful for futher investigation. I will inquire her family history of endometrial carcinoma, ovarian carcinoma or bowel cancer as it may increase the risk.

(b) How would you investigate her symptoms? [6 marks]
PMB should be investigated rapidly and accurately as up to 8% of women with PMB will have endometrial carcinoma. .Clinical examination should be carried out to identify any abdominal or pelvic masses pelvic emanation to look for genital tract atrophy, vlulval and vaginal tumors or ulceration, cervical polyp, cervicitis and obvious malignancies.
A Bimanual examination to assess the size of the uterus and mobility and adnexal masses.Cervical smear test may be required .if any suspicious lesion in the cervix colposcopy and biopsy is indicated.
Transvaginal ultrasound scanning (TVS) is an accurate method of initial investigation which look at endometrial thickness, including visualization of ovaries, if she has thin
(Different cutoff point used 3-5 mm )) regular endometrium can be reassured without futher investigation as negative predictive value almost 100% in excluding endometrial carcinoma. If the scan findings are abnormal she should be investigated with Hysteroscopy and endometrial biopsy which can be provided as inpatient procedure or out patient settings. Hysteroscopy and endometrial biopsy (EB) is regarded as the gold standard for diagnosis of postmenopausal bleeding. Out patient hysteroscopy higher patient acceptability and very cost effective, however if out patient hysteroscopy fails or if it is not available inpatient hysteroscopy and D&C is the suitable choice of investigation.
Out patient endometrial biopsy (Pipelle or vibra aspirator) is also a choice which is safe reliable and cheap. It may cause significant discomfort in 10 % cases, and there may be failure of canulate in 20% of cases. The pathology can be missed in some cases. Optimal mode of investigation is cotraversial. TVS and out patient EB or out patient hysteroscopy and biopsy may be suitable in majority of the women.

(c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].
Natural history of endometrial hyperplasias coexisting endometrial carcinoma, ovarian carcinoma and risk of progression to endometrial carcinoma.
If atypical endometrial hyperplasia has been diagnosed using an out patient instrument ( Pipelle or Vibra aspirator ) she need a formal examination under anaesthesia (EUA) and hysteroscopy and curettage are required. EUA should include palpating adnexa and endometrial and endocervical assessment to exclude coexisting malignancies.A serum Ca 125 and oestradiol investigation may be useful to investigate ovarianpathology.If she is on estrogens therapy or Oestrogen HRT she should be adviced to discontinue.Endometrial hyplasia coexisting with endometrial carnoma in 25-50% of cases. therefore Hysterectomy and Bilateal salphingo ophorectomy is the recommended option , however if she declines to have surgical option , she can be managed with medical therapy and repeated curettage or Conservative management ( Doing nothing ) . Persistent and progressive symptoms with risk of disease progression is the major concern with conservative management. Progestin can be given as short term courses or as continuous therapy but she should be warned that she may need it for many years. She can be treated with moderately high doses of prtogestins atleast 20mg /day megestrol. Long term and follow up is essential as recurrences may not appear for many years. However there is no reliable medical evidence to judge this treatment
Posted by Shankaralingaia N.
Sat Jan 12, 2008 08:19 pm
Post menopausal bleeding is a high risk and needs urgent referral to the one stop gynaecology clinic.
a)I would like to get further information on the use of any form of HRT,loss of weight, loss of appetite,history of vaginal dryness and about the amount of bleeding.Information about the last cervical smear and the result of it is essential.I would ask about the obstetrics history and the age of menarche.Obtaining personal history of breast cancer or bowel cancer is important.I would like to know any history of hypertension,diabetes and poly cystic ovaries.Family history of breast cancer,ovarian,endometrial and colorectal cancer is paramount.I would like to know if she is on any medication like warfarin or tamoxifen.
b)Urgent investigation and diagnosis is vital in treatment of the affected.Depending on the amount of bleeding we may request FBC.She needs an urgent transvaginal pelvic ultrasound scan to measure the endometrial thickness and identify any polyps.If greater than 3-5mm(depending on the type and duration of HRT) needs urgent hysteroscopy and endometrial biopsy.
Outpatient hysteroscopy is ideal for most of the women and avoids the need for general anaesthesia.Hysteroscopy can identify irregularly thickened endometrium,polyps or any other pathology.Avulsion of the polyp if present and endometrial curretting is sent off for urgent histology.
c)The suggested treatment for atypical endometrial hyperplasia is hysterectomy.Women should be shown lot of emphathy and support while breaking this news.
Atypical hyperplasia can be simple or complex.There is an increased risk of developing adenocarcinoma of the endometrium.After liasing with the oncologist I would discuss treatment options with the women.The main treatment option is hysterectomy and bilateral salpingo oophorectomy explaining risk associated with it in terms of infection,bleeding,injury to bowel,bladder and blood vessel and the risk of thrombosis.If this is acceptable the it should be done urgently and specimen should be sent for an urgent histology.
If she declines hysterectomy then she needs provera treatment or mirena coil insertion with close survelliance by frequent transvaginal ultrsound scans to monitor endometrial thickness.She should be explained about the risk of developing endometrial cancer and the need for regular monitoring.
Leaflets and support group information has to be given and give adequate time to take decision.
Posted by Idris O.
Sat Jan 12, 2008 08:30 pm
a) Important to identify risk factors in this woman with post menopausal bleeding. I would ask her the nature of the bleeding, if postcoital or associated with offensive vaginal discharge. Associated symptoms like dysuria , blood stained urine or bleeding from the rectum. History of pelvic swelling. I would ask about her parity and the age at Menarche as low parity increases the likelihood of endometrial carcinoma. I would ask about the result of her most recent cervical smear. I would ask for a family history of breast, ovarian , endometrial or colon cancer. I would ask if she was on HRT for menopausal symptoms and if she was complying with the medication..I would ask about the type of HRT as unopposed oestrogen increases the risk of endometrial cancer.
b) I would check her FBC to determine her haemoglobin and her WCC may suggest infection.
I would group and save because may require blood transfusion.
Urinalysis may suggest UTI and this would be confirmed with a m/c/s.
I would perform a TVS looking for ET > 5mm . I would also look for any endometrial polyp . I would assess the adnexae for any ovarian masses as this may be the estrogen source of the bleeding.
If there is any ovarian tumour , I would check the Ca-125 & LDH assay , to assess the nature of the ovarian tumour..
I would examine the vulva and vagina for atrophic changes and bleeding from the vagina in atrophic vaginitis. The cervix for any abnormal lesions and perform a smear if one is due. I would also counsel the woman for a pipelle biopsy as this may show the cause of the beeding. Sono- hysterography may help in the evaluation of endometrial polyp.The goal standard is diagnostic hysteroscopy and directed biopsy especially if inadequate specimen from a pipelle biopsy.
C) I would explain to the woman the diagnosis. The first option is expectant management. The benefit is that it prevents the complications of surgery and the side effects of progestogens.This has no role in atypical endometrial hyperplasia.This is because of the risk of co- existing cancer of the endometrium of 25-50% which may be missed by the biopsy. There is also and increased risk of progression to endometrial cancer of 22-88% without treatment.I would offer her information leaflets and document this discussion.
Medical treatment with progestogens is the second option. This may be administered systemically or locally. Systemic progestogen are not associated with the complications of major surgery.However, there side effects include bloating, irregular vaginal bleeding and the development of ovarian cyst. They are given in high doses for 3-6/12. After treatment she needs to be followed up for repeat biopsy to see resolution of lesion. She would require long term follow up as recurrence of atypical hyperplasia and malignancy as been reported after long interval following this treatment. If systemic progestogen fails she may still require surgery.
Locally administered progestogen like mirena , delivers progestogen locally and avoids some of the side effects of systemic progestogens. It may not be appropriate because associated with irregular vaginal bleeding. This may be confused with persistence or recurrence of atypical hyperplasia It also does not treat occult carcinoma which may be present in this case.
Surgery in the form of TAH+BSO would be the last option. This ensures that the endometrial pathology is removed as well as possible source of oestrogens( the ovaries). It provides cure and remove any occult carcinoma. After surgery,there would be no need to follow up this patient,. If there was a malignancy , rarely involves more than superficial invasion of the myometrium, this treatment would be effective. This may however, not be acceptable to this patient either because it is a major operation and associated with complications. This complications include frequently occurring like post operative pain, and wound infection. Major complication include bleeding requiring blood transfusion, injury to bladder, bowel and ureter. There is also risk of TE and prolonged hospital stay.
In view of the age of this patient and the fact that she?s healthy , surgery would be the best option as it provides a specimen for pathological confirmation of the diagnosis. If she however, insists on medical treatment , I would ask for a second opinion from my senior colleague.
Posted by SAIMA A.
Sat Jan 12, 2008 10:12 pm
To rule out sinister causes of postmenopausal bleeding additional informations are needed.I will ask her whether she is uptodate with her cervical smears and was it abnormal ever to rule out cervical malignancy.History of postcoital bleeding is important as it indicate cervical cause or vulvovaginal atrophy.Risk factos for endometrial malignancy such as nulliparity,early menarche , late menopause and use of unopposed estrogen should be determined.I will ask about HRT type,duration and compliance .History of anorexia and weight loss have association with malignancy.History of haematuria or rectal bleeding to exclude bladder and bowel cause should be taken.Family history of breast,ovarian or colon carcinoma should be ascertained to exclude genetic cause of malignancy.
Post menopausal is associated with malignant causes in 10% of cases out of which 8% due to endometrial malignancy and other 2% due to cervical ,vulval or vagianl malignancies.If she is not upto date with cervical smear,cervical smear should be done. Transvaginal ultrasound should be done as it is 80-100% sensitive in detecting endometrial malignancies at a cut off point level of 5 mm for endometrial thickness but associated with high false positive rates and 33% sensitivity of detecting beningn endometrial polyps.TVS is also helpful in detecting ovarian pathology and ascites. Outpatient endometrial aspiration sampling has sensitivity of 80-96% and provide histology by pipelle biopsy or vabra aspiration. Pipelle biopsy sample only 4%of endometrium whereas vabra sample 40 %of endometium and associated with pain and both of them don?t detect endometrial polyp. Outpatient hysteroscopy with flexible hysteroscope allows visualization of endometrial cavity and directed biopsies and avoids the anaesthetic risks as it can be done in outpatient under local anaesthesia.However sometime it is not possible to do outpatient hysteroscopy due to cervical stenosis and it is also not possible to treat endometrial polyp at same time.If outpatient aspiration samplingis not helpful or outpatient hysteroscopy is not possible then inpatient hysterosscopy and curettage is 100% sensitive in detecting endometrial pathology and treating endometrial polyp but associated with anaesthetic risks and complications of procedure such as perforation and haemoorrhage.
Atypical endometrial hyperplasia is associated with progression to malingnacy and also associated with 30-40% presence of coexistant carcinoma so conservative treatment without doing anything is associated with progression to carcinoma.Similarly progesterone treatment is associated with delayed diagnosis of carcinoma and need of regular followup and endometrial biopsies.TAH+BSO is treatment option for her and she should be provided with verbal and written information about the benefits and risk of this. TAH provide histology and removal of abnormal growth and further treatment accordingly .and BSO reduce the risk of ovarian carcinoma although doesn?t completely eliminate it .However this is major surgery and associated with anaesthetic complication and risk of venous thromboembolism,bowel and bladder injury and hemorrhage.She should be provided with written inforantion and contact detilals and followup appointment should be arranged.
Posted by Srivas  P.
Sun Jan 13, 2008 03:57 am
(a) As 10% cases of PMB are due to malignancy, of which 8% is due to endometrial carcinoma, I would like to assess her risks for it-any history of nulliparity, infertility, early menarche, as these factors increase her risks. H/O endometrial cancers, colonic cancers in the family which may suggest a Lynch Syndrome should be asked. I would enquire about her cervical smear history.

Any loss of weight, lower abdominal pain, uneasiness or distension, malaise?as estrogen secreting ovarian tumours may cause PMB and may present with these complaints. Post coital bleeding history may suggest cervical ectropian, polyp and cervical malignancies.

I would ask if she is taking HRT, enquire regarding compliance, if she is taking any antibiotics recently which might have increased estrogen metabolism causing break through bleeding, any vomiting, diarrhea interfering with absorption, all these likely to cause bleeding when on CCHRT.

(b) I would take cervical smear if due and if it is abnormal I would investigate further by doing colposcopy, cervical biopsy and Endometrial sampling.

TVUS is useful to assess endometrial thickness, endometrial polyps, adnexal mass. Different cutoffs have been used for endometrial thickness with varying sensitivity for detecting endometrial cancer. A 3mm ET cutoff if she has never been on HRT, or has been on CCHRT, gives nearly 99-100% sensitivity in ruling out endometrial cancer.

Since she is bleeding continuously, I would do outpatient endometrial sampling using Pipelle?s or vabra aspirator, combining it with outpatient hysteroscopy if available. Pipelle samples only 4% of the endometrium while Vabra aspirator samples 40% of the endometrium and is better. This gives 68-98% sensitivity in detecting endometrial cancer, but sampling may fail in 20% cases.

D&C alone is not advocated now as it is misses nearly 10% endometrial cancers and less than 50% of endometrium is sampled in 60% cases and is unreliable.

Inpatient hysteroscopy with D & C is the gold standard and gives nearly 100% accuracy in detecting endometrial cancer. I would do it only if endometrial sampling yield no tissues inspite of ET more than 5mm, as it involves admission and GA.

Sonohysterography if available gives better resolution than TVUS and can detect endometrial polyps, focal thickenings. 3 dimentional scanning, color Doppler are still in experimental stage.

(c) Atypical endometrial hyperplasia is associated with co-existent endometrial cancer in 40% cases and may progress to carcinoma if left untreated in 25-30% cases over next 5 years. Hence best option for this woman is TAH and BSO. There is no benefit in conserving the ovaries in this post menopausal woman. Besides there is likelihood of metastasis in ovary if there is any undetected carcinoma in uterus. After assessing her eligibility for surgery and anesthesia, informed decision should be taken consequent to wishes of the patient. The route of TAH may be vaginal, abdominal or laproscopic. If the woman has increased BMI, the abdominal route is more risky. Associated prolapse makes vaginal route more attractive proposition. Laproscopic method requires well trained laproscopist. The major risks of hysterectomy like injury to bowel, bladder, ureter , VTE and rare risk of death of 1:4000 should be discussed with her. Possibility of requiring blood transfusions should be told and her views on it ascertained. She may need additional procedures like repair of structures if damaged during hystectomy.

She should be told about possibility of detecting endometrial carcinoma in hystectomy specimen, earlier undetected and she may need post operative review about further adjuvant radiotherapy or hormones after discussing with oncologists about stage of disease. If the specimen does not show coincident carcinoma, she does not need special followup.

If she is reluctant for hysterectomy and wishes to preserve the uterus in spite of explaining the malignant potential of the lesion or she is unfit for surgery, she may be put on high dose progestogens 20 mg /day of megesterol for 3-6 months or MPA 100mg /day with repeated endometrial sampling every 3 months under hysteroscopy. There is no role for endometrial ablation methods. GnRH analogues and Danazol have been tried but they have unfavourable side effect profile; Severe hot flushes and osteoporosis with GnRh analogue; Acne, weight gain, depression, masculinization as side effect with Danazol. It is important to impress on her the necessity of very close follow up if she is on medical therapy as she may progress to endometrial carcinoma in spite of treatment. So she would need repeated endometrial assessments.

She should be provided with information booklets and her decisions should be recorded in her case file.
Posted by N S.
Sun Jan 13, 2008 04:53 am
A) I would like to obtain detail of the bleeding that does it happens after sexual intercourse which can possibly be atrophic vulval and vaginal tissue. Also I would like to know when did she had her last cervical smear and was it normal to exclude cervical cause. I would like to know if she is on any medication for example warfarin which can cause bleeding, use of tamoxifen in case she is under treatment for breast cancer. Also like to know if she has had any medical problem like chirosis of liver where the coagulation functions are deranged. Also I would like to know that if this bleeding is like fresh blood or mixed with urine to exclude any urinary causes. Also I would ask the patient whether the bleeding was associated with bowel movement to exclude anal fissure and haemorrhoids.

B)I would like to do a clinical examination of this patient to exclude any obvious cause of bleeding for example atrophic changes of the vulval and vaginal tissues, any abnormal looking growth on per speculum examination. I possible I would like to obtain a pipelle biopsy.How ever it is important to remember that the pathological area can be missed on pipelle biopsy.
I would like to arrange an ultra sound scan to assess for any pelvic pathology and thickness of the endometrium. The thickness of endometrium greater the 5mm in size indicate urgent hysteroscopy and endometrial biopsy .Also with hysteroscopy we can exclude any other pathology like endometrial polyp for urgent results .I would also like to check the FBC to assess the haemoglobin and platelet count , also LFT?s and coagulation screen to exclude any other abnormality.

C)I would like to explain to the patient the result telling her that there are some early abnormal changes of the endometrium and there is a high risk of developing endometrial cancer at a later stage . I would advice that Hysterectomy (abdominal or vaginal route) and bilateral salpingo oophorectomy will be safe option for treatment. As the removal of ovary reduces the risk of cancer,and removal of uterus also reduces the risk of any further risk of malignancy.
The other option is to use the Progesterone in very high doses. But there is no proven benefit of this. The endometrial ablation procedures does not have any role in the management of the atypical endometrial hyperplasia.

It is a possibility that patient my not be medically fit for the surgery then the option of use of high dose progesterone with regular uscan to assess the thickness of endometrium and hysteroscopy with endometrial biopsy at a regular interval is required(aproximately 6 monthly).

I would provide her with the information leaflet and give her time to discuss this with her family and if any further question to book an other appointment to discuss the issues in detail.
Posted by Lekshmi B.
Sun Jan 13, 2008 08:30 pm
A healthy 55 year old woman is referred to the gynaecology clinic because of a 3 months history of vaginal bleeding 5 years after her last menstrual period. (a) What additional information would you obtain from the history ? [7 marks] (b) How would you investigate her symptoms? [6 marks] (c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].

a) I would ask if she was having a routine cervical smear assessment and if so whether there is
history of abnormal cervical smear which would point to a cervical pathology. More details about the type of bleeding will be elicited, like whether it is spotting or profuse bleeding, as repeated episodes of severe bleeding are more suggestive of underlying malignancy. Any history of postcoital bleeding suggests cervical pathology. History of use of HRT, especially estrogen only preparation will be asked for to rule out exogenous estrogen stimulation of endometrium.I will also ask for a history of use of Tamoxifen which can have similar effect. History of previous menstrual cycles will be noted, whether regular and whether any ovulation induction in the past which could point to previous anovulatory cycles and resultant endometrial hyperplasia. Family history of any Gynaecological cancer or breast cancer will be asked for which would increase her risk of malignancy. History of vaginal dryness and coital problems will point to local hypooestrogenism which may be responsible for the bleeding.

b) I will do a complete blood count to assess her Hb status and the severity of blood loss. Speculum examination will be done to visualize cervix and a cervical smear taken if no bleeding. If appearance of cervix is suspicious of pathology colposcopy and directed biopsy will be done.Trans vaginal sonograghy will be done to assess endometrium and rule out adnexal or obvious endometrial or myometrial pathology. If endometrial thickness is less than 5 mm or with regular outline the patient can be reassured and sent home with advice to report if bleeding reccursBut if EM thickness is more than 5 mm or with irregular outline out patient endometrial biopsy with Pipelle forceps will be done. If no tissue is obtained or if tissue is benign patient will be reassured that endometrial malignancy is unlikely. If suggestive of pathology patient will be admitted and offered Hysteroscopy under GA with directed biopsy to confirm. Even if initial TVS findings are normal, if patient reports with repeated bleeding she will need Endometrial biopsy or Hysteroscopy and biopsy for evaluation

c) Considering the age of the patient TAH with BSO will be the first option. This is because atypical hyperplasia is associated with underlying malignancy in 10- 15 % cases and risk of progression to carcinoma in about 50 % cases Surgery alone can prevent occurrence of cancer. But the disadvantages include increased morbidity associated with surgery and risks of thromboembolism.Here the risk of malignancy far outweigh the surgical risks. If the woman does not agree for surgery the other potion includes high dose progesterone ( 30 mg Megestrol ) or LNG IUS for 6 months and reevaluation by hysteroscopic biopsy thereafter.Eventhough progesterone therapy is found beneficial in simple hyperplasia its role in atypical hyperplasia is not well proved. There is a definite risk of progression to cancer with this treatment in a post menopausal woman.
Posted by Reiaz M.
Sun Jan 13, 2008 10:05 pm
a) This patient has postmenopausal bleeding which should be investigated to rule out genital tract malignancy as the cause.

In the presenting complaint it is important to determine the amount of bleeding, when it started and whether it is getting worse or improving. Any possible precipitating factors such as preceeding sexual activity or trauma should also be sought.
Any prior episodes of post menopausal bleeding should also be determined. It should also be determined if any treatment had been commenced by the referring doctor prior to referral.
Symptoms of anemia such as headache, exertional dyspnea, palpitation and dizziness should be determined.
In the past gynecological history, it is important to determine the age of menarche. and the regularity of her menses in the past. Early menarche and a history of polycystic ovarian syndrome increases her risk of endometrial hyperplasia and carcinoma.
Age of coitarche, number of sexual partners and a history of sexually transmitted disease should be determined.
It is important to determine when her last pap smear was done and the results of this test.
A personal history of diabetes and hypertension should be determined. A family history of endometrial, ovarian and breast cancer is elicited.
Use of hormonal replacement therapy or drugs which can result in bleeding tendencies such as warfarin must be obtained.
The effect of the bleeding on her quality of life should be determined.

b)

Investigation of her symptoms is done by history, examination and investigations.

Examination should be done. Signs of anemia are sought. Vulval examination should assess any masses or ulceration. A speculum examination is done to assess the vagina and the cervix. Vaginal masses and cervical polyps can be visualised. If any abnormal lesions are detected a biopsy should be taken and sent for histology.

A pap smear should be done if she did not have a recent pap smear.

A complete blood count should be done to assess for anemia.

A transvaginal ultrasound scan should be done as the initial investigation of endometrial thickness. If the endometrial thickness is less than 3-4 mm and there is no evidence of fluid or masses in the uterine cavity, no further investigation is necessary at this time.


If the endometrial thickness is >3-4mm then endometrial sampling should be done. This can be done via outpatient hysteroscopy. Endometrial sampling can also be performed via a Pipelle biopsy, Novak curette or a Vabra aspirator.

If it is not possible to perform an outpatient procedure an EUA and D&C can be done. Another option is a formal hysteroscopy which allows treatment to be conducted at the same time, however this is associated with greater anesthetic risks, bleeding and uterine perforation.

c) A patient with atypical endometrial hyperplasia should be counseled on the risk of progression to endometrial cancer and also the risk of coexistent endometrial cancer.

This can be distressing to the patient and her family and she should be counseled on treatment options and provided with written information to assist in her decision making.

Conservative management is not recommended due to the risk of progression to endometrial cancer.

Medical management may include the use of iron supplementation in anemic patients. In severely anemic patients blood transfusion may be necessary.

Progestagen therapy is one option for treatment. High dose oral progestagens can be used. Repeat endometrial sampling should be done in 6 months time, if still present surgical treatment is indicated. The levonorgestrel intra uterine system is associated with initial bleeding which may cause diagnostic confusion.

Surgical management involves hysterectomy +/- bilateral salpingoophorectomy . A laparoscopic, abdominal or vaginal approach can be used.

Posted by M M A.
Sun Jan 13, 2008 10:22 pm
A] We look for use of HRT because it can lead to irregular bleeding also we ask about tamoxifen therapy and warfarin. All these can be a risk factor for endometrial malignancy.
History of PCOS and chronic unovulation expose endometrium to long term un-apposed estrogen which may predispose for endometrial hyperplasia and malignancy. PCOS can lead also to obesity, null parity and hyperandrogenism with long term complications like DM and hypertension . All these are regarded as risk factors also.
Un-apposed estrogen can occur if she had previously an estrogen secreting tumour.

We inquire about family history of colonic cancer, endometrial , breast or ovarian cancer as this woman may have familial genetic tendency for developing malignancy.

If the patient is smoker, this will be regarded as added risk factor.

B] Investigation should be prompt to rule out malignancy.
Transvaginal ultrasound can measure endometrial thickness and detect pelvic pathology, endometrial thickness of 5 mm and more goes with endometrial hyperplasia, cancer or polyp. It has high sensitivity( 94-100%) but low specificity (40-80%), it can not confirm whether the abnormality is benign or malignant. Confirmation is done by histopathological examination.
This can be obtained by outpatient endometrial biopsy by pippelle [ vabra or sharman], however, it can miss polyp or malignancy as it explore only 4% of endometrial cavity.
Hysteroscopy and D&C is the gold standard, it visualizes uterine cavity and allow for direct biopsy, it can be done as outpatient or inpatient procedure. Outpatient is cost effective, carries more patient satisfaction with no risk of anaesthesia. However, it allows to take small biopsy only while inpatient hysteroscopy allows to do polypectomy .
D&C can be used when outpatient endometrial biopsy is unsuccessful and there is no facility for hysteroscopy.

C] Atypical endometrial hyperplasia carries a significant malignant potential and some times there is co-existent endometrial cancer. Therefore; there is no role for expectant management.
The main stay of treatment is total abdominal hysterectomy and bilateral salpingo-oopherectomy after adequate patient counseling , we give her written information to allow her to give an informed consent. HRT use is not contra-indicated but it is better to be avoided.
TCRE is not recommended because it masks the picture. Radiotherapy is inappropriate even if patient is unfit or reluctant to surgery, although, palliative radiotherapy can be used to control bleeding.
High dose progesterone is prescribed for other type of hyperplasia, but this is not advised in atypical hyperplasia.
Multidisplanary team involved including general gynecologist, Gynaecological oncologist, medical oncologist, anesthetist and radiotherapist .
Psychological support is provided throughout investigations and management.
Posted by PAUL A.
Mon Jan 14, 2008 03:55 am
(a) What additional information would you obtain from the history ? [7 marks]

I will take a detailed history starting with her presentic complaint, and then going on to her obstetric, medical and family history not necessary .

I will start with asking her about the nature of the bleed and whether or not the bleed was associated with intercourse (1) or accompanied with foul discharge. I will ask the lady if she suffers from vaginal dryness and other menopausal symptoms (1) . I will ensure that she has not sustained any trauma in the perineum and is not using pessaries for uterovaginal prolapse. I will enqire about her menarche and also find out is she has any children. I will take a smear history (1) .
I will find out if she suffers from diabetes, hypertension, polycystic ovarian syndrome or bleeding diasthesis HEALTHY . I will also enquire about past history of breast cancer. I will ask her if she is on any medication like HRT (1) , Tamoxifen or Anticoagulants.
I will find out if she smokes or not
And last but not the least, I would enquire about family history(esp first degree relatives) of cancers like breast, ovarian and endometrial cancer.

(b) How would you investigate her symptoms? [6 marks]

Since 10% of patients with post menopausal bleed have endometrial cancer, PMB warrants urgent and detailed investigations.
I will arrange for an FBC to be done if the lady complains of heavy bleeding.I will also take a smear is PMB an indication for a smear? and arrange for an urgent USS (ideally TVS) for endometrial thickness (1) . If the endometrial thickness is greater than 5 5 what??? , if there is a polyp seen on scan or if the lady is at a high risk of developing endomerial cancer I will proceed with hysteroscopy why not an out-patient aspiration biopsy? .Hysteroscopy can be performed in outpatient setting or under GA . Out patient hysterteroscopy has the advantage of being immediate and cost effective (1) .

Another procedure that I can performin low risk women how do you classify women as high / low risk?? in an outpatient setting is a pipelle biopsy but it will not be able to sample the whole of the endometrium if you are taking a sample, why do you need the whole endometrium? Even a D&C under GA does not remove the whole endometrium and can miss the pathology. Moreover some women can find it uncomfortable.

Facilities for Sonohysteroscopy are also available in some centers.

If the diagnosis of endometrial cancer is established by hysteroscopy, further investigations for determing the extent of disease will need to be performed.
Your investigations have focused on endometrial cancer ? is this the only cause of PMB?
(c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].

Treatment of patient with atypical endometrial hyperplasia should be individualized and ideally started after consultation with Gynae oncologist.

Simple atypical hyperplasia has a 8% and Complex atypical Hyperplasia has a 30% risk of developing into adenocarcinoma of endometrium .

The conventional treatment for atypical hyperplasia is total abdominal hysterectomy with bilateral salphingo oopherectomy (1) . The advantages are that it definitively sorts out the problem at hand and decreases the hassle of follow up. However it is a major surgery and is associated with risks of infection, bleeding, injury to internal organs and pulmunary and thromboembolism (1) . The risks are more pronounced in women who are obese or have coexising chronic medical problems healthy .

In these women, TCRE (trans cervial resection of endometium) is thought to be an option not an option for the management of atypical hyperplasia . However, this too is not without its share of risks and would require follow up How will you follow her up? You cannot do further endometrial sampling as you would have obliterated the cavity .

Mirena coil and oral prgestagens (1) can be considered if the patient declines or is not suitable for either of the previous two options. This option would warrant careful follow up and patient cooperation with treatment if you put an IUS in, how will you know the cause of any further bleeding? How will you follow her up? .

In any case, the patient should be given detailed verbal and written information and allowed to make a decesion for herself.

vaginal hyst, LAVH or laparoscopic hysterectomy + BSO
Posted by PAUL A.
Mon Jan 14, 2008 04:06 am
1.This patient has post menopausal bleeding, therefore possibility of endometrial cancer should be ruled out. The significant of post menopausal bleeding (PMB) should be determine by asking the number of pads used and the presence of blood clots is the volume of blood loss of diagnostic significance? . Question should be asked if it was associated with post coital bleeding (1) . The duration of last cervical cytology and the result should be obtained (1) . Presence of diabetes mellitus and hypertension healthy , early menarche are the risk factor to develop endometrial cancer. History of breast cancer with Tamoxifen treatment should be asked. The use of hormone replacement therapy (1) is associated with withdrawal bleeding. Smoking is a protective factor toward endometrial cancer but nulliparous and family history of gynaecological cancer is associated with higher risk of endometrial cancer. Constitutional symptoms like loss of weight or appetite with bowel symptom are useful information (1) . The posibility of rectal bleeding or haematuria should be determined (1) .
2.Cervical smear or colposcopy if any abnormality on the cervix should be performed. If there is presence of suspicious growth, punch biopsy is justified to role out cervical cancer (1) . Transvaginal scan should be done to lmeasure for endometrial thickness and it has 80-100% sensitivity to detect endometrial cancer (1) ? cut-off for endometrial thickness . Presence of adnexal masses with PMB may be suggestive of oestrogen secreting tumor (1) . Pipelle or Vibra is acceptable method for assessment of PMB but it can miss endometrial polyps. Outpatient hysteroscopy and biopsy has similar effectiveness in detecting endometrial pathology but large polyps can not be removed (1) . Hysteroscopy with D&C is a gold standard for investigating PMB (1) but it is associated with complication like uterine perforation, bleeding, infection and haemorrhage. Rectoscopy or cystoscopy is required if clincially indcated.
3.Atypical hyperplasia has 50-75% risk to develop endometrial cancer and 25% of them may have an early stage of well differentiated endometrial cancer. Therefore, a conservative treatment is associated with higher risk of endometrial cancer. Medical treatment with high dose progestogen to revert atypical endometrial hyperplasia is not a good option if the patient is having concurrent breast cancer where does it mention breast cancer in the question? She is HEALTHY . Hysterectomy and bilateral salpingectomy is the best option (1) YOU SHOULD START WITH THIS of management for atypical hyperplasia in a menopause patient as there is no issue of fertility anymore what are the disadvantages? CRITICALLY evaluate . In this patient, vaginal route would be the most appropriate as it is associated with less morbidity and mortality as compared to abdominal route why is this most appropriate? How will you remove ovaries? . The patient should be given thorough information and discussions to enable inform decision. Follow up and written information leaflet should be given to the patient.

LAVH + BSO, Lap assisted VH + BSO with value and disadvantages ? you were asked to critically evaluate
Posted by Farina A.
Mon Jan 14, 2008 02:41 pm
a) The additional information I would like to obtain from her history is about any vaginal dryness and irritation,previous history of any benign or malignant gynaecological disease and treatment, personal or family history of breast or GIT malignancy,family history of GIT cancers,use of HRT,its compliance and associated GIT disease which may be impairing the absorption of the HRT is also relevant. Past or family history of bleeding tendancy like easy bruisability,menorrhagia and coagulopathy is also relevant.

b) After examination of the genital tract which can rule out vulval,vaginal and cervical lesions, TVS should be done to see the endometrial thickness and any growth within the uterine cavity and PCOs. Endometrial thickness greater than 5 mm warrants further investigations for endometrial CA. Hysteroscopic endometrial biopsy is the gold standard of the investigations which can be done as the out patients procedure and has 80% detection rate and is cost effective, but may be uncomfortable for the pt so hysteroscopic endometrial sampling under aneasthesia can be considered. Ca 125 and serum estradiol levels may be helpful in cases where the cause of endometrial hyperplasia is considered to be unopposed estrogen from a estrogen secreting tumour In addition a full blood count to see the degree of anemia and a raised ESR which, although less specific but suggestive of malignancy is beneficial. Paps smere may reveal cervicitis or CIN

c) TAH+BSO is the treatment of choice as 40% of the pts diagnosed as atypical hyperplasia turn out to be endometrial CA at histopathology and 50% of atypical endometrial hyperplasia progress to carcinoma so for this age group when fertility is not a concern pts acceptability to this treatment may be high accepting the risks of a major surgery like heamorrhage,visceral injury(urinary tract and GIT) and thromboembolism. Other treatment options like high dose(20 mg megestrol) and chemoradiation for this stage of the disease is not proved to be beneficial in various RCTs.
LAH+BSO is also a treatment option provided the expertise is available the otcome is not diferrent in open and laproscopic methods wihh additional advantages of laproscopic procedure like less pain and analgesia,bleeding, reduced hospital stay,earlier post op recovery and return to work.
VAH +BSO is technically difficult however could be performed with better recovery than abdominal approach.It has a disadvantage of poor acess to abdominal cavity to assess the other organs.
LAVH is one of the options provided the additional expertise,epuipment and staff is available,

Posted by hoping ..
Mon Jan 14, 2008 11:01 pm
I would enquire about amount of bleeding.If she has any postcoital bleeding. If she has symptoms of bleeding from other sites should also be checked.Current or recent use of HRT should be checked . I would obtain her smear history , past contraceptive,obstetric and gynaecological history. If there is any family history of Gynaecological or bowel cancers then she may be at higher risk of malignancy. Further information regarding her body mass index is valuable. If she is smoker or has smoked in last 10 years should be enquired.
I would check for FBC to rule out anaemia. Pelvic ultrasound should be first line of investigation to determine endometrial thickness and rule out any adenaxal pathology. If endometrial thickness is less than 5mm then her risk of endometrial cancer is reduced from 10% to 1%. If endometrial thickness is more than 4mm , endometrium should be sampled which can be outpatient by means of pipelle biopsy . Inpatient assessment by hysteroscopy and currettage should be undertaken if outpatient biopsy is insufficient or not possible. If scan shows adenaxal mass, CA125 should be checked. Coagulation profile should be checked if there is history of bleeding from other sites. If suscpicion of cervical pathology then EUA and biopsy should be performed.
Atypical endometrial hyperplasia has 30% risk of progression to endometrial cancer if untreated. Hysterectomy with bilateral salpingo-oopherectomy is treatment of choice for this woman .This could be open surgery which has benefits of quicker operation than laparoscopy, widely available.It is less likely to involve additional form of surgery. Demerits of traditional surgery are longer inpatient stay and postoperative recovery. It also increases risk of thrombotic event. Laparoscopic hysterectomy with oopherectomy has benefit of quicker recovery and less pain.It carries increased risk of visceral injury and vascular injury. There is also risk of conversion to laparotomy.Vaginal hysterectomy provides benefit of no abdominal scar and opportunity to repair pelvic floor if required. It however doesnot provide opportunity to visualise other pelvic structures which could be helped with laparoscopy assiste vaginal hysterectomy. If patient declines surgery then progesterone therapy along with repeat biopsy at six months can be considered .This option may lead to short term avoidance of surgery but carries significant risk of progression to cancer.
Posted by maha G.
Tue Jan 15, 2008 01:24 am
[a}PMB is associated with patient\" anexity so ,try to reassure her that majority are due to benign causes however,endometrial cancer should be execluded as 10% of PMB are due to EC.
I would ask about nature of bleeding ,whether it is cyclic or postcital which indicate cervical cause as ectopy,polp or cancer.

Ask about recent loss of weight,anorexia,or insomnia which suggest malignancy.

Ask about urinary or bowel symptoms as haematuria or bleeding per rectum to exclude non gynaecological causes.
History of menopausal symptoms especially vaginal dryness would be suggestive of bleeding due to atrophic changes,
and whether she is taking HRT ,detalis of her HRT should be clarified such as kind is it combined or unopposed estrogen,is it continous or sequential and the compliance of it which is recognized cause of PMB.
Ask her about her cervical smear and result of last smearand its date and if it is due to do cervical smear.
Detailed obsetric history as history of subfertility ,PCO,parity and her age at last delivery.
Menstrual history to be taken as age of menarche as risk of EC is more with early menarche and late menopause.
Family history of colorectal cancer,EC, breast ca.,or OC SHOULD BE TAKEN ALSO.
{B}
IF history and exam.are suggestive of cervical cause punch biopsy can be taken to rule out cervical cause.
If due to cervical smear ,I will take smear and if abnormal referal for colposcopy.
TVS to detect endometrial thickness,however still controversy regarding it ,so if it is 3 to 5 mm or more patient should be triaged for hysteroscopy,furthermore TVS can detect adenaxal masses as estrogen secreting tumours as granulosa cell tumour could be contributing cause of PMB,however it has high false positive rate in detecting benign lesion as polyps in such case we can use sonohystergraphy using saline or contrast which has more accurate diagnosis of polyps.
Outpatient hysteroscopy and aspiration biopsy to be done using pipelle biopsy,would biopsy 4% of endometrium but vabra aspirator take about 40% of endometrial biopsy,it is done without anaesthesiahowever diagnosed polyps can not be removed.
If no tissue taken inspite of thick endometrium or negative biopsy with existence of bleeding ,or in abscence of facility for outpatient hysteroscopy book patient for inpatient hysteroscopy and biopsy under anaesthesia to do examination under anaesthia ,good visualization of uterine cavity ,biopsy and removal of polyps if diagnosed.
Dand c is last resort as it will sample only 50% of endometrium,furthermore diagnosis of EC can be missed.
Preoperative investigation to be done in case surgery will be done,FBC to check HB ,LFTS,RFTS and group and save.
{c}
Iwould explin diagnosis to her ,try to reassure her that it is not cancer however it is associated with EC in about 25 to 50%and malignant change in 25 to 33%.

The best management option in this case is surgery,TAH and BSO
Consent for surgery to be taken after explining the purpose of surgery.routes,which may be abdominall vaginally or LAVH.
TAH is the traditional method of hysterectomy ,it caries the risk of bleedingand need for BT,bowel injury bladder injury ,VTE,wound infection and abdominal scar.
VH has advenages of no scar formation ,more cosmotic,less need of analgesia,less hospital stayand less bleeding,BSO can be done in 90% OF CASES
however it took longer time,unintented visceral injury and need expert gynaecologist.
LAVH is cosmotic ,can convert difficult VH to easy one ,less hospital stay ,less need of analgesiaand early return to normal activity,however it is associated with visceral and vascular injury,Rechter:s hernia,and need experienced surgeon.
If surgery resented by the women,alternatives including no treatment should be discussed with her.
Medical treatmentsuch as medroxy progesterone , megestrol for 3 to 6 monthsor Mirnea in case unwanted systemic side effects of progestogens.
Medical treatment need close regular mointoring by measuring endometrial thickness and biopsy if thickness more than 3 mm.
Side effects of progestogens inculde abnormal uterine bleeding,bloating,breast tenderness,abnormal lipid profile and possible weight gain.
LNG-IUS release 20 microgam LNG daily so act locally and little will be absorbed systemically so avoid side effect .
IF these 2 options are resented and women wants no treatment ,the woman\"wishes should be considered however proper counselling and docomentations of all notes are crucial.
Posted by Hala T.
Tue Jan 15, 2008 01:27 am
a) Information that is important in the history includes ; previous abnormal smears or post-coital bleeding may suggest cervical pathology.
History of relevant risk factors as nulliparity , early menarche , use of unopposed oestrogen and family history of endometrial cancer ; all of which increase the possibility of endometrial cancer.
History of rectal or urethral bleeding may suggest rectal and bladder pathology . These are often confused with vaginal bleeding.
History of dyspareunia and irritative bladder symptoms may suggest atrophic vaginitis .
b ) She needs Pap smear as part of evaluation of abnormal bleeding ,as it can be difficult to distinguish between cervical and upper uterine bleeding . Any visible cervical lesion needs to be biopsied ,even if Pap smear is normal.
Trans-vaginal Scan(T.V.S.) should be done initially as it has 80-100% sensitivity for detecting malignancy with high false positive rate. The finding of endometrial thickness above the relevant cut-off (3-5mm) indicates that there is risk of abnormality significant enough to warrant for further investigations. It also has the advantage of ovarian assessment and for presence ascites.
Out-patient endometrial sampling can be performed using Pipelle , which samples 4% of the endometrial surface. Vabra sampler utilizes electronic suction.It can be performed as out-patient and samples 41% of the endometrium ,but it is more painful than Pipelle.
Out-patient flexible hysteroscopy enables the uterine cavity to be visualised and directed biopsy can be taken . It is cost-effective with high patient acceptability.
Hysteroscopy and biopsy (curettage) under general anaesthesia is the gold standard. It should be performed when the out-patient procedure is not possible or the patient has strong preference for a general anaesthetic. The sensitivity of the procedure approaches 100% in detecting benign and malignant pathology.
c) The woman should be counselled and a management options should be explained to her , risks and benefits of each option.
When atypia is present there is a clear risk of invasive cancer developing or already present. Average time is required for progression from hyperplasia to carcinoma is approximately five years. The risk of progression is > 30%.
Standard management should be a total abdominal hysterectomy with bilateral salpingo-oophorectomy . The advantages are that gives cure to for the endometrial hyperplasia ,so long-term follow-up is unnecessary . This a major surgery ,which would require long hospital stay and a prolonged recovery at home. The operation itself involves the risk of bleeding ,infection ,bowel, bladder , ureteric injuries and thrombo-embolic disease and anaesthetic risks.
Laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy is an another option . Although the operating time is prolonged ,it has the advantages of shorter hospital stay, reduced pain relief and a quicker recovery with a good cosmetic results.
If the woman refuses to undergo a hysterectomy , high dose of progestogens such as medroxyprogestrone acetate in a dose of 100mg daily should be given for 6 months , with a repeat endometrial biopsy 3 months after cessation of treatment .Long-term close surveillance should continue. No treatment or do nothing , but this would not be recommended as there is a high risk of developing invasive cancer.
A leaflet supporting the above information should be provided and her wishes then taken into account.
Posted by Hala T.
Tue Jan 15, 2008 01:27 am
a) Information that is important in the history includes ; previous abnormal smears or post-coital bleeding may suggest cervical pathology.
History of relevant risk factors as nulliparity , early menarche , use of unopposed oestrogen and family history of endometrial cancer ; all of which increase the possibility of endometrial cancer.
History of rectal or urethral bleeding may suggest rectal and bladder pathology . These are often confused with vaginal bleeding.
History of dyspareunia and irritative bladder symptoms may suggest atrophic vaginitis .
b ) She needs Pap smear as part of evaluation of abnormal bleeding ,as it can be difficult to distinguish between cervical and upper uterine bleeding . Any visible cervical lesion needs to be biopsied ,even if Pap smear is normal.
Trans-vaginal Scan(T.V.S.) should be done initially as it has 80-100% sensitivity for detecting malignancy with high false positive rate. The finding of endometrial thickness above the relevant cut-off (3-5mm) indicates that there is risk of abnormality significant enough to warrant for further investigations. It also has the advantage of ovarian assessment and for presence ascites.
Out-patient endometrial sampling can be performed using Pipelle , which samples 4% of the endometrial surface. Vabra sampler utilizes electronic suction.It can be performed as out-patient and samples 41% of the endometrium ,but it is more painful than Pipelle.
Out-patient flexible hysteroscopy enables the uterine cavity to be visualised and directed biopsy can be taken . It is cost-effective with high patient acceptability.
Hysteroscopy and biopsy (curettage) under general anaesthesia is the gold standard. It should be performed when the out-patient procedure is not possible or the patient has strong preference for a general anaesthetic. The sensitivity of the procedure approaches 100% in detecting benign and malignant pathology.
c) The woman should be counselled and a management options should be explained to her , risks and benefits of each option.
When atypia is present there is a clear risk of invasive cancer developing or already present. Average time is required for progression from hyperplasia to carcinoma is approximately five years. The risk of progression is > 30%.
Standard management should be a total abdominal hysterectomy with bilateral salpingo-oophorectomy . The advantages are that gives cure to for the endometrial hyperplasia ,so long-term follow-up is unnecessary . This a major surgery ,which would require long hospital stay and a prolonged recovery at home. The operation itself involves the risk of bleeding ,infection ,bowel, bladder , ureteric injuries and thrombo-embolic disease and anaesthetic risks.
Laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy is an another option . Although the operating time is prolonged ,it has the advantages of shorter hospital stay, reduced pain relief and a quicker recovery with a good cosmetic results.
If the woman refuses to undergo a hysterectomy , high dose of progestogens such as medroxyprogestrone acetate in a dose of 100mg daily should be given for 6 months , with a repeat endometrial biopsy 3 months after cessation of treatment .Long-term close surveillance should continue. No treatment or do nothing , but this would not be recommended as there is a high risk of developing invasive cancer.
A leaflet supporting the above information should be provided and her wishes then taken into account.
Posted by PAUL A.
Tue Jan 15, 2008 03:27 am
(a)What additional information would you obtain from the history? [7 marks]
Post menopausal bleeding (PMB) is the most common presenting symptom of endometrial carcinoma. I will ask detailed history to asses the risk for endometrial carcinoma and also information related to other differential diagnosis of cervical,vuval and vaginal malignancies it is not clear what specific information you would obtain . Also ask nature of the bleeding whether it is cyclical if it is cyclical, will it make any difference? any association with sexual intercourse (1) . I will also inquire whether she is nulliparous. History of HRT (1) in more detail duration of its use and type of HRT will benefit to assess her risk. History of GI symptoms such as change of bowel habit and weight loss may suggest malignancy (1) .Cerviac smear history and any cervical atrophy (1) how will she know if she has cervical atrophy? may be useful for futher investigation. I will inquire her family history of endometrial carcinoma, ovarian carcinoma or bowel cancer as it may increase the risk.

(b) How would you investigate her symptoms? [6 marks]
PMB should be investigated rapidly and accurately as up to 8% of women with PMB will have endometrial carcinoma. . Clinical examination READ THE QUESTION - INVESTIGATE should be carried out to identify any abdominal or pelvic masses pelvic emanation to look for genital tract atrophy, vlulval and vaginal tumors or ulceration, cervical polyp, cervicitis and obvious malignancies.
A Bimanual examination to assess the size of the uterus and mobility and adnexal masses.Cervical smear test may be required .if any suspicious lesion in the cervix colposcopy and biopsy is indicated (1) .
Transvaginal ultrasound scanning (1) (TVS) is an accurate method of initial investigation which look at endometrial thickness, including visualization of ovaries, if she has thin
(Different cutoff point used 3-5 mm )) regular endometrium can be reassured without futher investigation as negative predictive value almost 100% in excluding endometrial carcinoma. If the scan findings are abnormal she should be investigated with Hysteroscopy and endometrial biopsy which can be provided as inpatient procedure or out patient settings (1) . Hysteroscopy and endometrial biopsy (EB) is regarded as the gold standard is this in-patient or out patient hysteroscopy & biopsy? for diagnosis of postmenopausal bleeding. Out patient hysteroscopy higher patient acceptability and very cost effective, however if out patient hysteroscopy fails or if it is not available inpatient hysteroscopy and D&C is the suitable choice of investigation.
Out patient endometrial biopsy (Pipelle or vibra aspirator) is also a choice which is safe reliable and cheap (1) . It may cause significant discomfort in 10 % cases, and there may be failure of canulate in 20% of cases. The pathology can be missed in some cases. Optimal mode of investigation is cotraversial. TVS and out patient EB or out patient hysteroscopy and biopsy may be suitable in majority of the women.

(c) A diagnosis of atypical endometrial hyperplasia is made. Critically evaluate her treatment options [7 marks].
Natural history of endometrial hyperplasias coexisting endometrial carcinoma, ovarian carcinoma and risk of progression to endometrial carcinoma ? meaning .
If atypical endometrial hyperplasia has been diagnosed using an out patient instrument ( Pipelle or Vibra aspirator ) she need a formal examination under anaesthesia (EUA) and hysteroscopy and curettage are required NO ? THE WOMAN SHOULD BE TREATED. YOU WERE ASKED ABOUT TREATMENT . EUA should include palpating adnexa and endometrial and endocervical assessment to exclude coexisting malignancies.A serum Ca 125 and oestradiol investigation may be useful to investigate ovarianpathology this is not a treatment option .If she is on estrogens therapy or Oestrogen HRT she should be adviced to discontinue.Endometrial hyplasia coexisting with endometrial carnoma in 25-50% of cases. therefore Hysterectomy and Bilateal salphingo ophorectomy is the recommended option (1) , however if she declines to have surgical option , she can be managed with medical which drug? therapy and repeated curettage or Conservative management ( Doing nothing ) will you give medical treatment and then do nothing? (-1) . Persistent and progressive symptoms with risk of disease progression is the major concern with conservative management. Progestin can be given as short term courses ? what is a short term course? or as continuous therapy but she should be warned that she may need it for many years. She can be treated with moderately high doses of prtogestins atleast 20mg /day megestrol. Long term and follow up is essential as recurrences may not appear for many years. However there is no reliable medical evidence to judge this treatment

You have wasted time and space writing unnecessary material. In the exam, you will almost certainly have run out of time / space
Posted by PAUL A.
Tue Jan 15, 2008 03:09 pm
a) Important to identify risk factors in this woman with post menopausal bleeding. I would ask her the nature of the bleeding, if postcoital (1) or associated with offensive vaginal discharge. Associated symptoms like dysuria , blood stained urine or bleeding from the rectum (1) . History of pelvic swelling. I would ask about her parity and the age at Menarche (1) as low parity increases the likelihood of endometrial carcinoma. I would ask about the result of her most recent cervical smear (1) . I would ask for a family history of breast, ovarian , endometrial or colon cancer. I would ask if she was on HRT (1) for menopausal symptoms and if she was complying with the medication..I would ask about the type of HRT as unopposed oestrogen increases the risk of endometrial cancer.
b) I would check her FBC to determine her haemoglobin and her WCC may suggest infection.
I would group and save do you group & save women who come to your gynae clinic with PMB?? (-1) because may require blood transfusion.
Urinalysis may suggest UTI and this would be confirmed with a m/c/s.
I would perform a TVS looking for ET > 5mm (1) . I would also look for any endometrial polyp . I would assess the adnexae for any ovarian masses (1) as this may be the estrogen source of the bleeding.
If there is any ovarian tumour , I would check the Ca-125 & LDH assay , to assess the nature of the ovarian tumour..
I would examine you were not asked about examination the vulva and vagina for atrophic changes and bleeding from the vagina in atrophic vaginitis. The cervix for any abnormal lesions and perform a smear if one is due. I would also counsel the woman for a pipelle biopsy as this may show the cause of the beeding. Sono- hysterography may help in the evaluation of endometrial polyp why is this sentence on scanning written between two sentences about endometrial sampling? .The goal standard gold standard for what? Evaluation of polyps? is diagnostic hysteroscopy and directed biopsy especially if inadequate specimen from a pipelle biopsy what about out-patient hysteroscopy & biopsy? .
C) I would explain to the woman the diagnosis. The first option is expectant management you cannot present this as a treatment option in a woman with atypical hyperplasia ? that would be dangerous (-1) . The benefit is that it prevents the complications of surgery and the side effects of progestogens. This has no role in atypical endometrial hyperplasia how then can it be an option if it has NO role?? .This is because of the risk of co- existing cancer of the endometrium of 25-50% which may be missed by the biopsy. There is also and increased risk of progression to endometrial cancer of 22-88% without treatment.I would offer her information leaflets and document this discussion. you should start with the most valuable option ? TAH + BSO
Medical treatment with progestogens is the second option why is this the second option? This can be interpreted to mean the second best option . This may be administered systemically or locally. Systemic progestogen are not associated with the complications of major surgery.However, there side effects include bloating, irregular vaginal bleeding and the development of ovarian cyst what is the mechanism? Will you expect progestogens to be associated with ovarian cysts in a post-menopausal woman? . They are given in high doses for 3-6/12. After treatment she needs to be followed up for repeat biopsy to see resolution of lesion (1) . She would require long term follow up as recurrence of atypical hyperplasia and malignancy as been reported after long interval following this treatment. If systemic progestogen fails she may still require surgery.
Locally administered progestogen like mirena , delivers progestogen locally and avoids some of the side effects of systemic progestogens. It may not be appropriate because associated with irregular vaginal bleeding. This may be confused with persistence or recurrence of atypical hyperplasia It also does not treat occult carcinoma which may be present in this case.
Surgery in the form of TAH+BSO would be the last option you have not made it clear that this is the recommended option . This ensures that the endometrial pathology is removed as well as possible source of oestrogens( the ovaries). It provides cure and remove any occult carcinoma. After surgery,there would be no need to follow up this patient,. If there was a malignancy , rarely involves more than superficial invasion of the myometrium, this treatment would be effective. This may however, not be acceptable to this patient either because it is a major operation and associated with complications. This complications include frequently occurring like post operative pain, and wound infection. Major complication include bleeding requiring blood transfusion, injury to bladder, bowel and ureter (1) . There is also risk of TE and prolonged hospital stay.
In view of the age of this patient and the fact that she?s healthy , surgery would be the best option (1) You should be able to present the same information using fewer words and saving time & space as it provides a specimen for pathological confirmation of the diagnosis. If she however, insists on medical treatment , I would ask for a second opinion from my senior colleague.
Posted by PAUL A.
Tue Jan 15, 2008 03:33 pm
To rule out sinister causes of postmenopausal bleeding additional informations are needed.I will ask her whether she is uptodate with her cervical smears and was it abnormal ever to rule out cervical malignancy (1) .History of postcoital bleeding (1) is important as it indicate cervical cause or vulvovaginal atrophy.Risk factos for endometrial malignancy such as nulliparity,early menarche (1) , late menopause and use of unopposed estrogen should be determined.I will ask about HRT (1) type,duration and compliance .History of anorexia and weight loss have association with malignancy (1) .History of haematuria or rectal bleeding to exclude bladder and bowel cause should be taken (1) .Family history of breast,ovarian or colon carcinoma should be ascertained to exclude genetic cause of malignancy.
Post menopausal is associated with malignant causes in 10% of cases out of which 8% due to endometrial malignancy and other 2% due to cervical ,vulval or vagianl malignancies.If she is not upto date with cervical smear,cervical smear should be done. Transvaginal ultrasound should be done as it is 80-100% sensitive in detecting endometrial malignancies at a cut off point level of 5 mm for endometrial thickness (1) but associated with high false positive rates and 33% sensitivity of detecting beningn endometrial polyps.TVS is also helpful in detecting ovarian pathology (1) and ascites. Outpatient endometrial aspiration sampling has sensitivity of 80-96% and provide histology by pipelle biopsy or vabra aspiration. Pipelle biopsy sample only 4%of endometrium whereas vabra sample 40 %of endometium and associated with pain and both of them don?t detect endometrial polyp. Outpatient hysteroscopy (1) with flexible hysteroscope allows visualization of endometrial cavity and directed biopsies and avoids the anaesthetic risks as it can be done in outpatient under local anaesthesia.However sometime it is not possible to do outpatient hysteroscopy due to cervical stenosis and it is also not possible to treat endometrial polyp at same time.If outpatient aspiration samplingis not helpful or outpatient hysteroscopy is not possible then inpatient hysterosscopy and curettage is 100% sensitive (1) there is no clinical test with 100% sensitivity in detecting endometrial pathology and treating endometrial polyp but associated with anaesthetic risks and complications of procedure such as perforation and haemorrhage you were not asked about complications or disadvantages. You are wasting time & space .
Atypical endometrial hyperplasia is associated with progression to malingnacy and also associated with 30-40% presence of coexistant carcinoma so conservative treatment is this an option? If not, why are you writing it? without doing anything is associated with progression to carcinoma. Similarly progesterone treatment the value of progestogens is not similar to that of conservative treatment is associated with delayed diagnosis of carcinoma and need of regular followup and endometrial biopsies.TAH+BSO (1) is treatment option for her and she should be provided with verbal and written information about the benefits and risk of this. TAH provide histology and removal of abnormal growth and further treatment accordingly .and BSO reduce the risk of ovarian carcinoma although doesn?t completely eliminate it .However this is major surgery and associated with anaesthetic complication and risk of venous thromboembolism,bowel and bladder injury and hemorrhage (1) . She should be provided with written inforantion and contact detilals and followup appointment should be arranged you were not asked about management ? you were asked to critically evaluate treatment options. .
Posted by PAUL A.
Tue Jan 15, 2008 04:33 pm

(a) As 10% cases of PMB are due to malignancy, of which 8% is due to endometrial carcinoma, I would like to assess her risks for it-any history of nulliparity, infertility, early menarche (1) , as these factors increase her risks. H/O endometrial cancers, colonic cancers in the family which may suggest a Lynch Syndrome should be asked. I would enquire about her cervical smear history (1) .

Any loss of weight, lower abdominal pain, uneasiness ? meaning or distension, malaise?as estrogen secreting ovarian tumours may cause PMB and may present with these complaints (1) . Post coital bleeding history may suggest cervical ectropian will you diagnose a cervical ectropion in a post-menopausal woman? , polyp and cervical malignancies.

I would ask if she is taking HRT (1) , enquire regarding compliance, if she is taking any antibiotics recently which might have increased estrogen metabolism causing break through bleeding what is the evidence for this association? , any vomiting, diarrhea interfering with absorption, all these likely to cause bleeding when on CCHRT.

(b) I would take cervical smear if due and if it is abnormal I would investigate further by doing colposcopy, cervical biopsy and Endometrial sampling will you manage an abnormal smear by endometrial sampling? .

TVUS is useful to assess endometrial thickness, endometrial polyps, adnexal mass (1) . Different cutoffs have been used for endometrial thickness with varying sensitivity for detecting endometrial cancer. A 3mm ET cutoff if she has never been on HRT, or has been on CCHRT, gives nearly 99-100% sensitivity in ruling the sensitivity of a test is its ability to detect a condition. The ability of a test to exclude a condition is its negative predictive value out endometrial cancer.

Since she is bleeding continuously the word ?continuously? does not appear in the question , I would do outpatient endometrial sampling using Pipelle?s or vabra aspirator, combining it with outpatient hysteroscopy if available why are you combining aspiration biopsy with out-patient hysteroscopy??? . Pipelle samples only 4% of the endometrium while Vabra aspirator samples 40% of the endometrium and is better. This gives 68-98% sensitivity in detecting endometrial cancer, but sampling may fail in 20% cases.

D&C alone is not advocated now as it is misses nearly 10% endometrial cancers and less than 50% of endometrium is sampled in 60% cases and is unreliable.

Inpatient hysteroscopy with D & C is the gold standard and gives nearly 100% accuracy in detecting endometrial cancer (1) . I would do it only if endometrial sampling yield no tissues inspite of ET more than 5mm, as it involves admission and GA.

Sonohysterography if available gives better resolution than TVUS and can detect endometrial polyps, focal thickenings. 3 dimentional scanning, color Doppler are still in experimental stage.

(c) Atypical endometrial hyperplasia is associated with co-existent endometrial cancer in 40% cases and may progress to carcinoma if left untreated in 25-30% cases over next 5 years. Hence best option for this woman is TAH and BSO (1) . There is no benefit in conserving the ovaries in this post menopausal woman. Besides there is likelihood of metastasis in ovary if there is any undetected carcinoma in uterus. After assessing her eligibility for surgery and anesthesia, informed decision should be taken consequent to wishes of the patient. The route of TAH may be vaginal TA = total ABDOMINAL , abdominal or laproscopic (1) . If the woman has increased BMI, the abdominal route is more risky. Associated prolapse makes vaginal route more attractive proposition. Laproscopic method requires well trained laproscopist. The major risks of hysterectomy like injury to bowel, bladder, ureter (1) , VTE and rare risk of death of 1:4000 should be discussed with her. Possibility of requiring blood transfusions should be told and her views on it ascertained. She may need additional procedures like repair of structures if damaged during hystectomy.

She should be told you were not asked about this. You were asked to critically evaluate treatment options about possibility of detecting endometrial carcinoma in hystectomy specimen, earlier undetected and she may need post operative review about further adjuvant radiotherapy or hormones after discussing with oncologists about stage of disease. If the specimen does not show coincident carcinoma, she does not need special followup.

If she is reluctant for hysterectomy and wishes to preserve the uterus in spite of explaining the malignant potential of the lesion or she is unfit for surgery, she may be put on high dose progestogens (1) 20 mg /day of megesterol for 3-6 months or MPA 100mg /day with repeated endometrial sampling every 3 months under hysteroscopy (1) . There is no role for endometrial ablation methods. GnRH analogues what is the logic of using this in a post-menopausal woman? It works by inducing a medical menopause (-1) and Danazol in a post-menopausal woman? have been tried but they have unfavourable side effect profile; Severe hot flushes and osteoporosis with GnRh analogue; Acne, weight gain, depression, masculinization as side effect with Danazol. It is important to impress on her the necessity of very close follow up if she is on medical therapy as she may progress to endometrial carcinoma in spite of treatment. So she would need repeated endometrial assessments.

She should be provided with information booklets and her decisions should be recorded in her case file.

you have wasted time & space writing unnecessary information. You should focus on the question
Posted by PAUL A.
Tue Jan 15, 2008 05:27 pm
A) I would like to obtain detail of the bleeding that does it happens after sexual intercourse which can possibly be atrophic vulval and vaginal tissue ? cervical malignancy . Also I would like to know when did she had her last cervical smear (1) and was it normal to exclude cervical cause. I would like to know if she is on any medication for example healthy in case she is under treatment for breast cancer. Also like to know if she has had any medical problem like chirosis of liver where the coagulation functions are deranged HEALTHY ? have you ever seen a woman with PMB secondary to this??? (-1) . Also I would like to know that if this bleeding is like fresh blood or mixed with urine to exclude any urinary causes. Also I would ask the patient whether the bleeding was associated with bowel movement to exclude anal fissure and haemorrhoids if she had rectal bleeding, are there other causes that will concern you? .

B)I would like to do a clinical examination if the examiner wanted clinical examination, they would have asked for it of this patient to exclude any obvious cause of bleeding for example atrophic changes of the vulval and vaginal tissues, any abnormal looking growth on per speculum examination. I possible would you or would you not? I would like to obtain a pipelle biopsy.How ever it is important to remember that the pathological area can be missed on pipelle biopsy.
I would like to arrange an ultra sound scan to assess for any pelvic pathology and thickness of the endometrium. The thickness of endometrium greater the 5mm (1) in size indicate urgent hysteroscopy and endometrial why not aspiration biopsy? biopsy .Also with hysteroscopy (1) we can exclude any other pathology like endometrial polyp for urgent results .I would also like to check the FBC to assess the haemoglobin and platelet count , also LFT?s and coagulation screen not necessary to exclude any other abnormality.

C) I would like to explain to the patient YOU WERE NOT ASKED ABOUT MANAGEMENT ? you were asked to CRITICALLY EVALUATE TREATMENT OPTIONS the result telling her that there are some early abnormal changes of the endometrium and there is a high risk of developing endometrial cancer at a later stage . I would advice that Hysterectomy (abdominal or vaginal route) and bilateral salpingo oophorectomy (1) will be safe option is hysterectomy without complication? Is it the safest or the most effective option? for treatment. As the removal of ovary reduces the risk of cancer,and removal of uterus also reduces the risk of any further risk of malignancy .
The other option is to use the Progesterone progesterone is not used therapeutically ? you use progestogens in very high doses. But there is no proven benefit of this. The endometrial ablation procedures does not have any role in the management of the atypical endometrial hyperplasia.

It is a possibility that patient my not be medically fit for the surgery READ THE QUESTION - HEALTHY then the option of use of high dose progesterone with regular uscan to assess the thickness of endometrium and hysteroscopy with endometrial biopsy at a regular interval (1) is required(aproximately 6 monthly).

I would provide her with the information leaflet and give her time to discuss this with her family and if any further question to book an other appointment to discuss the issues in detail.
Posted by PAUL A.
Tue Jan 15, 2008 07:32 pm
a) I would ask if she was having a routine cervical smear assessment and if so whether there is
history of abnormal cervical smear which would point to a cervical pathology (1) . More details about the type of bleeding will be elicited, like whether it is spotting or profuse bleeding, as repeated episodes of severe bleeding are more suggestive of underlying malignancy volume of blood loss is not a useful discriminator . Any history of postcoital bleeding suggests cervical pathology (1) ? atrophic vaginitis? . History of use of HRT (1) , especially estrogen only preparation will be asked for to rule out exogenous estrogen stimulation of endometrium.I will also ask for a history of use of Tamoxifen which can have similar effect. History of previous menstrual cycles will be noted, whether regular and whether any ovulation induction in the past which could point to previous anovulatory cycles and resultant endometrial hyperplasia (1) . Family history of any Gynaecological cancer or breast cancer will be asked for which would increase her risk of malignancy. History of vaginal dryness and coital problems will point to local hypooestrogenism which may be responsible for the bleeding. rectal bleeding, weight loss / anorexia

b) I will do a complete blood count to assess her Hb status and the severity of blood loss. Speculum examination will be done to visualize cervix and a cervical smear taken if no bleeding. If appearance of cervix is suspicious of pathology colposcopy and directed biopsy will be done (1) .Trans vaginal sonograghy will be done to assess endometrium and rule out adnexal (1) or obvious endometrial or myometrial pathology. If endometrial thickness is less than 5 mm or with regular outline the patient can be reassured what will you say was the cause of her bleeding? Will you send her home with an 8mm regular endometrium??? (-1) and sent home with advice to report if bleeding reccursBut if EM thickness is more than 5 mm or with irregular outline out patient endometrial biopsy with Pipelle forceps You cannot describe it as a forceps ? the examiner will assume you have never seen or used one will be done. If no tissue is obtained or if tissue is benign patient will be reassured that endometrial malignancy is unlikely. If suggestive of pathology patient will be admitted and offered Hysteroscopy under GA what is the point of the biopsy has already given you a diagnosis? with directed biopsy to confirm. Even if initial TVS findings are normal, if patient reports with repeated bleeding she will need Endometrial biopsy or Hysteroscopy and biopsy for evaluation you have not demonstrated clear understanding of the investigation of PMB

c) Considering the age of the patient TAH with BSO (1) will be the first option. This is because atypical hyperplasia is associated with underlying malignancy in 10- 15 % cases and risk of progression to carcinoma in about 50 % cases Surgery alone can prevent occurrence of cancer. But the disadvantages include increased morbidity associated with surgery and risks of thromboembolism. (1) what about other routes for hysterectomy? Here the risk of malignancy far outweigh the surgical risks. If the woman does not agree for surgery the other potion includes high dose progesterone progestogen ( 30 mg Megestrol ) or LNG IUS for 6 months what will you do if you put in an IUS and she is bleeding all the time? and reevaluation by hysteroscopic biopsy thereafter.Eventhough progesterone therapy is found beneficial in simple hyperplasia you were not asked about this its role in atypical hyperplasia is not well proved. There is a definite risk of progression to cancer with this treatment in a post menopausal woman.
Posted by PAUL A.
Tue Jan 15, 2008 07:50 pm

a) This patient has postmenopausal bleeding which should be investigated to rule out genital tract malignancy as the cause.

In the presenting complaint it is important to determine the amount of bleeding, when it started you are told this in the question and whether it is getting worse or improving. Any possible precipitating factors such as preceeding sexual activity (1) or trauma should also be sought.
Any prior episodes of post menopausal bleeding should also be determined. It should also be determined if any treatment had been commenced by the referring doctor prior to referral. which treatment are you thinking of?
Symptoms of anemia such as headache, exertional dyspnea, palpitation and dizziness should be determined.
In the past gynecological history, it is important to determine the age of menarche. and the regularity of her menses in the past. Early menarche and a history of polycystic ovarian syndrome increases her risk of endometrial hyperplasia and carcinoma (1) .
Age of coitarche, number of sexual partners these are ?personal? questions which have little, if any diagnostic value and a history of sexually transmitted disease should be determined.
It is important to determine when her last pap smear was done and the results of this test (1) .
A personal history of diabetes and hypertension should be determined read the question - HEALTHY . A family history of endometrial, ovarian and breast cancer is elicited.
Use of hormonal replacement therapy (1) or drugs which can result in bleeding tendencies such as warfarin must be obtained.
The effect of the bleeding on her quality of life should be determined.

b)

Investigation of her symptoms is done by history, examination and investigations what is the difference between ?investigations? at the end of your sentence and ?investigations? in the question? Why should ?investigations? in the question mean history, examination??? .

Examination should be done. Signs of anemia are sought. Vulval examination should assess any masses or ulceration. A speculum examination is done to assess the vagina and the cervix. Vaginal masses and cervical polyps can be visualised. If any abnormal lesions are detected a biopsy should be taken and sent for histology.

A pap smear should be done if she did not have a recent pap smear.

A complete blood count should be done to assess for anemia.

A transvaginal ultrasound scan (1) should be done as the initial investigation of endometrial thickness. If the endometrial thickness is less than 3-4 mm and there is no evidence of fluid or masses in the uterine cavity, no further investigation is necessary at this time what will to tell her about the cause of bleeding? .


If the endometrial thickness is >3-4mm then endometrial sampling should be done. This can be done via outpatient hysteroscopy. Endometrial sampling can also be performed via a Pipelle biopsy, Novak curette or a Vabra aspirator (1) .

If it is not possible to perform an outpatient procedure an EUA and D&C can be done are you suggesting you will do an EUA + D&C without hysteroscopy? (-1) . Another option is a formal hysteroscopy which allows treatment treatment of endometrial cancer?? to be conducted at the same time, however this is associated with greater anesthetic risks, bleeding and uterine perforation.

c) A patient with atypical endometrial hyperplasia should be counseled you were not asked about this on the risk of progression to endometrial cancer and also the risk of coexistent endometrial cancer.

This can be distressing to the patient and her family and she should be counseled on treatment options and provided with written information to assist in her decision making.

Conservative management you were not asked about management. You were asked about TREATMENT OPTIONS is not recommended due to the risk of progression to endometrial cancer.

Medical management may include the use of iron supplementation in anemic patients. In severely anemic patients blood transfusion may be necessary.

Progestagen therapy is one option for treatment. High dose oral progestagens can be used. Repeat endometrial sampling should be done in 6 months time (1) what are the limitations? CRITICALLY EVALUATE , if still present surgical treatment is indicated. The levonorgestrel intra uterine system is associated with initial bleeding which may cause diagnostic confusion.

Surgical management involves hysterectomy +/- bilateral salpingoophorectomy (1) . A laparoscopic, abdominal or vaginal approach can be used what are the limitations?


Every word in the question is there for a reason and must be considered in your answer
.
Posted by PAUL A.
Tue Jan 15, 2008 08:04 pm
A] We look for use of HRT (1) because it can lead to irregular bleeding also we ask about tamoxifen therapy and warfarin HEALTHY . All these can be a risk factor for endometrial malignancy is warfarin a risk factor?? .
History of PCOS and chronic anovulation unovulation expose endometrium to long term un-apposed estrogen which may predispose for endometrial hyperplasia and malignancy. PCOS can lead also to obesity, null parity and hyperandrogenism with long term complications like DM and hypertension healthy. You were asked to take a history, not write about risk factors . All these are regarded as risk factors also.
Un-apposed estrogen can occur if she had previously an estrogen secreting tumour.

We inquire about family history of colonic cancer, endometrial , breast or ovarian cancer as this woman may have familial genetic tendency for developing malignancy.

If the patient is smoker, this will be regarded as added risk factor for what? .

B] Investigation should be prompt to rule out malignancy.
Transvaginal ultrasound can measure endometrial thickness and detect pelvic pathology (1) , endometrial thickness of 5 mm (1) and more goes with endometrial hyperplasia, cancer or polyp. It has high sensitivity( 94-100%) but low specificity (40-80%), it can not confirm whether the abnormality is benign or malignant. Confirmation is done by histopathological examination.
This can be obtained by outpatient endometrial biopsy by pippelle [ vabra or sharman], however, it can miss polyp or malignancy as it explore only 4% of endometrial cavity (1) .
Hysteroscopy and D&C is the gold standard, it visualizes uterine cavity and allow for direct biopsy, it can be done as outpatient or inpatient procedure. Outpatient is cost effective, carries more patient satisfaction with no risk of anaesthesia. However, it allows to take small biopsy only while inpatient hysteroscopy allows to do polypectomy (1) .
D&C can be used when outpatient endometrial biopsy is unsuccessful and there is no facility for hysteroscopy.

C] Atypical endometrial hyperplasia carries a significant malignant potential and some times there is co-existent endometrial cancer. Therefore; there is no role for expectant management.
The main stay of treatment is total abdominal hysterectomy and bilateral salpingo-oopherectomy (1) after adequate patient counseling , we give her written information to allow her to give an informed consent. HRT use is not contra-indicated but it is better to be avoided. where is the CRITICALLY EVALUATE bit?
TCRE is not recommended because it masks the picture. Radiotherapy is inappropriate even if patient is unfit or reluctant to surgery, although, palliative radiotherapy can be used to control bleeding.
High dose progesterone is prescribed for other type of hyperplasia, but this is not advised in atypical hyperplasia.
Multidisplanary team involved including general gynecologist, Gynaecological oncologist, medical oncologist, anesthetist and radiotherapist .
Psychological support is provided throughout investigations and management.

You need a more detailed answer. Critically evaluate means ?state the value and limitations / disadvantages
Posted by PAUL A.
Tue Jan 15, 2008 08:24 pm
a) The additional information I would like to obtain from her history is about any vaginal dryness and irritation (1) ,previous history of any benign or malignant gynaecological disease and treatment, personal or family history of breast or GIT malignancy,family history of GIT cancers,use of HRT (1) this is all one sentence!!,its compliance and associated GIT disease which may be impairing the absorption of the HRT is also relevant. Past or family history of bleeding tendancy like easy bruisability,menorrhagia and coagulopathy is also relevant.

b) After examination you were not asked about examination of the genital tract which can rule out vulval,vaginal and cervical lesions, TVS should be done to see the endometrial thickness (1) and any growth within the uterine cavity and PCOs will you expect PCO in a post-menopausal woman? (-1) . Endometrial thickness greater than 5 mm warrants further investigations for endometrial CA. Hysteroscopic endometrial biopsy is the gold standard (1) of the investigations which can be done as the out patients procedure and has 80% detection rate and is cost effective, but may be uncomfortable for the pt so hysteroscopic endometrial sampling under aneasthesia can be considered what about aspiration biopsy? . Ca 125 and serum estradiol levels may be helpful in cases where the cause of endometrial hyperplasia is considered to be unopposed estrogen from a estrogen secreting tumour In addition a full blood count to see the degree of anemia and a raised ESR which, although less specific but suggestive of malignancy is beneficial. Paps smere may reveal cervicitis or CIN will a cervical smear detect cervicitis?

c) TAH+BSO is the treatment of choice (1) as 40% of the pts diagnosed as atypical hyperplasia turn out to be endometrial CA at histopathology and 50% of atypical endometrial hyperplasia progress to carcinoma so for this age group when fertility is not a concern pts acceptability to this treatment may be high accepting the risks of a major surgery like heamorrhage,visceral injury(urinary tract and GIT) and thromboembolism (1) use shorter sentences addressing single issues otherwise you will lose marks . Other treatment options like high dose(20 mg megestrol) and chemoradiation for this stage of the disease is not proved to be beneficial in various RCTs which RCTs are you referring to? I could not find any RCTs of megestrol in post-menopausal women with atypical hyperplasia .
LAH+BSO is also a treatment option (1) provided the expertise is available the otcome is not diferrent ? evidence in open and laproscopic methods wihh additional advantages of laproscopic procedure like less pain and analgesia,bleeding, reduced hospital stay,earlier post op recovery and return to work what are the disadvantages? CRITICALLY EVALUATE .
VAH +BSO is technically difficult however could be performed with better recovery than abdominal approach.It has a disadvantage of poor acess to abdominal cavity to assess the other organs.
LAVH is one of the options provided the additional expertise,epuipment and staff is available (1) ,
Posted by Dr seema jain J.
Tue Jan 15, 2008 08:29 pm
a)My aim in this case of postmenopausal bleeding would be to differentiate between gynecologic and non-gynecologic causes of bleeding.
The pattern of bleeding whether it is heavy or just spotting or staining need to be discerned.Any association of the bleeding being postcoital is of paramount importance.Vaginal dryness or pruritus vulvae leading to scratching will be inquired.History of lump or pain in abdomen may be found. Bladder or bowel complaints may point towards a non gynecologic cause.
Past history of any surgery performed on the uterus or breast will be asked.Medical history suggestive of diabetes mellitus should be noted.Menstrual history suggestive of an early menarche is a high risk factor for endometrial cancer.Any past prolonged history of irregular scanty periods pointing towards PCOS is helpful.Obstetric history with special emphasis on any history of infertility or treatment taken for it and number of pregnancies is important.Family history pertaining to breast cancer or colorectal cancer
will be inquired.One of the commonest causes of postmenopausal bleeding is intake of HRT or tamoxifen and this will be noted.

b)The most important investigations are a transvaginal ultrasound,office hysteroscopy,endometrial biopsy and Pap smear.
Transvaginal ultrasound to detect the endometrial thickness(should be ≤5mm),polyps,submucous fibroids or any ovarian tumor is done.Saline sonohysterography can be done in cases in which there is a doubt regarding the delineation of endo-myometrial interface.Office hysteroscopy to rule out an endometrial polyp or a submucous fibroid is helpful.A Pipelle biopsy gives adequate sample in around 70-80 percent of cases failing which a D & C under general anesthesia can be done.A Pap smear may show up abnormal cytology which should be further followed `up with colposcopy and a colposcopy guided biopsy.Further investigations will depend on the results of these investigations.MRI and chest xray if cervical or ovarian cancer is suspected.CA-125 may help in cases suspicious of ovarian cancer.Colonoscopy if family history of Lynch2 syndrome can be done.

c)Expectant management with proper follow up and endometrial biopsies every six months can be considered in woman who do not desire any medical or surgical intervention after thorough counseling that the chances of progression to malignancy are about 40-50 percent.
Medical treatment in the form of cyclical or continuous progestogen can be an option.Medroxyprogesterone acetate 200mg twice a day has been used. The other progestogens which can be used are megestrol or norethisterone.The disadvantage is that it is necessary to follow up with endometrial biopsies and that that it may not prove to be definitive form of treatment.Also the high dose may cause undesirable side-effects.
Surgical treatment may consist of abdominal or vaginal hysterectomy.Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the most appropriate and definitive treatment and should be the first choice if the woman is medically fit(these women are quite often obese and may have diabetes mellitus).Anesthetic risk,risk of wound infection and thromboembolism should always be kept in mind .Vaginal hysterectomy with removal of adnexa vaginally or laparoscopically is another option which prompts quick postoperative recovery.Removal of adnexa vaginally is found to be difficult by some operators and laparoscopic removal involves specialized equipment and training
Posted by PAUL A.
Tue Jan 15, 2008 08:33 pm
I would enquire about amount of bleeding.If she has any postcoital bleeding (1) . If she has symptoms of bleeding from other sites should also be checked.Current or recent use of HRT (1) should be checked . I would obtain her smear history (1) , past contraceptive,obstetric and gynaecological history. If there is any family history of Gynaecological or bowel cancers then she may be at higher risk of malignancy. Further information regarding her body mass index is valuable. If she is smoker or has smoked in last 10 years should be enquired. anorexia, weight loss, PR bleeding, haematuria
I would check for FBC to rule out anaemia. Pelvic ultrasound should be first line of investigation to determine endometrial thickness (1) and rule out any adenaxal pathology (1) . If endometrial thickness is less than 5mm then her risk of endometrial cancer is reduced from 10% to 1%. If endometrial thickness is more than 4mm , endometrium should be sampled which can be outpatient by means of pipelle biopsy (1) . Inpatient assessment by hysteroscopy and currettage should be undertaken if outpatient biopsy is insufficient or not possible (1) . If scan shows adenaxal mass, CA125 should be checked. Coagulation profile should be checked if there is history of bleeding from other sites. If suscpicion of cervical pathology then EUA and biopsy should be performed (1) .
Atypical endometrial hyperplasia has 30% risk of progression to endometrial cancer if untreated. Hysterectomy with bilateral salpingo-oopherectomy is treatment of choice for this woman (1) .This could be open surgery which has benefits of quicker operation than laparoscopy, widely available.It is less likely to involve additional form of surgery. Demerits of traditional surgery are longer inpatient stay and postoperative recovery. It also increases risk of thrombotic event (1) . Laparoscopic hysterectomy with oopherectomy (1) has benefit of quicker recovery and less pain.It carries increased risk of visceral injury and vascular injury. There is also risk of conversion to laparotomy.Vaginal hysterectomy provides benefit of no abdominal scar and opportunity to repair pelvic floor if required. It however doesnot provide opportunity to visualise other pelvic structures which could be helped with laparoscopy assiste vaginal hysterectomy (1) . If patient declines surgery then progesterone therapy along with repeat biopsy at six months can be considered (1) .This option may lead to short term avoidance of surgery but carries significant risk of progression to cancer (1)

Good answer
.

Posted by Azza S.
Tue Jan 15, 2008 10:03 pm
This is post menopausal bleeding. I will ask about nature of bleeding amount if there any associated factor like intercourse I will ask about parity, previous use of hormonal contraception and recent use of hormonal replacement therapy or other drugs like Tamoxiefen. I will also ask about cervical screening program if compliant and what are her results and when was the last screening done. Family history of cancer should be documented Any urinary or bowel symptoms should be asked about. I should ask about sexual history and symptoms of dry vagina.
FBC, MSU, U&E and LFT as base line investigations. Hysteroscopy and endometrial sampling is effective in identifying endometrial pathology as polyps hyperplasia or carcinoma. A trans vaginal ultrasound [TV-USS] is a good opportunity to screen for ovarian masses and to measure endometrial thickness. T V-USS is poor in detecting endometrial pathology as polyps. There is no general agreement on cut-off point for the thickness [3-4-5 cm]. Out-patient endometrial biopsy is an alter native method with reduced sensitivity, avoid the use of anesthesia and with reduced cost. In the presence of vulval, vaginal, or cervical lesion biopsy should be taken and referral for urgent colposcopy if necessary. In case of urinary or bowel symptoms referral to a specialist clinic.
Treatment options for atypical endometrial hyperplasia include medical treatment with progesterone therapy [ oral, injectable, depot, or intra-uterine system] or surgical management. Surgical management is hysterectomy, which is a major procedure that needs anesthesia and carry risk of thrombo-embolism, haemorrhage, infection and injury to viscera. As this patient is healthy hysterectomy may be better choice as with atypical hyperplasia there is association with endometrial cancer.
Posted by Shankaralingaia N.
Wed Jan 16, 2008 03:21 pm
Hi Paul,it looks like you have not assessed my answer,please can you look into it.
Thanks
Posted by Azza Shawky E.
Wed Jan 16, 2008 05:24 pm
A)This patient has PMB.up to 10%of womenwith PMB have primary or secondary malignancy most commenly endometrial cancer 80%,cervical cancer or overian ca.over 90%have begin cause usually gental tract atrophy and less commenly polps, endmetrial hyperplsiaor exgental pathlogy.I should ask this women about duration of bleeding,heavenies number of pads ,clots and if this bleeding is postcoital .History of previes cervical smeer,cervical ca,overian ca or breast ca is more important . Past medical history of HTN, DM ,obesty are predispsing factor for endometrial ca.however Ishould ask patient about drug history as HRT or tamoxfine which are cause endometrial hyperplasia or cancer. i should exclud heamaturia and rectal bleeding from history and ask patient about loss of wt and any change of bowel habit
B)investigation
Frist ,General examination should be done including general condition if their is pallor (anaemia) ,cachexia(malignancy) then abdominal and plevic exam.to detect any mass then inspect vuva for any abnormality , speculum exam should be done to detect vaginal abnormality as ca, atrophy and laceration and cervix inspected for erosion, tumour. PR should be done to exclude rectal cause. Retrosigmoidescopy and cystoscopy should be done under general anaesthesia to take biopsyif their is frank cx ca. cervical smeer should be done and colposcopy if their is postcoital bleeding.FBC should done also to detect HB and exclud anaemia. dilatation and currettage should done but it is alone cane loss 15% of endometrial ca. However Hytroscopy and biopsy is gold stander which can be done as inpatient or out patient ,hystoscopy andD&C also can be done. Transvaginal ultrasound is non invasive method and using acut of4mm of endmetrial thickness is highly senstive to detect endometrial ca and fluid in endometril cavity associated with ca in 25%of cases also can detect extrauterine anomalyas overian ca. However sonhystrography improve detection of polps submucus fibroid or focal endometrial thickness. Doppler and colour image can detect change of endometrial and uterine blood flow associated with malegnancy it is remain Research techneque.
c)atypical enometrial hyperplasia
atypical endometrial hyperplasia 25-30% risk ofedometrial ca so the best option of treatment TAH+BSO this advantage to inspect well abdominal and pelvic cavity and detect other pelvic mass but it has agreat risk of haemorrage,infectionand delay hospital post operative recovery. vaginal hyterectomy has less complicatin than abdominal .Laproscopic assistedvaginal hystrectomy new techneque allow visualise pelvic cavty and has less complication. multydisplinary team should be involved gyaencology oncologist , anaesthestist medical oncology. medical treatment is other option of treatment using high dose of progetrone medroxy progesteron 100mg daily for 6 month and repeat biopsy after3 month but this discribed after proper counsel about benfit and risk.If patient has HB blood transfution should be done and given iorn supply. D&C can be done it is helpful in sever bleeding. apporpriat counsel should be done to patient and provide leaflet and written information about benfit and risk of disease and treatment. Patient can decid what treatment option she want and we should respect her option.

A.EL. SAUDI ARABIA
Posted by PAUL A.
Thu Jan 17, 2008 09:17 pm
Sorry we missed your answer

Post menopausal bleeding is a high risk and needs urgent referral to the one stop gynaecology clinic.
a)I would like to get further information on the use of any form of HRT (1) ,loss of weight, loss of appetite,history of vaginal dryness and about the amount of bleeding (1) these are unrelated issues and should not be addressed in the same sentence .Information about the last cervical smear (1) and the result of it is essential.I would ask about the obstetrics history and the age of menarche ? parity . Obtaining personal history of breast cancer or bowel cancer is important healthy .I would like to know any history of hypertension,diabetes and poly cystic ovaries healthy .Family history of breast cancer,ovarian,endometrial and colorectal cancer is paramount.I would like to know if she is on any medication like warfarin or tamoxifen healthy .
b)Urgent investigation and diagnosis is vital in treatment of the affected.Depending on the amount of bleeding we may request FBC.She needs an urgent transvaginal pelvic ultrasound scan to measure the endometrial thickness (1) ? adnexae and identify any polyps.If greater than 3-5mm(depending on the type and duration of HRT) needs urgent hysteroscopy and endometrial biopsy.
Outpatient hysteroscopy (1) is ideal for most of the women and avoids the need for general anaesthesia.Hysteroscopy can identify irregularly thickened endometrium,polyps or any other pathology.Avulsion of the polyp if present and endometrial curretting is sent off for urgent histology is there a role for aspiration biopsy / in-patient hysteroscopy? .
c)The suggested treatment for atypical endometrial hyperplasia is hysterectomy ? BSO .Women should be shown lot of emphathy and support while breaking this news.
Atypical hyperplasia can be simple or complex.There is an increased risk of developing adenocarcinoma of the endometrium.After liasing with the oncologist I would discuss treatment options with the women.The main treatment option is hysterectomy and bilateral salpingo oophorectomy (1) explaining risk associated with it in terms of infection,bleeding,injury to bowel,bladder and blood vessel and the risk of thrombosis (1) .If this is acceptable the it should be done urgently and specimen should be sent for an urgent histology ? VAGINAL / LAPAROSCOPIC?? .
If she declines hysterectomy then she needs provera treatment or mirena coil insertion with close survelliance by frequent transvaginal ultrsound scans to monitor endometrial thickness.She should be explained about the risk of developing endometrial cancer and the need for regular monitoring what about risk of bleeding with IUS? How will you measure endometrial thickness? .
Leaflets and support group information has to be given and give adequate time to take decision.
Posted by Toyin A.
Thu Jan 17, 2008 09:18 pm
A) I would want to know her parity.I would enquire about the quantity and nature of the bleeding.I would like to know if the bleeding is postcoital or unprovoked.I would ask about her cervical smear history and smear results.I would enquire about any associated symptoms such as weight loss,anorexia,abdominal pain.I would rule out rectal or urethral bleeding.I would need to know if she has ever been on HRT or Tamoxifen or if she had a past history of breast cancer.I would enquire about her smoking status.

B) I would initially perform an abdominal examination to pick up any pelvic mass.A vaginal examination with a speculum to check for any local cervical causes,any atrophic vulvovaginal changes,any vaginal abnormalities,and a bimanual pelvic examination.I would also perform a cervical smear if she was due one.I would take a pipelle endometrial biopsy(outpatient sampling)for histological diagnosis but if this was not possible or an insufficient sample,she would need to have a formal inpatient hysteroscopy and endometrial biopsy.A transvaginal ultrasound scan would be done to check the endometrial thickness as this is sensitive for detecting endometrial carcinoma(80-90%),but less so for benign polyps(about 30%).

C)There is a 30% risk of progression from atypical hyperplasia to endometrial carcinoma therefore a conservative(do nothing)treatment option is not recommended.
Surgical treatment with a total hysterectomy and bilateral salpingooophorectomy is the treatment of choice in this case.The open abdominal route is widely available and may have a quicker operating time than laparoscopic routes but has disadvantages of a longer hospital stay and post operative recovery and increased risk of post op thrombosis.
Laparoscopic total hysterectomy and bilateral salpingooophorectomy results in a shorter hospital stay and post operative analgesia and recovery but carries an increased risk of vascular and visceral injury and the risk of conversion to a laparotomy.
Vaginal hysterectomy(laparoscopically assisted)with BSO has the benefit of shorter recovery time and hospital stay and allows visualisation of the pelvic organs.
Medical option if she refuses surgery is with progestogens(oral/Mirena IUS) and repeating the endometrial biopsy after 6 months.This may have the advantage of avoiding the surgical risks but the risk of disease progression persists.
Written information leaflets on all treatment options should be given to the patient to aid her decision making.
Posted by PAUL A.
Thu Jan 17, 2008 09:33 pm
[a}PMB is associated with patient\" anexity so ,try to reassure her that majority are due to benign causes however,endometrial cancer should be execluded as 10% of PMB are due to EC what is EC??? .
I would ask about nature of bleeding ,whether it is cyclic or postcital (1) which indicate cervical cause as ectopy will you diagnose ectropion in a post-menopausal woman? ,polp or cancer.

Ask about recent loss of weight,anorexia, (1) or insomnia which suggest malignancy.

Ask about urinary or bowel symptoms as haematuria or bleeding per rectum (1) to exclude non gynaecological causes.
History of menopausal symptoms especially vaginal dryness would be suggestive of bleeding due to atrophic changes (1) ,
and whether she is taking HRT ,detalis of her HRT (1) should be clarified such as kind is it combined or unopposed estrogen,is it continous or sequential and the compliance of it which is recognized cause of PMB.
Ask her about her cervical smear and result of last smearand its date and if it is due to do cervical smear (1) .
Detailed obsetric history as history of subfertility ,PCO,parity and her age at last delivery.
Menstrual history to be taken as age of menarche (1) as risk of EC is more with early menarche and late menopause.
Family history of colorectal cancer,EC, breast ca.,or OC SHOULD BE TAKEN ALSO.
{B}
IF history and exam.are suggestive of cervical cause punch biopsy can be taken to rule out cervical cause.
If due to cervical smear ,I will take smear and if abnormal referal for colposcopy (1) .
TVS to detect endometrial thickness,however still controversy regarding it is this controversial??? (-1) ,so if it is 3 to 5 mm or more patient should be triaged for hysteroscopy,furthermore TVS can detect adenaxal masses (1) as estrogen secreting tumours as granulosa cell tumour could be contributing cause of PMB,however it has high false positive rate in detecting benign lesion as polyps in such case we can use sonohystergraphy using saline or contrast which has more accurate diagnosis of polyps this is one very long sentence. Use short sentences addressing single issues .
Outpatient hysteroscopy and aspiration biopsy to be done will you do an out-patient histeroscopy AND THEN take a blind aspiration biopsy??? using pipelle biopsy,would biopsy 4% of endometrium but vabra aspirator take about 40% of endometrial biopsy,it is done without anaesthesiahowever diagnosed polyps can not be removed.
If no tissue taken inspite of thick endometrium or negative biopsy with existence of bleeding ,or in abscence of facility for outpatient hysteroscopy book patient for inpatient hysteroscopy and biopsy under anaesthesia (1) to do examination under anaesthia ,good visualization of uterine cavity ,biopsy and removal of polyps if diagnosed.
Dand c is last resort blind D&C should not be done as it will sample only 50% of endometrium,furthermore diagnosis of EC can be missed.
Preoperative investigation to be done in case surgery will be done,FBC to check HB ,LFTS,RFTS and group and save.
{c}
Iwould explin diagnosis to her ,try to reassure her that it is not cancer however it is associated with EC in about 25 to 50%and malignant change in 25 to 33% you were asked to critically evaluate treatment options .

The best management option in this case is surgery,TAH and BSO (1)
Consent for surgery you are not answering the question to be taken after explining the purpose of surgery.routes,which may be abdominall vaginally or LAVH.
TAH is the traditional method of hysterectomy ,it caries the risk of bleedingand need for BT,bowel injury bladder injury ,VTE,wound infection and abdominal scar (1) .
VH has advenages of no scar formation ,more cosmotic ? meaning ,less need of analgesia,less hospital stayand less bleeding,BSO can be done in 90% OF CASES
however it took longer time,unintented visceral injury and need expert gynaecologist.
LAVH is cosmotic ? meaning? Do you mean has better cosmetic results? ,can convert difficult VH to easy one ,less hospital stay ,less need of analgesiaand early return to normal activity,however it is associated with visceral and vascular injury (1) ,Rechter:s hernia,and need experienced surgeon.
If surgery resented by the women,alternatives including no treatment should be discussed with her.
Medical treatmentsuch as medroxy progesterone , megestrol for 3 to 6 monthsor Mirnea in case unwanted systemic side effects of progestogens.
Medical treatment need close regular mointoring by measuring endometrial thickness and biopsy if thickness more than 3 mm. with atypical hyperplasia, you should biopsy rather than rely on scan
Side effects of progestogens inculde abnormal uterine bleeding,bloating,breast tenderness,abnormal lipid profile and possible weight gain (1) .
Posted by PAUL A.
Thu Jan 17, 2008 10:40 pm
a) Information that is important in the history includes ; previous abnormal smears or post-coital bleeding may suggest cervical pathology (1) .
History of relevant risk factors as nulliparity , early menarche (1) , use of unopposed oestrogen is sequential HRT not a risk factor? and family history of endometrial cancer ; all of which increase the possibility of endometrial cancer.
History of rectal or urethral bleeding may suggest rectal and bladder pathology (1) . These are often confused with vaginal bleeding.
History of dyspareunia and irritative bladder symptoms may suggest atrophic vaginitis (1) .
b ) She needs Pap smear as part of evaluation of abnormal bleeding ,as it can be difficult to distinguish between cervical and upper uterine bleeding . Any visible cervical lesion needs to be biopsied (1) ,even if Pap smear is normal.
Trans-vaginal Scan(T.V.S.) should be done initially as it has 80-100% sensitivity for detecting malignancy with high false positive rate. The finding of endometrial thickness above the relevant cut-off (3-5mm) (1) indicates that there is risk of abnormality significant enough to warrant for further investigations. It also has the advantage of ovarian assessment and for presence ascites (1) .
Out-patient endometrial sampling can be performed using Pipelle , which samples 4% of the endometrial surface. Vabra sampler utilizes electronic suction what is this?? .It can be performed as out-patient and samples 41% of the endometrium ,but it is more painful than Pipelle .
Out-patient flexible hysteroscopy enables the uterine cavity to be visualised and directed biopsy can be taken . It is cost-effective with high patient acceptability (1) .
Hysteroscopy and biopsy (curettage) under general anaesthesia is the gold standard. It should be performed when the out-patient procedure is not possible or the patient has strong preference for a general anaesthetic (1) . The sensitivity of the procedure approaches 100% in detecting benign and malignant pathology.
c) The woman should be counselled and a management treatment IS NOT management options should be explained to her , risks and benefits of each option.
When atypia is present there is a clear risk of invasive cancer developing or already present. Average time is required for progression from hyperplasia to carcinoma is approximately five years. The risk of progression is > 30%.
Standard management should be a total abdominal hysterectomy with bilateral salpingo-oophorectomy (1) . The advantages are that gives cure to for the endometrial hyperplasia ,so long-term follow-up is unnecessary . This a major surgery ,which would require long hospital stay and a prolonged recovery at home. The operation itself involves the risk of bleeding ,infection ,bowel, bladder , ureteric injuries and thrombo-embolic disease and anaesthetic risks (1) .
Laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy is an another option (1) . Although the operating time is prolonged ,it has the advantages of shorter hospital stay, reduced pain relief and a quicker recovery with a good cosmetic results.
If the woman refuses to undergo a hysterectomy , high dose of progestogens such as medroxyprogestrone acetate in a dose of 100mg daily should be given for 6 months , with a repeat endometrial biopsy 3 months after cessation of treatment (1) what are the risks? .Long-term close surveillance should continue. No treatment or do nothing , but this would not be recommended as there is a high risk of developing invasive cancer.
A leaflet supporting the above information should be provided and her wishes then taken into account.
good answer
Posted by PAUL A.
Fri Jan 18, 2008 05:04 pm
a)My aim in this case of postmenopausal bleeding would be to differentiate between gynecologic and non-gynecologic causes of bleeding.
The pattern of bleeding whether it is heavy or just spotting or staining need to be discerned.Any association of the bleeding being postcoital (1) is of paramount importance.Vaginal dryness (1) or pruritus vulvae leading to scratching will be inquired.History of lump or pain in abdomen may be found. Bladder or bowel complaints haematuris / PR bleeding may point towards a non gynecologic cause.
Past history of any surgery performed on the uterus or breast will be asked.Medical history suggestive of diabetes mellitus should be noted healthy .Menstrual history suggestive of an early menarche is a high risk factor for endometrial cancer.Any past prolonged history of irregular scanty periods pointing towards PCOS (1) is helpful.Obstetric history with special emphasis on any history of infertility or treatment taken for it and number of pregnancies is important.Family history pertaining to breast cancer or colorectal cancer
will be inquired.One of the commonest causes of postmenopausal bleeding is intake of HRT (1) or tamoxifen and this will be noted.

b)The most important investigations are a transvaginal ultrasound,office hysteroscopy,endometrial biopsy and Pap smear.
Transvaginal ultrasound to detect the endometrial thickness(should be ≤5mm) (1) ,polyps,submucous fibroids or any ovarian tumor (1) is done.Saline sonohysterography can be done in cases in which there is a doubt regarding the delineation of endo-myometrial interface.Office hysteroscopy (1) to rule out an endometrial polyp or a submucous fibroid is helpful.A Pipelle biopsy gives adequate sample in around 70-80 percent of cases failing which a D & C under general anesthesia can be done ? plus hysteroscopy?? .A Pap smear may show up abnormal cytology which should be further followed `up with colposcopy and a colposcopy guided biopsy (1) .Further investigations will depend on the results of these investigations.MRI and chest xray if cervical or ovarian cancer is suspected.CA-125 may help in cases suspicious of ovarian cancer.Colonoscopy if family history of Lynch2 syndrome can be done.

c) Expectant management with proper follow up and endometrial biopsies every six months can be considered not an appropriate option in woman who do not desire any medical or surgical intervention after thorough counseling that the chances of progression to malignancy are about 40-50 percent.
Medical treatment in the form of cyclical ? value of cyclical treatment in a post-menopausal woman or continuous progestogen can be an option.Medroxyprogesterone acetate 200mg twice a day has been used. The other progestogens which can be used are megestrol or norethisterone.The disadvantage is that it is necessary to follow up with endometrial biopsies and that that it may not prove to be definitive form of treatment.Also the high dose may cause undesirable side-effects (1) .
Surgical treatment may consist of abdominal or vaginal hysterectomy.Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the most appropriate and definitive treatment (1) and should be the first choice so why are you writing this third? If you ran out of time, you will get fewer marks if the woman is medically fit(these women are quite often obese and may have diabetes mellitus) question tells you she is healthy .Anesthetic risk,risk of wound infection and thromboembolism should always be kept in mind (1) .Vaginal hysterectomy with removal of adnexa vaginally or laparoscopically is another option (1) which prompts quick postoperative recovery.Removal of adnexa vaginally is found to be difficult by some operators and laparoscopic removal involves specialized equipment and training ? lap hyst + BSO
Posted by PAUL A.
Fri Jan 18, 2008 05:15 pm
This is post menopausal bleeding. I will ask about nature of bleeding amount if there any associated factor like intercourse (1) I will ask about parity, previous use of hormonal contraception and recent use of hormonal replacement therapy (1) or other drugs like Tamoxiefen. I will also ask about cervical screening (1) program if compliant and what are her results and when was the last screening done. Family history of cancer should be documented Any urinary or bowel symptoms should be asked about haematuria / PR bleeding . I should ask about sexual history and symptoms of dry vagina (1) .
FBC, MSU, U&E and LFT Not in women with PMB (-1) as base line investigations. Hysteroscopy and endometrial sampling is effective in identifying endometrial pathology as polyps hyperplasia or carcinoma will you do this before the scan? . A trans vaginal ultrasound [TV-USS] is a good opportunity to screen for ovarian masses (1) and to measure endometrial thickness. T V-USS is poor in detecting endometrial pathology as polyps. There is no general agreement on cut-off point for the thickness [3-4-5 cm] (1) . Out-patient endometrial biopsy is an alter native alternative to scanning?? method with reduced sensitivity, avoid the use of anesthesia and with reduced cost. In the presence of vulval, vaginal, or cervical lesion biopsy (1) should be taken and referral for urgent colposcopy if necessary. In case of urinary or bowel symptoms referral to a specialist clinic.
Treatment options for atypical endometrial hyperplasia include medical treatment with progesterone therapy [ oral, injectable, depot, or intra-uterine system] ?? use of depot progestogens to treat atypical hyperplasia??? or surgical management. Surgical management is hysterectomy ? BSO , which is a major procedure that needs anesthesia and carry risk of thrombo-embolism, haemorrhage, infection and injury to viscera (1) . As this patient is healthy hysterectomy may be better choice as with atypical hyperplasia there is association with endometrial cancer.

You have more space / time and need a more detailed answer
Posted by PAUL A.
Fri Jan 18, 2008 05:34 pm
A) This patient has PMB.up to 10%of womenwith PMB have primary or secondary malignancy most commenly endometrial cancer 80%,cervical cancer or overian ca.over 90%have begin cause usually gental tract atrophy and less commenly polps, endmetrial hyperplsiaor exgental pathlogy you were not asked about the causes .I should ask this women about duration of bleeding,heavenies number of pads ,clots and if this bleeding is postcoital (1) .History of previes cervical smeer, cervical ca,overian ca or breast ca healthy. is more important . Past medical history of HTN, DM ,obesty are predispsing factor for endometrial ca. HEALTHY however Ishould ask patient about drug history as HRT (1) or tamoxfine which are cause endometrial hyperplasia or cancer. i should exclud heamaturia and rectal bleeding (1) from history and ask patient about loss of wt and any change of bowel habit (1)
B)investigation
Frist , General examination you were asked about INVESTIGATION should be done including general condition if their is pallor (anaemia) ,cachexia(malignancy) then abdominal and plevic exam.to detect any mass then inspect vuva for any abnormality , speculum exam should be done to detect vaginal abnormality as ca, atrophy and laceration and cervix inspected for erosion, tumour. PR should be done to exclude rectal cause. Retrosigmoidescopy and cystoscopy should be done under general anaesthesia to take biopsyif their is frank cx ca. cervical smeer should be done and colposcopy if their is postcoital bleeding.FBC should done also to detect HB and exclud anaemia. dilatation and currettage blind C&C should not be done (-1) should done but it is alone cane loss 15% of endometrial ca. However Hytroscopy and biopsy is gold stander which can be done as inpatient or out patient (1) ,hystoscopy andD&C also can be done. Transvaginal ultrasound is non invasive method will you do this before or after hysteroscopy?? and using acut of4mm of endmetrial thickness is highly senstive to detect endometrial ca and fluid in endometril cavity associated with ca in 25%of cases also can detect extrauterine anomalyas overian ca (1) you should take a few minutes to read what you write and correct any spelling errors. . However sonhystrography improve detection of polps submucus fibroid or focal endometrial thickness. Doppler and colour image can detect change of endometrial and uterine blood flow associated with malegnancy it is remain Research techneque.
c)atypical enometrial hyperplasia
atypical endometrial hyperplasia 25-30% risk ofedometrial ca so the best option of treatment TAH+BSO this advantage to inspect poor English well abdominal and pelvic cavity and detect other pelvic mass but it has agreat risk of haemorrage,infectionand delay hospital post operative recovery is there a GREAT risk of haemorrhage at hysterectomy?? . vaginal hyterectomy has less complicatin than abdominal . Laproscopic assistedvaginal hystrectomy new techneque LAVH is not a new technique. Your English remains poor allow visualise pelvic cavty and has less complication. multydisplinary team should be involved gyaencology oncologist , anaesthestist medical oncology. medical treatment is other option of treatment using high dose of progetrone medroxy progesteron 100mg daily for 6 month and repeat biopsy after3 month (1) why after 3 months if you are treating for 6 months? but this discribed after proper counsel about benfit and risk.If patient has HB blood transfution should be done and given iorn supply. D&C can be done it is helpful in sever bleeding D&C is NOT a treatment for bleeding (-1) . apporpriat counsel should be done to patient and provide leaflet and written information about benfit and risk of disease and treatment. Patient can decid what treatment option she want and we should respect her option.

Your English is poor and you have not read your answer before submitting it. In the exam, you should have time to read through your answer to make sure it conveys the intended information
Posted by PAUL A.
Fri Jan 18, 2008 05:50 pm
A) I would want to know her parity.I would enquire about the quantity and nature of the bleeding.I would like to know if the bleeding is postcoital (1) or unprovoked.I would ask about her cervical smear history and smear results (1) .I would enquire about any associated symptoms such as weight loss,anorexia (1) ,abdominal pain.I would rule out rectal or urethral bleeding (1) .I would need to know if she has ever been on HRT (1) or Tamoxifen or if she had a past history of breast cancer.I would enquire about her smoking status.

B) I would initially perform an abdominal examination to pick up any pelvic mass.A vaginal examination with a speculum to check for any local cervical causes,any atrophic vulvovaginal changes,any vaginal abnormalities,and a bimanual pelvic examination The word EXAMINATION does not appear in the question. You were asked for INVESTIGATIONS .I would also perform a cervical smear if she was due one. I would take a pipelle endometrial biopsy(outpatient sampling)for histological diagnosis but if this was not possible or an insufficient sample,she would need to have a formal inpatient hysteroscopy and endometrial biopsy this is not logical. You could subject a woman to an out-patient biopsy followed by GA + hysteroscopy because of insufficient sample when a scan would have told you she has a 2mm regular endometrium .A transvaginal ultrasound scan would be done to check the endometrial thickness ? cut-off for normal. ? adnexal pathology. You will do a scan before an endometrial biopsy and should write it in that order as this is sensitive for detecting endometrial carcinoma(80-90%),but less so for benign polyps(about 30%).

C)There is a 30% risk of progression from atypical hyperplasia to endometrial carcinoma therefore a conservative(do nothing)treatment option is not recommended.
Surgical treatment with a total hysterectomy and bilateral salpingooophorectomy is the treatment of choice (1) in this case.The open abdominal route is widely available and may have a quicker operating time than laparoscopic routes but has disadvantages of a longer hospital stay and post operative recovery and increased risk of post op thrombosis (1) .
Laparoscopic total hysterectomy and bilateral salpingooophorectomy results in a shorter hospital stay and post operative analgesia and recovery but carries an increased risk of vascular and visceral injury and the risk of conversion to a laparotomy (1) .
Vaginal hysterectomy(laparoscopically assisted)with BSO has the benefit of shorter recovery time and hospital stay and allows visualisation of the pelvic organs (1) .
Medical option if she refuses surgery is with progestogens(oral/Mirena IUS) (1) ? value of IUS ? what will you do if she is bleeding continuously? and repeating the endometrial biopsy after 6 months.This may have the advantage of avoiding the surgical risks but the risk of disease progression persists (1) .
Written information leaflets on all treatment options should be given to the patient to aid her decision making not necessary ? you were not asked about what should be done to the patient. You were asked a factual question: Critically evaluate treatment options .
Posted by PAUL A.
Fri Jan 18, 2008 05:52 pm
A good candidate should
(a)
History
? Take a history of presenting symptom ? amount of bleeding, precipitating factors (? Post-coital), associated pain, vaginal discharge / dryness; dyspareunia (2)
? Rectal bleeding / haematuria (1)
? Take a menstrual history ? age at menarche, history of menstrual irregularity suggestive of anovulation (1)
? Gynaecological / obs history ? smear history / parity (1)
? Features of malignant disease ? weight loss, anorexia (1)
? Drug history - HRT (1)


(b) Investigations

? Biopsy of any vulval lesion (1)
? Colposcopy +/- cervical smear if cervix abnormal; removal of cervical polyp provides diagnosis as well as treatment (1)
? Request trans-vaginal scan for endometrial thickness + examine adnexae (2)
? Endometrial biopsy ? either out-patient aspiration biopsy, out-patient hysteroscopy and biopsy or formal hysteroscopy D&C under anaesthesia (2)

(c ) Management options for atypical hyperplasia

? Know that in a healthy post-menopausal woman, TAH + BSO is the most appropriate treatment for atypical hyperplasia as there is a possibility of an underlying carcinoma. Associated with risks of major surgery. (2)
? Laparoscopic hysterectomy / LAVH + BSO is an option allowing quicker recovery but requires specialised equipment and additional operative skill. Associated with risks of laparoscopic surgery (2)
? If surgery is declined, oral progestogen with repeat hysteroscopy + endometrial sampling within 6 months. Carries risk of progression of disease and uncertainty about duration of follow-up. Risk of progestogenic side-effects (2)
dad Posted by PAUL A.
Mon May 7, 2012 01:41 am

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