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Essay 289 - PMB

Essay 289 - PMB Posted by PAUL A.
A healthy 65 year old woman has been referred to the gynaecology clinic because of a 3 months history of blood-stained vaginal discharge. (a) Which information would you obtain from the history? [7 marks] (b) What will you tell her about the likely cause of her symptoms?[2 marks] (c) Justify your investigations given that clinical examination was normal [5 marks] (d) She is found to have atypical endometrial hyperplasia. Evaluate her treatment options [6 marks].
Posted by clarice M.
a) I would enquire about symptoms of vaginal atrophy such as vaginal dryness or burning and dyspareunia.
I would enquire if the blood loss is constant or associated with any precipitants such as intercourse as the latter could indicate a cervical cause such as a cervical polyp, cervical cancer or vaginal atrophy.
I would enquire if about the consistency of the blood loss as a constant watery blood stained discharge can be associated with a malignancy of the fallopian tube.
I would enquire if she uses hormone replacement therapy and ascertain the duration of use, as well as if it is oestrogen only, sequential or continuous combined HRT.
I would also enquire if she has a history of breast cancer and Tamoxifen use.
I would ask when her last smear was and if she has ever had abnormal smears. I would ask if she had previous treatment to her cervix for abnormal smears or for any other reason.
I would ask if she has had a hysterectomy and if it was for a benign or malignant cause.
For completion, I would ask if she has noticed a sudden unintentional weight loss as this could be associated with malignancy.

b) The most likely cause of postmenopausal bleeding is endometrial in origin. This may be endometrial hyperplasia or an endometrial polyp. Endometrial hyperplasia is a thickening in the lining of the womb. An endometrial polyp is fleshy growth of the lining of the womb. It will not be possible to differentiate the 2 on the basis of the history alone and further investigations are needed.

c) I would obtain blood for a full blood count to exclude anaemia.

I would perform a cervical smear as the transformation zone is not visible in postmenopausal women.

I would perform a transvaginal ultrasound scan to assess the endometrial thickness. A TV US has a high sensitivity for detecting endometrial cancer using a cut off of 5mm. However it has low sensitivity for detecting endometrial polyps. Its accuracy can be improved by saline ultrasonography. However, this is a specialist investigation and is not offered universally. Furthermore it is operator dependent. Triaging patients using a transvaginal ultrasound scan reduces the number hysteroscopies without compromising the detection of endometrial cancer. An ultrasound scan can also identify ovarian cysts.

If the endometrial thickness is regular and equal to or greater than 5mm, I would perform a pipelle biopsy. The advantage of this procedure is that it can be done as an outpatient procedure and has a sensitivity and specificity of greater than 90% for endometrial cancer. It is comparable to a formal dilation and curettage.

An outpatient hysteroscopy should be performed if the endometrium is irregular on ultrasound scan as it has a higher sensitivity for endometrial polyps compared with ultrasound. Endometrial sampling is still necessary as hysteroscopy ony has a sensitivity of 30% for endometrial cancer if used in isolation.

A hysteroscopy, dilation and curettage should be performed under general anaesthetic if endometrial sampling or hysteroscopy is not possible in an outpatient setting.

c) Complex atypical hyperplasia (CAH) is a mandate for a hysterectomy owing to its high risk of progression to endometrial carcinoma. The patient should be informed that occult cancer has been identified on uterine specimens removed for CAH.

The next issue to discuss is whether her ovaries are removed simultaneously when she has a hysterectomy. A bilateral salpingoophrectomy is advisable. There is no benefit of leaving them in situ. Furthermore, there is a small risk of developing ovarian cancer if they are not removed. There is also a small risk of residual ovary syndrome causing chronic pain. If only a hysterectomy is performed and occult endometrial cancer is identified, she will then require another operation to remove her ovaries.

There are 2 possible routes for a hysterectomy: abdominal or vaginal. The advantages of the abdominal approach are ease of access and a bilateral salpingoophrectomy (BSO) can be performed at the same time. Peritoneal washings can also be obtained.

A vaginal hysterectomy would offer a faster recovery and has the advantage of avoiding an abdominal scar. Blood loss is less compared with a laparotomy. A BSO can be performed via the vaginal route but it is technically challenging to do so. Some ovarian tissue may be left behind. Peritoneal washings cannot be obtained if the vaginal route is chosen.

Laparoscopic assisted vaginal hysterectomy and BSO is another option. Peritoneal washings can be obtained. Recovery times are similar to vaginal hysterectomy and the scars are smaller. However, it is associated with risk of injury to visceral organs, requires specialist skills and if it is not offered locally, a referral to a specialist centre may delay treatment.

The patient should be provided with literature about complex atypical hyperplasia as well as information about a hysterectomy and BSO.
Posted by dr neelangini G.
a) The information I would obtain from her history is, age of menopause, any similar h/o PMB & investigations done for the same. I will also ask her amount of bleeding, associated foul smell . Any abdominal or vaginal pain or history of postcoital bleeding. I would like to know her age of menarche & previous history of treatment of infertility or PCOS. Her gravidity & parity, mode of delivery should be sought. I would like to know whether she is on HRT, Tamoxifen. Her family history is important to know familial cancers like HNPCC, endometrial ca, ovarian ca, breast ca. Previous history of fibroid uterus should be taken. I will ask her, history of dysuria, frequency of micturition, vaginal dryness to rule out atrophic vaginitis. I would also like to know her Status of pap smears & if any recall she has missed. Her history of weight gain or weight loss, change in bowel habits will also be taken.


b) I would tell her that this is PMB & most likely cause is atrophic vaginitis or atrophic endometrium. I will tell her that it may be because of local causes like cervical or endometrial polyp.I would also tell her that about 10% of PMB at this age are associated with endometrial cancer , so she requires further investigations to rule out Ca endometrium, endometrial hyperplasia , Ca cervix.

c) Her routine investigations including FBC to know anaemia, Urine routine & microscopy to see haematuria, U & E , Blood sugar to rule out Diabetes. Investigations for her PMB include TVS to know endometrial thickness , uterine size, ovarian mass . As TVS is non-invasive & will give us information of endometrial hyperplasia if more than 4mm thickness although it is debatable. I will also like to take her papsmear for CIN, Ca cervix. Colposcopy , if previous abnormal papsmear or history of postcoital bleeding & abnormal cervix. I will take her endometrial sample either by vabra aspirator or Pipelle to see hyperplasia/malignancy. If sample obtained is inadequate or there is difficulty in obtaining sample because of menopausal atrophy , I will like to do hysteroscopy & D&C. Hysteroscopy has added advantage to rule out endometrial polyp.

d) Presence of atypical cells in her endometrium would require surgical approach of Total Abdominal Hysterectomy & Bilateral salpingoophorectomy .As she is postmenopausal & there is no benefit of retaining ovaries , ovaries to be removed. Route of surgery includes abdominal , vaginal or Laparoscopic assisted vaginal hysterectomy. With abdominal approach peritoneal washings can be obtained & same is true for laparoscopic approach. Vaginal hysterectomy is an alternative to abdominal route, but sometimes difficulty in removal of adenexa. Wih vaginal hysterectomy & LAVH postoperative recovery is faster . For LAVH , laparoscopy expertise is required
Posted by S M.
a)
I would determine her parity, age at menarche and menopause because nulliparity, early age at menarche and late age at menopause increases the risk of endometrial cancer. I would find out if she was taking hormone replacement therapy, the type of HRT and the duration of use. This is important because HRT can increase the risk of endometrial hyperplasia and enedometrial cancer. I would also enquire whether she was taking Tamoxifen which can also increase the risk of endometrial hyperplasia and endometrial cancer. I would ask when was her last cervical smear and if it was negative. This is important since cervical smears can identify cervical intraepithelial neoplasia which can progress to cervical cancer. I would find out if she has had operations such as hysterectomy and comorbidities such as hypertension or diabetes mellitus.

b)
I would tell her that the cause of her symptoms can be due to endometrial cancer. It can also be due to cervical cancer or vaginal cancer. It can also be due to endometrial or cervical polyps which are benign. The bleeding can be a side effect of the HRT. I would provide her with written information.

c) An ultrasound scan of the pelvis should be done for endometrial thickness. An endometrial thickness of 5mm or more would indicate that further investigation needs to be done to rule out endometrial cancer. If the endometrial thickness is 5mm or more then an endometrial biopsy should be done to obtain specimen for histological studies to determine the type of endometrial hyperplasia or if there is endometrial cancer. The endometrial biopsy can be done as an outpatient using the pipelle biopsy method. This is limited since it only samples 4% of the cavity. The endometrial biopsy can also be done in conjunction with hysteroscopy as an inpatient or outpatient. Hysteroscopy is a good investigative tool because it allows visualisation of the endometrial cavity. Biopsy at the time of hysteroscopy with an endometrial curette should obtain a larger specimen for histology than the pipelle.

d) The first treatment option is a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH BSO). Atypical endometrial hyperplasia has a 70% risk of progressing to endometrial cancer. TAH BSO by removing the uterus removes the risk of developing endometrial cancer or if there was an underlying cancer already present, the TAH BSO reduces the risk of metastasis and advanced stage cancer developing.
The second treatment option, if the woman does not wish surgery, is medical treatment with progestogens such as the levonorgestrel intrauterine system or medroxyprogesterone acetate for 3 months, and then repeating the ultrasound scan and biopsy. This is limited in value because an underlying cancer may already be present and will remain undiagnosed, untreated and may progress in stage during the progestogen treatment. Also the progestogen therapy may not work and the atypical hyperplasia may progress to endometrial cancer.
The third treatment option is to do nothing. This is of no value and should not be done because of the high risk of progression of endometrial cancer.
Posted by S D.
a) I will enquire if this is the first episode of PMB and if there were previous episodes of PMB, any investigations undertaken and their results. Dryness of vagina, dyspareunia and postcoital bleeding suggests atrophic vaginitis. Any use of HRT, especially sequential HRT predisposes to endometrial cancer; Abnormal cervical smears in the past and any tratments to cervix may suggest cervical pathology such as cervical cancer. Her parity as nulliparity is associated with endometrial cancer. H/o urinary symptoms such as dysuria, frequency and haematuria; Bowel symptoms such as rectal bleeding should be enquired as sometimes these can be confused with vaginal bleeding. Red flag symptoms such as loss of appetite and weight, shortness of breath, melaena may suggest malignancy. Medical problems such as Diabetes, hypertension, obesity increases the risk of endometrial cancer. Past H/o breast ca and use of tamoxifen; Family h/o endometrial, breast, ovarian cancer further increases her risk of endometrial cancer.
b) I will explain to her that in most cases the cause is benign such as atrophic vaginitis. However it is important to rule out sinister causes such as endometril, cervical, vaginal and vulval cancers. The most common malignancy associated with PMB is endometrial cancer which is present in 10% of cases.
c) Further investigations should be directed to identify the cause of PMB and exclude endometrial and other malignancies. The first line investigation is transvaginal ultrasound. It gives information on endometrial thickness and any adnexal masses. It is 80-90% sensitive in detecting endometrial malignancy. It is easy to perform and reliable but may miss polyps.
Outpatient endometrial biopsy by pipelle or vabra aspirator is commonly performed. Pipelle samples 4% of endometrum and d 70-80% senitive in picking up maliganancy. It is however painful, cannot pick up polyps and may not give adequate sample. Vabra aspirator samples 44% of endometrium but is more painful.
Outpatient hysteroscopy and endometrial biopsy allows visualisation of endometrial cavity and to take guided biopsies. Patient acceptability is high. Small polyps can be removed but large polyps cannot be removed and needs removal under GA. It also avoids the risks of GA and is cost effective.
Inpatient hysteroscopy and biopsy is the gold standard investigation. It is 100% sensitive in detection of endometrial cancer and allows removal of large polyps. It is also useful when outpatient procedures fail or if there is inadequate sample. It is however associated with risks of GA and risk of injury to bladder, bowel which may require additional procedures.
d) I will explain that the lining of womb has abnormal cells; there is a possibility that cancer can co-exist in 5% of cases and if left untreated can progress to cancer in 25-30% of cases over 5-10 years. The treatment of choice is total hysterectomy and bilateral salpingooophorectomy. This can be done abdominally, vaginally and laparoscopically depending on patient\'s wishes, clinical findings, feasibility and availability of skill for laparoscopic techniques. If refuses surgery or unsuitable and moribund, then oral progestogens or mirena IUS with endometrial biopsy every 6-12 months is an option. However it should be explained that there are no trials asessing their efficacy and there is a risk of progression of disease. Information leaflets should be given, further appointments if the patient wishes and her decision should be respected.
Posted by A S.
Am
a) Her parity , age of menarch and age of menopause are relevant . I will ask about the bleeding continuous or intermittent , post coital or with urination. Is she sexually active , is she experiencing dysparunia ? The use of HRT especially sequential can cause post menopausal bleeding . If she is using HRTwhen did she started treatment? may be she is a new user . The use of tampons or pessary may precipitate bleeding with atrophic vagina especially if left in place for a long period . I will also ask about the date of her last cervical smear . Recent weight loss or anorexia may accompany malignancy . Her family history may be relevant if she has a relative with gynecological cancer . ( she is healthy so we will not ask about DM, breast cancer or hypertension )
b) I will tell her that most of the causes are benign . Cancer represents only 10 – 15 % of causes. Deficiency of female hormones may cause atrophic changes in the vagina or uterus causing bleeding in 60 % of cases . Abnormal proliferation of the lining of the uterus is called hyperplasia and it may the reason for her complaint . Other causes include polyps or infections . I will provide her with information leaflet.
c) Cervical smear will be done to detect abnormal cells . Full blood count to detect aneamia . Other investigations will aim to exclude malignancy and hyperplasia of the endometrium . Pelvic U/S trans vaginally done to measure the endometrial thickness and detect ovarian masses . Endometrial thickness if less than 5 mm has a good negative predictive value to exclude endometrial carcinoma . Endometrial sampling done outpatient using Pipelle or Vabra endometrial sampler has high sensitivity around 80 % . This is is nearly equivalent to formal inpatient D&C biopsy but the later requires hospital admission and anaesthesia . The best method for endometrial sampling is hysteroscopic guided biopsy . It has high sensitivity and specifity ( above 90 % ) .
d)Since she is not in need for conservative surgery because of her age the recommended line of treatment is total abdominal hysterectomy with bilateral salpingo oopharectomy . This can be achieved by the abdominal route or vaginal or laparoscopic assisted vaginal route . Total laparoscopic surgery is also an option with shorter hospital stay and less post operative morbidity but needs specials skills and expertise . If hysterectomy is declined the patient may use progestines either high dose oral or levonorgestrel intrauterine system . If this is used she will need follow up and endometrial biopsy every 3-6 month to judge regression or progression of the atypia . Expectant treatment is not recommended because atypical hyperplasia may be associated with foci of malignancy or may be transformed into frank carcinoma in 40% of cases .



Posted by G. K.
A thorough history should be obtained regarding the amount of blood stained vaginal discharge, any associated passage of clots or abdominal pain.
She should be asked whether she is sexually active. If yes, the inquiry should be made regarding postcoital episodes of bleeding\' and any discomfort asociated with coitus such as vaginal dryness leading to dyspareunia.
Also a full cervical smear history should be taken to make sure whether she\'s been having them regularly or not; any problems with the most recent smear should be inquired about.
She should also be inquired whether she is taking HRT or not.If yes, the the duration, type of HRT should be established i.e whether continuos combined, sequential or estrogen only.It is important to confirm the presence of an intact uterus when such questions are asked.
Inquiry about family history of cancers should be asked as well since familial conditions such as hereditary nonpolyposis colonic cancer is associated withan increased risk of CA. endometrium.

After taking a full history, the patient should be councelled about the likely causes of bleeding which include atrophic vaginitis, atrophic endometritis which are both related to estrogen deficiency. Other possible causes include cervical and endometrial polyps. Other more sinister causes like cervical cancer, premelignant changes in the endometrium such as atypical endometrial hyperplsia and the possibility of endometrial cancer should be explained to her.

Investigations include full blood count to assess the degree of blood loss. A transvaginal ultrasound to measure the endometrial thickness. Thickness of < 5mm is reassuring and the patient can be manged conservatively since it rules out the possibility of endometrial hyperplasia and endometrial cancer and is more suggestive of an atrophic endometrium . If the endometrial thickness is more than 5mmm, it raise the possibility of endometrial hyperplasia and cancer of endometrium and should be investigated by an inpatient hysteroscopy and endometrial biopsy.Alternatively outpatient pipelle biopsy can be undertaken as well.

Atypical hyperplasia on histology of endometrial biopsy is a serious matter and it\'s significance of progression to cancer as well the possibility of co-existent cancer should be explained to the patient. The ideal manegement in this case would be a hysterctomy.If thepatient doesn\'t agree to the proposed management, treatment with high dose progesterone and regular hysteroscopy at regular intervals of at least 3 months should be carried out. The risk of progression of cancer in this option should be made clear to her.
Posted by Mark D.
Mark

a)

I will askdetails of blood stained discharge- the amount,any associated pain or itching or any post coital bleeding.i will ask if there is any hematuria or PR bleeding.i will ask if she has dysparunia, vaginal dryness suggestive of urogenital atrophy. I wll enquire if she has any vague gastric symptoms ot weight loss loss of appetite or abdominal distension.
I will enquire about her past menstrual history- age of menarche, menopause, any oligomenorea or irregularity suggestive of anovulation.I will ask about her obstetric history - parity and long standing infertility.I will ask if she has medical disorders like DM, HT.I will take smear history and if she has taken any treatments for abnormal smears.
Her family history including relatives with colorectal,endometrial or breast cancers will be enquired. I will ask if she is taking any medications like HRT or tamoxifen.

b)
I will tell her that that the bleeding can be from vulva, cervix, vagina or uterus like atrophy,cervical polyp,cancer or endometrial polyp or cancer. It may be due to benign or mailgnant causes .At this age we need to rule out malignant causes.we will need to examine and investigate her for the same. I w ill provide written information on likely causes.

c)
I will collect a pap smear with spatula and endocervical brush if it is due. This is to check for any cervical preinvasive lesions which cannot be seen on examination.she will need colposcopy and biopsy if it is abnormal.
I will ask for a TVS to check for endometrial thickness(ET) ovaries and rule out ascitis.
It is noninvasive quick and with a cut off of 4 mm it gives 100 % negative predictive value to rule out endometrial pathology.It identifies women( ET more than 4 mm) who need further investigations.However it need trained operator and equipment.
If her ET is more than 4 mm she should be offered endometrial sampling by pipelle vabra or aspiration. Pipelle is the most sensitive of all 80-87% sensitivity to diagnose endometrial pathology.it is cheap, done in OPD and without anesthesia. How ever it is blind and samples only 7-41% endometrium and may miss few cases of endometrial
Carcinoma.saline infusion sonography can be used to delineate the endometrial ling but it may be uncomfortable in post menopausal women and dosent sample the endometrium hence not recommended.
Out patient hysteroscopy allows direct visualisation of endometrial cavity and targeted endometrial biopsy . it is 100% sensitive . it need expertise equipment local anesthesia and there is a very small risk of preforation. Hysteroscopy cannot be recommended alone without bipisy as it has high false positive rates due to subjective interobserver variations.
Inpatient hysterscopy and biopsy is gold standard as gives advantages of out patient hysteroscopy plus allows treatment of local causes like polyp and submucous fibroids.

d)
Total abdominal hysterectomy and bilateral salpingo oopherectomy TAH BSO remains the definitive treatment at her age. Atypical hyperplasia may progress to invasive adenocarcinoma in 40% cases in 4 years and may be associated with 35-50% incidence of coexisting adenocarcinoma endometrium. However TAH BSO is associated with serious risks like visceral injuries ,blood transfusion and thromboembolism and frequent risks of wound morbidity , pain and bladder dysfunction. Vaginal hysterectomy can be done if there is descent to decrease operative morbidity but ovaries may be difficult to remove. Laproscopically assisted ot total laproscopic hysterectomy with BSO can be done .It reduces wound morbidity,decreases hospital stay ahd facilitates early return to daily activities and has low risk of VTE. However it has higher risk of visceral injuries,longer operating time, need expertise and equipment and GA.
Is she declines surgery the she can beoffered oral high dose progestogens like medroxy progesterone acetate or norethisterone .They regress the hyperplasia in 65-70% cases after 6-18 months of treatment but are associated with side effects like mastalgia, bloating and depression. Resistant cases will require TAH BSO.
Lng IUS can also be used , it has milder progestogenic side effects but small risks of perforation, expulsion and infection . Both methods need close follow up and hysteroscopy and biopsy afer every 6 months. The exact duration of follow up is not clear and there is a risk of invasive endometrial carcinoma later.

I will provide written information regarding all options and final treatment depends on her wishes and fitness for various modalities.
Posted by Farzana N.
a)History is taken regarding factors associated with increased risk of endometrial cancer , such as age at menarche,parity,age at menopause.Smear history is taken,also any associated vulval or vaginal soreness .Use of HRT and compliance is enquired.Non compliance with HRT is associated with PMB.
History of loss of appetite or weight is taken.
b)She should be told that cause of bleeding is most probably benign pathology,but bleeding in her age should be further investigated to rule out any cancer of uterus or cervix.
c)TVS is done to find the endrometrial thickness.Cut off 3-5mm is taken to detect endometrial cancer.It is highly sensitive 80-100%.Endometrial thickness of >5mm would be further investigated by doing endometrial biopsy. Out patient endometrial aspiration biopsy can be done with different devices which sample ,4%- Pipelle,to 41% vabra of endometrium.It is easy to do and successful in 80% of cases. Alternatively out patient hysteroscopy and biopsy may be done using fibreoptic flexible hysteroscope .It is cost effective with high patient acceptability.It avoids anesthetic complications.
If out patient procedures fail to detect any pathology,and she continues to be symptomatic, Hysteroscopy and D&C would be done under general anesthesia.
MRI can detect can detect any tumor and its extent.
d)Atypical endometrial hyperplasia is associated with high risk of progression to endometrial cancer~30-80%.There may be coexistent cancer in about 25-30% of cases.
Treatment options would be ,no treatment – associated with high risk of progression to cancer.Best option for her is Hysterectomy with BSO.This procedure can be abdominal or vaginal.Abdominal hysterectomy has the advantage that BSO is easier and peritoneal washings may be obtained for cytology and staging.But it is associated with higher morbidity , higher risk of hemorrhage ,bowel and bladder injury.
Vaginal hysterectomy has less morbidity,less risk of hemorrhage ,bowel and bladder injury.Removal of ovaries is sometimes difficult with vaginal hysterectomy and Laparoscopic assisstance is required .
If she refuses hysterectomy,high dose progestins may be given but it needs regular follow-up to check progreesion to cancer
Posted by zakaria M.
A)
I will take detailed history of presenting symptom, including nature of bleeding and any precipitating factors (post-coital) , association with pain, excessive vaginal discharge or pruritis vulvae.I will inquire about any rectal bleeding or hematuria. Regarding her past menstrual history will ask about age at menarche and menopause, any history of menstrual irregularity. Obstetrical history i.e. parity, mode of deliveries, and history of miscarriages. Gynecological history including history of polycystic ovaries and cervical smears, any past abnormal smears and treatment received for that. Medical history includes history of diabetes, hypertension, liver disease and thyroid disorders. Drug history including hormone replacement therapy and use of tamoxifen. Past history of breast cancer. Family history of malignancies (eg.endometrial cancer, breast, colon).I will ask about any weight loss, change in bowel habit and anorexia.
b)
I will inform her bleeding is most likely caused by underlying endometrial pathology this includes, a thinning of the uterine lining (endometrial atrophy) most common, and polyps (noncancerous fleshy growths ), Endometrial hyperplasia (a condition in which the lining of the uterus grows too much; if left untreated for a long time, it may lead to cancer) & Endometrial cancer (Cancer of the lining of the uterus).However only 20% of patients has significant underlying pathology.
c)
Principal aim of investigations is to rule out endometrial pathology. Investigation will include CBC, to check for anemia, platelet count, urine routine analysis to look for hematuria, liver functions tests for underlying liver disease, blood sugar level to rule out diabetes. Cervical smear should be taken if routine screening has been missed. Trans-vaginal ultrasound scan (TVS) to measure endometrial thickness, sensitivity for detecting endometrial malignancy is 80-100%, adnexal pathology can also be detected. Out-patient hysteroscopy and directed biopsy is a superior diagnostic tool compared to blind biopsies, especially considering high risk of malignancy in this age group. Has similar efficacy to use of rigid hysteroscope under general anesthesia. May require paracervical block but avoids complications of general anesthesia. Is very cost-effective and has high degree of patient’s acceptability. In-patient hysteroscopy and curettage under anesthesia will be considered in case of failed out-patient.
c)
When significant surgical risk is not an issue presence of cytological atypia with its risk of concomitant carcinoma i.e. 50% (being of higher stage) or highest risk of progression (30%) to carcinoma mandate hysterectomy, with removal of ovaries, as she is menopausal and there is no benefit of leaving them in situ, there is risk of developing ovarian cancer and furthermore there is risk of sub clinical metastases in case of coexisting endometrial carcinoma. Patient will be evaluated carefully for presence of more advance disease prior to planning surgery. Regarding routes of hysterectomy the advantages of the abdominal approach offers good access, visualization and tactile information of the whole pelvis and abdomen and easier adnexectomy. Peritoneal washings can also be obtained. A vaginal hysterectomy would offer a faster recovery and has the advantage of avoiding an abdominal scar. Blood loss is less compared with a laparotomy. Removal of ovaries may be technically difficult and peritoneal washings cannot be obtained .Laparoscopic assisted vaginal hysterectomy and BSO is another option, with shorter hospital stay and less post operative morbidity, peritoneal washings can be obtained, but needs specials skills and expertise. Recovery times are similar to vaginal hysterectomy and the scars are smaller. If significant co morbidities precludes surgery, or surgery is declined, high dose progestogens or intrauterine progesterone releasing system can be the alternative option, but risk of progression and need for close surveillance and follow up should be explained. In case of persistent symptoms surgery is recommended.
The patient will be provided with written information.




Posted by Manoj Babu  R.
(a) Which information would you obtain from the history? [7 marks]

History should include details about her vaginal discharge including the amount and frequency and any similar history in the past. A foul smelling discharge, post coital bleeding and passage of fleshy tissues suggests malignancy especially cervical cancer. Other symptoms like loss of appetite, abdominal mass is important. Age of menarche and menopause, parity and any family history gynecological breast or colonic cancer is to be asked. Cervical smear history, current or past history of HRT and its type and duration of use is to be asked. The timing of bleeding in relation to the progesterone phase is important in evaluating women on cyclical HRT.

(b) What will you tell her about the likely cause of her symptoms? [2 marks]

She should be told that about 90% of women who present with post menopausal bleeding have only minor problems or no specific cause at all. The commonest cause is atrophic vaginitis due to reduced estrogen level after menopause. But it is safer to have further evaluation to find the cause since the remaining 10% may have serious causes like endometrial or cervical cancer.

(c) Justify your investigations given that clinical examination was normal [5 marks]

About 13% of women above 65 years presenting with postmenopausal bleeding might be having an endometrial or cervical cancer. The main aims of investigations are to detect serious causes like cancer and also to reassure the women if the results are normal.

The ideal setting for evaluating such women is a one-stop clinic with access to TVS, outpatient endometrial biopsy and hysteroscopy. If the smear history is normal and up-to-date, and cervix is clinically normal cervical cancer is unlikely. Transvaginal sonography is found to be sensitive initial tool for evaluation postmenopausal bleeding. It can measure the thickness of endometrium and detect endometrial abnormalities like polyps and cancer. If the endometrial thickness is less than 3 mm the chance of having endometrial cancer reduces to 0.6-0.8%. In such a situation further evaluation is needed only if there is recurrence of bleeding. TVS is a simple investigation with minimal patient discomfort and no adverse effects. But it is operator dependent, adequate training is mandatory.

But if the endometrium is thicker than 3 mm or if there are other abnormalities endometrial histology is required. But outpatient endometrial biopsy or dilatation and curettage both are associated with about 10% false negativity. Hence the ideal step is an out patient hysteroscopy along with an endometrial sampling. It is comparable to an inpatient hysteroscopy and D&C under GA and can be done in most patients without the need for cervical dilatation. Minor causes like endometrial polyps can be treated in the same sitting.

(d) She is found to have atypical endometrial hyperplasia. Evaluate her treatment options [6 marks].

Atypical endometrial, hyperplasia can either simple or complex. The risk of progression to endometrial cancer is about 7% in simple atypical hyperplasia and about 29% in complex atypical hyperplasia. Recent studies have shown that there may foci of associated endometrial cancer in up to 50% case of atypical hyperplasia.

As she is otherwise healthy and there is no need of uterine cincervation for fertility purposes a total hysterectomy with bilateral salpingooophorectomy should be considered the fist option. Because of the possibility of endometrial carcinoma an MRI should be considered to assess the depth of penetration into the myometrium and extension to the cervix as well to rule out pelvic lymphadenopathy. If any of the above factors are present consider referral to a gynecologic oncologist for management as she may need pelvic lymph node sampling as part of staging.

If there was no atypia medical treatment with could have been an option for her.
Posted by Priti T.
prt

a] I would like to enquire about the amount of bleeding with any precipitating factors like post coital bleeding.She should be asked about vaginal dryness and dyspareunia associated with blood stained vaginal discharge.Hx of bleeding from other sites like rectal bleeding or haematuria should be elicited.
Details of menstrual history,age of menarche and menstruating irregularly suggestive of anovulation needs to be elicited.
Details of obstetric history like number of children is asked.Cervical smear hx should be taken ,whether they have been normal till date.
Any history of weight loss/anorexia or increasing abdominal girth should be elicited to exclude ovarian pathology.
Her personal history of smoking,the number and duration of cigrettes should be found out.
Any hx of taking HRT ;or past hx of taking infertility drugs should be elicited.

b]I would like to tell the woman that in 90% of the cases no pathology may be detected but she need investigations.
There can be a possibility of increased thickening of the lining of her womb,causing blood stained discharge.This is a premalignant condition and needs thourough investigations to rule out malignancy.

c]FBC is done to assess anaemia.Coagulation profile is done if there is hx of bleeding from other sites.
TVS is done to assess endometrial thickness and to rule out adenexal mass.If the endometrial thickness is less than 5mm,then her risk of endometrial cancer is reduced from 10% to 1 %. If endometrial thickness is greater than 4mm then the endometrial sampling should be done. Endometrial biopsy can be done in outpatient by means of Pipelle biopsy. Alternatively outpatient hysteroscopy and biopsy is taken or in patient hysteroscopy with currettage under anasthesia is undertaken.
In case of adenexal mass CA 125 should be checked.
If there is suspicion of cervical pathology then EUA with biopsy should be performed.

d) A typical endometrical hyperplasia has 30% risk of progression to endometrial cancer if untreated. Hystrectomy with bilateral salpingo-oophrectome(TAH with BSO) is the treatment of choice for this healthy post menopausal woman. This could be an open surgery which has a benefit of quicker operation than laproscopy and widely available, less likely to involve additional form of surgery. Demerits of traditional surgery are longer inpatient stay and post operative recovery. It also increases the thrombotic event.
Laproscopic hysterectomy with oophrectomy has benefit of quicker recovery and less pain. It carries increased risk of visceral and vascular injury. There is increased risk of conversion to laprotomy.
Vaginal hystrectaomy provides benefit of no abdominal scar and opportunity to repair pelvic floor if required. It does not provide the opportunity to provide other pelvic structures. It can be combined with LAVH.
In case patient declines surgery then progestogen therapy oral or injectable can be given along with repeat hysteroscopy and endometrial sampling in 6 months. This option leads to risk of progestogenic side effects like weight gain, acne, oedema. There is uncertainty about the duration of follow up and the risk of disease progression.
Posted by Ron C.
RonRon
A.
I’ll enquire whether this is a first episode or whether she had similar episodes in the past. I’ll further ask regarding pain / bleeding on intercourse, recent cervical smears and smear history, when she turned menopausal and when she had her menarche. I want to know whether she has (ever) used any form of HRT. I’ll ask about her obstetric history and methods of contraception and any previous (gynae) surgery such as removal of endometrial polyps. I want to know whether she noted changes in her weight or abdominal distension / mass. I’ll enquire regarding hypertension and diabetes, history of breastcancer (+ tamoxifen use), as well as a family history of cancer in general and of endometrium or colon in particular.

B.
I’ll acknowledge her anxiety but explain that the majority, up to 90%, of causes for post-menopasual bleeds are relatively innocent such as postmenopausal atrophy or polyps. I will however explain that it is still very important to investigate the complaints, as sometimes the cause is a pre-malignant or even cancerous growth in endometrial lining or cervix.

C.
A transvaginal ultrasound will pick up the majority of problems in the uterine cavity. If the endometrial lining is >4 mm a pipelle endometrial sample will be done. The combination of this investigation has very low false-negative rate for endometrial (pre)cancerous lesions. Those where pipelle sampling is not possible, may have the hysteroscopy as an outpatient, provided they are low risk and a polyp is not expected. An ultrasound finding suggestive for polyp would best be followed up with a hysteroscopy, as pipelle sampling will often fail to identify the polyp and if there is a polyp it can be removed at the same time.

D.
This is a pre-malignant lesion, which in time will develop into cancer in 30-50% if left untreated, thus conservative management is not an option. In a younger patient where fertility is an issue, high-dosed progesterone treatment (medroxy-progesteron 20 mg/day) with reassessment by pipelle or hysteroscopy after 3 months can be tried, but response in atypical hyperplasia is poor with often relapse, as compared to hyperplasia without atypia. Placing a Mirena coil would serve a similar purpose, though its use for this purpose is currently not established practice. Progesterone therapy is not appropriate in menopausal patients where fertility is obviously not an issue, especially since cancerous
Posted by Neelam A.
(a)A detailed history of postmenopausal bleeding should be taken to know nature frequency precipitating factors and severity of bleeding. Precipitating factors may be following trauma, intercourse or use of hormonal replacement therapy or tamoxifen. Menstrual history is also important to find out high risk factors in form early age of menarche or late menopause. Obstetric history should also be enquired to know whether she is nulliparous. Medical history of diabetes hypertension or other associated illness should also be documented.
Past history of any gynaecological problem or cancer or breast cancer should also be asked. Cervical smear status should also asked to rule out any cervical pathology. It is important to ask for associated urinary or bowel symptoms to rule out urinary or colon pathology. History of anorexia recent changes in weight or bowel habits should also be enquired. Family history of breast cancer or gynaecological cancer should also be obtained. Personal history of smoking and use of alcohol should also be obtained.

(b) vulval or vaginal causes are atrophic changes, dystrophic, trauma including use of ring pessary and carcinoma.
Cervical causes are cervicitis, atrophic, trauma, cervica polyp or carcinoma.
Uterine causes includes endomteritis, endometrial polyp, hyperplasia and carcinoma.
Uterine leiomyosarcoma
fallopian tube or ovarian cancer
oestrogen producing tumour and use of exogenous oestrogen.
(c) trans-vaginal scan for endometrial thickness is non invasive, cheaper with 80 – 98% sensitivity to detect endometrial cancer and a higher acceptability rate. Although it has got higher false positive rate with poor sensitivity to detect endometrial polyp and it may uncomfortable to women.
Sonohysterography is a better alternative to diagnose polyps, however it is not available in most units.
Out-patient biopsy is cheaper and quick option to obtain tissue from endometrium, however availability of tissue obtained depend on the methods use vebra or pipelle.
Out-patient hysterography avoids the risks of surgery or anaesthesia, however it may be uncomfortable to women and it has got the limitation to remove big polyps.
Hysteroscopy and D&C has got the advantages of being pain free, availability of removing big polyps and doing any additional procedures. However it is expensive, risk of perforation, infection and bleeding.

(d) Treatment options depend on women wishes and her suitability for surgery.
As atypical hyperplasia has tendency to progress to carcinoma in about one third women. Hysterectomy would be the ideal option if she is fit for surgery. Moreover about 50% hysterectomy specimens removed for atypical hyperplasia have histological evidence of endometrial carcinoma. However, it is major surgery and it is associated with anaesthetic and surgical risks of infection, bleeding, need for blood transfusion, damage to bladder, bowel blood vessels or ureters, thrombo-embolism and death. High doses of progestogen would be the other option. It would avoid major surgical or anaesthetic risks. However she should be followed up and re-sampling of endometrium should be done. Hysterectomy should be advised if persistence of atypical hyperplasia or progression to endometrial carcinoma.

Posted by Shoba V.
Hist of pain associated with bleeding,whether the bleeding is associated with clots or is watery.History of age of menarche,menopause,contraceptive history,history of feeling dryness during intercourse,use of HRT (continuous,sequential or unopposed estrogen use),use of Tamoxifen.
Family h/o ovarian or breast cancer,colorectal ca.,should be taken.
Cervical smear history & if colposcopic examination was done previously.
H/o loss of appetite,weight,haematuria or bleeding per rectum.
2)The patient should be told that the most likely cause of her sypmtoms is atrophic cervicitis or vaginitis which is quite common due to her hypoestrogenic state.Whereas, other causes like cervical or endometrial polyps, ca of endometrium,cervix,vagina or fallopian tube should be ruled out.
3) Considering the clinical examination is normal,a cervical smear should be taken & if suspecios a colposcopy should be done.
A TVS scan should be done to asses the endometrial thickening(if >5 cm,further investigations may be required),endometrial polyps may be difficult to diagnose & so a HyCoSy scan may be undertaken.Asimple trans abd Usg may be also done to r/o any adnexal mass.
An outpatient sampling using vabra or pipelle may be performed although sometimes the area with lesion may be missed out.An outpatient hysteroscopy may also help to improve in collecting the sample with the above instruments.Inpatient hysteroscopy under GA & using a rigid hysteroscope may be performed although larger polyps cannot be aspirated,smaller ones can be removed.
The gold standard is an Hysterscopy & DNC which will reveal the the most likely type of endometrial lesion.A informed consent form should be taken prior to any of the above invasive proceedure.
Finally an MRI scan although expensive may be required .
4)The diagnosis should be explained to the patient supported by information leaflets.She should be told that there is a chance of her condition turning to malignancy & considering she is already menopausal,the surgical management should be explained which is Hysterectomy & Bilateral salpingo oopherectomy.
If she declines the surgical option advise regarding the useof Progestrogens in the form of medroxyprogesterone acetate or Levnorgestral containing IUCD(Mirena coil ) can be used.The final treatment of choice is what the patient chooses & it should be considered.
Posted by J P.
a.I will enquire whether the blood stained discharge is continuous or intermittent ,any provocating factor such as post coital bleeding if present indicates local cervical cause.Previous cervical smears history will be noted.History suggestive of anovulation,PCOS,infertility suggestive of hyperestrogenism will be enquired.History of infertility ,ovulation induction may indicate ovarian cause.History of vaginal dryness,dyspareunia is suggestive of atrophic vaginitis as the cause.History of any mass in abdomen bleeding is likely to cause significant anxiety .I will tell her that the symptoms are most likely may indicate ovarian mass.History of use of medications like tamoxifen and HRT will predispose to bleeding. History of any surgeries done before including hysterectomy will be asked.Family and personal history of endometrial,breast and ovarian cancer will be enquired .History of rectal bleeding and hematuria may indicate gastro or urinary cause.History of recent loss of weight and appetite may suggest malignancy.
b.Post menopausal to a benign cause but in 10 % of cases malignancy may be associated which has to be ruled out by investigations.
c.Trans vaginal ultrasound is essential to estimate endometrial thickness. Using a cut off of 4-5 mm ,it has a sensitivity of 80% in detecting endometrial cancer.It can also detect adnexal mass and non invasive..But it has a high false positive rate and fails to detect benign endometrial polyps.Out patient endometrial sampling is possible by vabra and karmaan curette has a sensitivity of 60-80%.This is cost effective and has better patient acceptability.But this may fail to produce sample in 10-20% of cases and cause discomfort and pain. Hysteroscopy and endometrial sampling is the gold standard technique.Out patient hysteroscopy is possible using flexible fibre optic hysteroscope.this can produce endometrial sample but not remove polyp.There may be difficulty in insertion of hysteroscope in nulliparous women. Hysteroscopy and D &C under anaesthesia is the best method which is least likely to miss endometrial cancer and is also able to remove polyps.There are risks associated with the procedure like infection,haemorrhage,uterine perforation.Optimum method may be TVS followed by out patent hysteroscopy in at rsk women.
c.Atypical endometrial hyperplasia has the risk of progression to cancer in 25 % of women and there may be an underlying cancer.Hence expectant management is not an option.Surgicla treatment is the definitive treatment. This includes TAH with BSO and biopsy of any suspicious lesions.The risks are due to the procedure infection,haemorrhage,anaesthetic risks,VTE.Hysterectomy can be done by vaginal route which has less morbidity but it is difficult to remove ovaries.Lavh with BSO is an option associated with less morbidity, less hospital stay. But this requires expertise and risks of laproscopy.Medical treatment involves medroxy progesterone acetate 100 mg 0d for 6 months followed by endometrial sampling 3 months later can be tried if surgery declined.This requires long follow up and the duration is not clear.
Posted by Manoj M.
a) Information about the discharge if malodourous may suggest underlying infection / malignancy.
Associated symptoms like abdominal pain / history of loss of weight and appetite may suggest malignancy.
A history of blood stained discharge post coital may suggest local lesions of cervix or vagina.
Her menstrual history should be taken as early menarche and late menopause increases risk for endometrial cancer.
History of pregnancies, use of combined oral contraceptive pills should be taken as these may have a protective effect for endometrial cancer.
History of tubal sterilisation may also provide a protective effect on endometrial cancer.
Family history of endometrial cancer, breast cancer, colonic cancer may increase the risk of endometrial cancer.
History of any hormone replacement therapy(HRT) and details of type of HRT should be taken because if on sequential HRT may sometimes attribute to the cause of her current symptoms.
A history of any treatment with coils like Mirena for progesterone arm of HRT may be the cause of discharge.
History of urinary or bowel symptoms should be taken to exclude underlying advanced malignancies.
History of smear, with recent results and any treatment will help in managing with her current symptoms.

b) A likely cause is unknown and needs further investigations to arrive at the diagnosis.
Most likely causes are benign conditions like HRT withdrawl bleed /cervical / endometrial polyps and may only need reassurance or simple treatment.
Serious causes could be like endometrial cancer or cervical cancer which occurs in about 10% of women presenting with post menopausal bleeding and may need treatment depending on their respective stages.

c)Vaginal swabs to exclude infection and FBC to exclude anaemia.
Trans vaginal ultrasound(TVS) is a very useful investigation because an endometial thickness of less than 5mm will exclude underlying endometrial cancer in more than 85% of PMB, but with less sensitivity to detect endometrial polyp.
TVS can also safely minimise the need for invasive procedure like hysteroscopy when a endometrial thickness cut off is used.
Endometrial sampling with pipelle/vibra aspirator is useful investigation and can be done in outpatient setting to detect endometrial pathologies.
Hysteroscopy and directed endometrial biopsy is the gold standard and can be done in outpatient and inpatient setting. This provides direct view of endometrial cavity and obtaining endometrial biopsy samples for pathological diagnosis.

d) Atypical endometrial hyperplasia is a diagnosis which merits hysterectomy and bilateral salphingo-oopherectomy(BSO) in her age group. This is because of the significant risk of progression to endometrial cancer and presence of possible occult underlying undiagnosed endometrial cancer.
BSO is recommended in her age group as she has gone through menopase and also completes the treatment if underlying early endometrial cancer and prevents future ovarian pathologies.
The routes of hysterectomy are vaginal/ abdominal / laparoscopic hysterectomy.
Vaginal approach avoids abdominal surgery with quicker recovery compared to abdominal hysterectomy but may pose challenge if no significant uterine descent/ for removal of ovaries.
Abdominal hysterectomy provides easy access for total hysterectomy and BSO but associated with risks of major abdominal surgery.
Laparoscopic hysterectomy may avoid risk of major abdominal surgery but has its own risk of laparoscopic injuries and may not be available in all centres.
If the patient is not willing for surgical intervention, she should be fully counselled regarding the risk of progression and association of undiagnosed endometrial cancer and consider treatment with progestin therapy with GnRH analogue treatment. This should have regular follow up with 6 monthly Hysterocopy and endometrial directed biopsy.









Posted by Ahmad A.
I would ask about her menstrual history, menopause. I would ask about post coital bleeding and if her initial symptoms related to local lesion., vaginal or cervical. I would ask about drug history of hormonal replacement therapy (HRT) which may have direct relation for break through bleeding, according to the type of HRT. I would ask about her obstetrical history, infertility and anovulatory cycles, Polycystic ovaries?. Family history should be asked, breast, endometrial, colon, prostate…

I would tell that her symptoms are most likely related to HRT or atrophic or hypertrophic endometrial changes, However, the other serious aetiolgy should be excluded.

Investigations should be given includes, Pelvic a, transvaginal ultrasound which may rule out ovarian mass, cyst and evaluate endometrial thickness. As, the cut off value is 5mm, though endometrial cancer may be excluded. Also, endometrial polyp can be excluded through trans vaginal scan. Otherwise, endometrial biopsy should be offered. Out patient endometrial sampling using Pipelle catheter. However, almost 4% of cases can be missed. Hysteroscopy with endometrial sampling is the diagnostic gold standard investigation, outpatient or inpatient. Dilatation and curettage biopsy may miss about 3 % of endometrial pathology.

Atypical endometrial hyperplasia is a precancerous condition as about 30% of cases may change to endometrial ca. So, abdominal hysterectomy is the first line of treatment. Bilateral oophrectomy is advised during the procedure as, there is a possibility of concomitant hidden cancerous lesion may be discovered with histopatholoical examination. Other types of hysterectomy can be offered includes, vaginal route, however there is technical difficulties with removal of the ovaries. Also, laparoscopic assisted vaginal hysterectomy can be offered with expertise in laparoscopic procedures. Medical treatment can be offered in case of refusal of surgical option. Progestagen, norethistrone in relatively high dose can be given. However, side effects of progestagen like, breast pain, bloating, distension, headache. Also, this needs regular follow up by repeated ultrasound and endometrial sampling to rule out change to endometrial ca.
Posted by Arun J.
a-- I would ask whether her discharge was present daily or associated with postcoital bleeding.Associated features like pruritis,foulsmell,frequency of micturition,dysuria,hematuria and altered bowel habits like blleeding per rectum would also be asked. I would ascertain about previous similar episodes if any, the treatment taken and the outcome. I would ask about her her menarche , menopause,obstetric history with respect to the number of children ,breastfeeding, and history of HRT intake.Smear history is asked.Family history of thrombosis and cancers of breast, endometrium, ovary and colon asked.Smoking,intake of alcohol and addictive drugs also would be asked.
b -I would tell her that her symptoms are probably benign but the aim would be to rule out sinister pathology like cancers of cervix,ovary,and endometrium before arriving at a conclusion.I would provide her with written information.

c-I would do USS to see for the endometrial thickness as more than 4mm warrants futher investigations like outpatient hysteroscopy and directed biopsy . Its advantage is that it helps to visualise the endometrium and take biopsy from suspicious areas and associated polyps if any can be diagnosed.If the expertiese and equipment is unavailable endometrial biopsy is done as it is easy to do,easily available and cheap.Pipell samples ~4% of the endometrium and vabra aspirator samples ~40% of the endometrium.

d--Conservative management with high dose progestogens is an option but it needs longterm follow up with scans and endometrial biopsy so as to diagnose progression of disease and patients compliance is also vital.Hysterectomy with bilateral salpingo oophorectomy is another option.This is an optimal treatment as it removes the organ with the pathology( because undiagnosed underlying endometrial cancer is present in ~25% of cases).Hysterectomy can be done either vaginally( less morbidity but can have problems in removing the adnexa) or abdominally(morbidity likely to be more but removal of adnexa is easy) or via laproscopically(needs expertise and equipment and has its entry related risks of visceral injury,and is less morbid ).

Posted by Seema  B.
A) I will ask her about the nature and severity of discharge,any foul smell or any associated symptoms like post coital bleeding or dyspareunia.I will ask regarding vaginal pain or symptoms of menopause like vaginal dryness ,hot flushes as atrophic vaginitis may be the cause of her symptoms.
Enquiry is made regarding haematuria and rectal bleeding.
I will also ask her about use of vaginal tampons or pessaries
A detailed menstrual history is taken regarding age of menarche and menopause and regularity of cycle.Early menarche and late menopause are predisposing factors for endometrial carcinoma.
history is taken about any recent Pap smear and the result if available
Enquiry is made regarding use of any contraception
Ask if any treatment has been taken earlier and the effect of treatment.
A note is made of her parity.
History is taken regarding use of any drugs like hormone replacement therapy
I will ask her about presence of any predisposing factors for endometrial carcinoma like diabetes,hypertension or tamoxifen intake


B) Regarding likely cause of her symptom I will explain her that most likely her symptoms may be due to a benign pathology in the genital tract like endometrial/cervical polyp or atrophic vaginitis/cervicitis.However malignancy is a possibility at this age and needs to be excluded and investigations will need to be done.I will provide her with written explanation.



C) A FBC is done to assess anaemia.
I will also do a Pap smear particularly as an atrophic cervix is difficult to assess clinically and cervical cancer may be a possibility.It is difficult to visualise transformation zone in a post menopausal woman and colposcopy may be difficult.An experienced colposcopist is needed if Pap smear report abnormal.
Transvaginal scan will be done to assess the endometrial thickness and see any adnexal mass.It is a non invasive easily available method with good sensitivity in triaging for further endometrial biopsy.However sensitivity is low in detecting endometrial polyps.The cut value for endometrial thickness varies between 3-5 mm in post menopausal women.It is dependant upon the equipment and skill of operator.Sonohysteroscopy is more sensitive than TVS but is not widely available.
If endometrial thickness is more than 5 mm I will do an outpatient endometrial aspiration biopsy or ahysteroscopy and biopsy.Sensitivity of these outpatient procedures is good and they are acceptable and cost effective.The complications of anaesthesia and surgery are avoided.
However if the results are inconclusive or the symptoms persist inspite of a negative result I will do a formal hysteroscopy D&c under general anaesthesia which is considered as gold standard for invesigating post menopausal bleeding.Tissue can be taken for biopsy from suspicius areas and any polyp if seen can be removed simultaneously.Associated with complications of anaesthesia and surgery like uterine perforation and haemorrhage


D)Total abdominal hysterectomy with bilateral salpigo oophorectomy is the most appropriate treatment for her.However it is associated with morbidity and mortality of major surgery.Complications like haemorrhage,injury to viscera and thromboembolism can occur.
Vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy with bilateral salping oophorectomy is another option with lower morbidity and better cosmetic effects.Laparoscopic surgery needs specialised equipment and a surgeon with additional expertise for the operation.Haemorrhage and post operative recovery are faster.Associated with complications of laparoscopy like visceral and vascular injury.
Ovaries are better removed considering her post menopausal age to reduce the chances of future malignancy.
Hormonal treatment with high dose progesterone Megesterol Acetate is an alternative if the woman declines surgery.Disadvantage is the need to follow up within 6 months with hyseroscopy and endometrial biopsy.Besides the chances of progress to invasive cancer still exists.
Woman would be explained expectant management is not justified considering the premalignant nature of the lesion and the possibility of progress to invasive cancer.She will be explained child bearing is unlikely at her age if fertility is an issue
Womans wishes will be taken into account.
I will provide her with written information and give her contact details of support groups as the finding is associated with considerable anxiety.
Posted by Marcus M.
a) History should include parity, age at menarche and menopause along with use, previous or current, of HRT and it\'s type. The type of bleeding (fresh red or dark), precipitating events such as intercourse and associated hormonal symptoms including breast tenderness or cramping should be established. Past medical history of diabetes, hypertension, polycystic ovarian syndrome should be elucidated as these all increase the risk of endometrial cancer.

b) Her symptoms are most likely to be due to a benign condition however a small but significant number of women will have a more sinister cause in the form of endometrial cancer and this must be excluded.

c) Ultrasound scan provides a sensitive method of assessing the endometrium. The transvaginal route is best and cut-offs of 5mm or less and 3mm or less are used for \'normal\' in women with and without HRT respectively. A pipelle endometrial biopsy has 81% sensitivity and 98% specificity for detecting endometrial cancer in spitet of only sampling 4% of the endometrium. Hysteroscopy is the \'gold standard\' for endometrial assessment, allowing visualisation of the entire cavity and has high sensitivity for endometrial cancers. All 3 tests are acceptable to most women and can usually be performed as out-patients.

d) Atypical endometrial hyperplasia is recognised as a pre-malignant condition. A significant number of cases will progress to endometrial cancer without treatment. Some may regress, but conservative management is not to be recommended. Treatment with progesterone locally (LNG-IUS) or systemically can induce regression to a normal endometrium but given her age hysterectomy should be advised. This may be vaginal or abdominal however foci of invasion may exist along with atypical hyperplasia and as such a total abdominal hysterectomy and bilateral salpingo-oopherectomy is the best choice to eradicate disease and reduce recurrence.

Apologies for any spelling mistakes, the \"t\" button on my keyboard is somewhat unreliable...
Posted by A H.
ah
a)Post menopausal bleeding can be caused by genital tract malignancy in ten percent of cases. The history will serve to identify risk factors and features of malignancy.
Her parity, age at menarche, and menopause will be asked as nulliparity, early menarche and late menopause are risk factors.
A history of polycystic ovary disease, diabetes and hypertension will also be asked as they are associated with endometrial cancer.
The use of unoppsed oestrogen, tamoxifen are strong risk factors; sequential hormone replacement therapy (HRT) is thought to be associated with endometrial cancer and this will be asked.
Precipitating factors for her symptoms will be asked. if related to coitus a cervical or vaginal lesion may be causative. A smear history will be taken, including results and any previous treatment.

b)I would tell her that the most likely cause of her symptoms is atrophy of the genital tract due to a hypo-oestrogenic postmenopausal state.

c)She will be offered transvaginal ultrasound evaluation of the endometium. The endometrial thickness will be measured,because if this is less than 4 millimetrs,she can be reassured that she is unlikely to have endometrial cancer. It has a sensitivity of 80 to 100 percent of detecting endometrial cancer in a woman not on HRT.
It however has a poor sensitivity for endometrial polyps and other benign lesions, and is not reliable if she is taking HRT. However it is non-invasive, cheap and acceptable to patients and results immediately available.
Endometrial sampling can be done in the out-patient department using either a pipelle sampler which is a blind procedure or hysteroscopy and directed biopsy in which case the endometrium can be visualised. These out-patient procedures avoid the use of general anaesthesia and admission. Both are well tolerated in most patients. Only 10 percent complain of severe pain with the Pipelle and local anaesthesia may be required for a small percentage of patients having hysteroscopyand find it painful.Both out-patient hysteroscopy and pipelle are cost-effective and suitable for patients unfit for general anaesthesia.
In-patient hysteroscopy and dilatation and curettage is considered the gold standard and is useful if there is a significant area of the endometrim involved. Alternately, hysteroscopy guided biopsy can be done under general anaesthesia if there was difficulty in obtaining a sample in the outpatient setting.

c) Atypical hyperplasia is associated with coexistent malignancy, the lesion tends to progress to malignancy, or persist .
The patient will be couselled about the options and given written information so that she can make an informed decision.
The optimum treatment is hysterectomy and bilateral salpingho-oophorectomy by the general gynaecologist.The specimen can be examined histologically for presence of malignancy and appropriate follow-up implemented. However there is the risk of anaesthesia and surgery and the patient may not be fit for major surgery.
Medical treatment can be offered to these patients not fit for surgery.
High dose oral progestogens or depot medroxyprogesterone acetate can be prescribed for three to six months and the
endometrium re-biopsied to check for regression. If there is no response the dose can be increased.The regression rate is lower than if there was no atypia (50 to 80 percent compared to 90 percent), and associated side-effects are bloatedness and headaches. Alternatively the levonorgestel intrauterine system (Mirena) can be used.
Alternative treatment include the use of Danazol, or goadotrophin releasing analogues with or without subsequent endometrial resection. The response rates are between 60 to 75 percent.

Posted by PAUL A.
a) I would enquire about symptoms of vaginal atrophy such as vaginal dryness or burning and dyspareunia (1) .
I would enquire if the blood loss is constant or associated with any precipitants such as intercourse (1) as the latter could indicate a cervical cause such as a cervical polyp, cervical cancer or vaginal atrophy.
I would enquire if about the consistency of the blood loss as a constant watery blood stained discharge can be associated with a malignancy of the fallopian tube.
I would enquire if she uses hormone replacement therapy (1) and ascertain the duration of use, as well as if it is oestrogen only, sequential or continuous combined HRT.
I would also enquire if she has a history of breast cancer and Tamoxifen use.
I would ask when her last smear was and if she has ever had abnormal smears. I would ask if she had previous treatment to her cervix for abnormal smears (1) or for any other reason.
I would ask if she has had a hysterectomy and if it was for a benign or malignant cause.
For completion, I would ask if she has noticed a sudden unintentional weight loss (1) as this could be associated with malignancy Your Hx is not systematic. For instance, you have a woman with PMB and you have not taken a menstrual Hx .

b) The most likely cause of postmenopausal bleeding is endometrial in origin. This may be endometrial hyperplasia or an endometrial polyp. Endometrial hyperplasia is a thickening in the lining of the womb. An endometrial polyp is fleshy growth of the lining of the womb. It will not be possible to differentiate the 2 on the basis of the history alone and further investigations are needed. Majority of women have benign disease; about 10% have malignant disease

c) I would obtain blood for a full blood count to exclude anaemia.

I would perform a cervical smear as the transformation zone is not visible in postmenopausal women.

I would perform a transvaginal ultrasound scan (1) to assess the endometrial thickness. A TV US has a high sensitivity for detecting endometrial cancer using a cut off of 5mm. However it has low sensitivity for detecting endometrial polyps. Its accuracy can be improved by saline ultrasonography. However, this is a specialist investigation and is not offered universally. Furthermore it is operator dependent. Triaging patients using a transvaginal ultrasound scan reduces the number hysteroscopies without compromising the detection of endometrial cancer. An ultrasound scan can also identify ovarian cysts (1) .

If the endometrial thickness is regular and equal to or greater than 5mm, I would perform a pipelle biopsy (1) . The advantage of this procedure is that it can be done as an outpatient procedure and has a sensitivity and specificity of greater than 90% for endometrial cancer. It is comparable to a formal dilation and curettage.

An outpatient hysteroscopy should be performed if the endometrium is irregular is this the key ultrasound feature in identifying endometrial polyps? on ultrasound scan as it has a higher sensitivity for endometrial polyps compared with ultrasound. Endometrial sampling is still necessary as hysteroscopy ony has a sensitivity of 30% for endometrial cancer if used in isolation.

A hysteroscopy, dilation and curettage should be performed under general anaesthetic if endometrial sampling or hysteroscopy is not possible in an outpatient setting (1) .

c) Complex where does the word complex appear in the question? atypical hyperplasia (CAH) is a mandate for a hysterectomy (1) possibility of co-existent carcinoma owing to its high risk of progression to endometrial carcinoma. The patient should be informed that occult cancer has been identified have you identified cancer? How can it be ‘occult’ if it has been identified? on uterine specimens removed for CAH.

The next issue to discuss is whether her ovaries are removed simultaneously when she has a hysterectomy. A bilateral salpingoophrectomy is advisable. There is no benefit of leaving them in situ. Furthermore, there is a small risk of developing ovarian cancer if they are not removed. There is also a small risk of residual ovary syndrome causing chronic pain this is not a 40 year old woman having hystsrectomy for say fibroids – she should have hysterectomy + BSO and there should be no debate about the ovaries . If only a hysterectomy is performed and occult endometrial cancer is identified, she will then require another operation to remove her ovaries.

There are 2 possible routes for a hysterectomy: abdominal or vaginal (1) . The advantages of the abdominal approach are ease of access and a bilateral salpingoophrectomy (BSO) can be performed at the same time. Peritoneal washings can also be obtained.

A vaginal hysterectomy would offer a faster recovery and has the advantage of avoiding an abdominal scar. Blood loss is less compared with a laparotomy. A BSO can be performed via the vaginal route but it is technically challenging to do so. Some ovarian tissue may be left behind. Peritoneal washings cannot be obtained if the vaginal route is chosen.

Laparoscopic assisted vaginal hysterectomy and BSO is another option (1) . Peritoneal washings can be obtained. Recovery times are similar to vaginal hysterectomy and the scars are smaller. However, it is associated with risk of injury to visceral organs, requires specialist skills and if it is not offered locally, a referral to a specialist centre may delay treatment.

The patient should be provided with literature about complex atypical hyperplasia as well as information about a hysterectomy and BSO. your answer is very wordy and could be more focused. Atypical endometrial hyperplasia – likely co-existent endometrial Ca therefore Hysterectomy + BSO recommended
Posted by PAUL A.
a) The information I would obtain from her history is, age of menopause need detailed menstrual Hx , any similar h/o PMB & investigations done for the same. I will also ask her amount of bleeding, associated foul smell . Any abdominal or vaginal pain or history of postcoital bleeding (1) . I would like to know her age of menarche & previous history of treatment of infertility or PCOS what has age at menarche got to do with Hx of infertility / PCOS? Surely age at menarche should go with LMP and the rest of the menstrual Hx . Her gravidity & parity, mode of delivery should be sought. I would like to know whether she is on HRT (1) , Tamoxifen. Her family history is important to know familial cancers like HNPCC, endometrial ca, ovarian ca, breast ca. Previous history of fibroid uterus should be taken. I will ask her, history of dysuria, frequency of micturition, vaginal dryness to rule out atrophic vaginitis (1) . I would also like to know her Status of pap smears & if any recall she has missed (1) . Her history of weight gain or weight loss, change in bowel habits will also be taken (1) .


b) I would tell her that this is PMB & most likely cause is atrophic vaginitis or atrophic endometrium. I will tell her that it may be because of local causes like cervical or endometrial polyp (1) .I would also tell her that about 10% of PMB at this age are associated with endometrial cancer (1) , so she requires further investigations to rule out Ca endometrium, endometrial hyperplasia , Ca cervix.

c) Her routine investigations including FBC to know anaemia, Urine routine & microscopy to see haematuria, U & E , Blood sugar to rule out Diabetes ? value in a healthy woman?? Will blood sugar identify diabetes? . Investigations for her PMB include TVS to know endometrial thickness , uterine size, ovarian mass (1) . As TVS is non-invasive & will give us information of endometrial hyperplasia if more than 4mm thickness although it is debatable what is debatable?? . I will also like to take her papsmear for CIN, Ca cervix. Colposcopy , if previous abnormal papsmear or history of postcoital bleeding & abnormal cervix READ THE QUESTION – NORMAL EXAMINATION!! . I will take her endometrial sample either by vabra aspirator or Pipelle (1) to see hyperplasia/malignancy. If sample obtained is inadequate or there is difficulty in obtaining sample because of menopausal atrophy , I will like to do hysteroscopy & D&C. Hysteroscopy has added advantage to rule out endometrial polyp (1) ? OUT-PATIENT HYSTEROSCOPY + Biopsy.

d) Presence of atypical cells in her endometrium would require surgical approach of Total Abdominal Hysterectomy & Bilateral salpingoophorectomy (1) .As she is postmenopausal & there is no benefit of retaining ovaries , ovaries to be removed. Route of surgery includes abdominal , vaginal or Laparoscopic assisted vaginal hysterectomy (1) . With abdominal approach peritoneal washings can be obtained & same is true for laparoscopic approach. Vaginal hysterectomy is an alternative to abdominal route, but sometimes difficulty in removal of adenexa. Wih vaginal hysterectomy & LAVH postoperative recovery is faster (1) . For LAVH , laparoscopy expertise is required Evaluate the options: options are TAH + BSO (definitive surgery, allows definitive diagnosis &staging), LAVH + BSO (quicker recovery, staging), medical treatment with progestogens if surgery declined but risk of disease progression,
Posted by PAUL A.
a)
I would determine her parity, age at menarche and menopause (1) because nulliparity, early age at menarche and late age at menopause increases the risk of endometrial cancer. I would find out if she was taking hormone replacement therapy (1) , the type of HRT and the duration of use. This is important because HRT can increase the risk of endometrial hyperplasia and enedometrial cancer. I would also enquire whether she was taking Tamoxifen which can also increase the risk of endometrial hyperplasia and endometrial cancer. I would ask when was her last cervical smear and if it was negative you need a smear Hx including previous smears and treatments to Cx . This is important since cervical smears can identify cervical intraepithelial neoplasia which can progress to cervical cancer. I would find out if she has had operations such as hysterectomy and comorbidities such as hypertension or diabetes mellitus HEALTHY

symptoms of vaginal atrophy; bowel / urinary symptoms including PR bleeding / haematuria; anorexia + weight loss – you would have covered all these if you had taken a systematic approach
.

b)
I would tell her that the cause of her symptoms can be due to endometrial cancer. It can also be due to cervical cancer or vaginal cancer. It can also be due to endometrial or cervical polyps which are benign. The bleeding can be a side effect of the HRT. I would provide her with written information. Majority of women have benign disease. ~10% have malignant disease

c) An ultrasound scan of the pelvis should be done for endometrial thickness. An endometrial thickness of 5mm (1) TV scan or more would indicate that further investigation needs to be done to rule out endometrial cancer. If the endometrial thickness is 5mm or more then an endometrial biopsy should be done to obtain specimen for histological studies to determine the type of endometrial hyperplasia or if there is endometrial cancer. The endometrial biopsy can be done as an outpatient (1) using the pipelle biopsy method. This is limited since it only samples 4% of the cavity. The endometrial biopsy can also be done in conjunction with hysteroscopy as an inpatient or outpatient (1) . Hysteroscopy is a good investigative tool because it allows visualisation of the endometrial cavity. Biopsy at the time of hysteroscopy with an endometrial curette should obtain a larger specimen for histology than the pipelle.

d) The first treatment option is a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH BSO) (1) . Atypical endometrial hyperplasia has a 70% risk of progressing to endometrial cancer (1) there might be co-existent carcinoma . TAH BSO by removing the uterus removes the risk of developing endometrial cancer or if there was an underlying cancer already present, the TAH BSO reduces the risk of metastasis and advanced stage cancer developing (1) .
The second treatment option, if the woman does not wish surgery, is medical treatment with progestogens such as the levonorgestrel intrauterine system or medroxyprogesterone acetate for 3 months, and then repeating the ultrasound scan and biopsy (1) . This is limited in value because an underlying cancer may already be present and will remain undiagnosed, untreated and may progress in stage during the progestogen treatment. Also the progestogen therapy may not work and the atypical hyperplasia may progress to endometrial cancer.
The third treatment option is to do nothing. This is of no value and should not be done because of the high risk of progression of endometrial cancer. what about LAVH + BSO?
Posted by PAUL A.
a) I will enquire if this is the first episode of PMB and if there were previous episodes of PMB, any investigations undertaken and their results. Dryness of vagina, dyspareunia and postcoital bleeding suggests atrophic vaginitis (1) POST-COITAL BLEEDING MAY INDICATE CERVICAL CANCER . Any use of HRT (1) , especially sequential HRT predisposes to endometrial cancer; Abnormal cervical smears (1) in the past and any tratments to cervix may suggest cervical pathology such as cervical cancer. Her parity as nulliparity is associated with endometrial cancer. H/o urinary symptoms such as dysuria, frequency and haematuria; Bowel symptoms such as rectal bleeding (1) should be enquired as sometimes these can be confused with vaginal bleeding. Red flag symptoms such as loss of appetite and weight (1) , shortness of breath, melaena may suggest malignancy. Medical problems such as Diabetes, hypertension READ THE QUESTION , obesity increases the risk of endometrial cancer. Past H/o breast ca and use of tamoxifen; Family h/o endometrial, breast, ovarian cancer further increases her risk of endometrial cancer (1) .
b) I will explain to her that in most cases the cause is benign (1) such as atrophic vaginitis. However it is important to rule out sinister causes such as endometril, cervical, vaginal and vulval cancers. The most common malignancy associated with PMB is endometrial cancer which is present in 10% of cases (1) .
c) Further investigations should be directed to identify the cause of PMB and exclude endometrial and other malignancies. The first line investigation is transvaginal ultrasound (1) . It gives information on endometrial thickness and any adnexal masses (1) . It is 80-90% sensitive in detecting endometrial malignancy. It is easy to perform and reliable but may miss polyps.
Outpatient endometrial biopsy by pipelle or vabra aspirator (1) is commonly performed. Pipelle samples 4% of endometrum and d 70-80% senitive in picking up maliganancy. It is however painful, cannot pick up polyps and may not give adequate sample. Vabra aspirator samples 44% of endometrium but is more painful.
Outpatient hysteroscopy and endometrial biopsy (1) allows visualisation of endometrial cavity and to take guided biopsies. Patient acceptability is high. Small polyps can be removed but large polyps cannot be removed and needs removal under GA. It also avoids the risks of GA and is cost effective.
Inpatient hysteroscopy and biopsy (1) is the gold standard investigation. It is 100% sensitive in detection of endometrial cancer and allows removal of large polyps. It is also useful when outpatient procedures fail or if there is inadequate sample. It is however associated with risks of GA and risk of injury to bladder, bowel which may require additional procedures.
d) I will explain that the lining of womb has abnormal cells NOT ANSWERING THE QUESTION. You were not asked to explain anything to the woman / manage / treat her. You were simply asked a factual question. What are the treatment options and what is their value? ; there is a possibility that cancer can co-exist (1) in 5% of cases and if left untreated can progress to cancer in 25-30% of cases over 5-10 years. The treatment of choice is total hysterectomy and bilateral salpingooophorectomy (1) . This can be done abdominally, vaginally and laparoscopically depending on patient\'s wishes, clinical findings, feasibility and availability of skill for laparoscopic techniques what is the value of the different options? . If refuses surgery or unsuitable and moribund YOU WERE ASKED ABOUT A HEALTHY 65 YEAR OLD WOMAN , then oral progestogens or mirena IUS with endometrial biopsy every 6-12 months is an option. However it should be explained that there are no trials asessing their efficacy and there is a risk of progression of disease (1) . Information leaflets should be given, further appointments if the patient wishes and her decision should be respected not necessary .
Posted by PAUL A.
Am
a) Her parity , age of menarch and age of menopause are relevant (1) detailed menstrual Hx . I will ask about the bleeding continuous or intermittent , post coital or with urination. Is she sexually active , is she experiencing dysparunia ? do not ask questions The use of HRT (1) especially sequential can cause post menopausal bleeding . If she is using HRTwhen did she started treatment? may be she is a new user . The use of tampons or pessary may precipitate bleeding with atrophic vagina especially if left in place for a long period . I will also ask about the date of her last cervical smear you want detailed smear Hx not just date of last smear . Recent weight loss or anorexia (1) may accompany malignancy . Her family history (1) may be relevant if she has a relative with gynecological cancer . ( she is healthy so we will not ask about DM, breast cancer or hypertension )
b) I will tell her that most of the causes are benign (1) . Cancer represents only 10 – 15 % of causes (1) . Deficiency of female hormones may cause atrophic changes in the vagina or uterus causing bleeding in 60 % of cases . Abnormal proliferation of the lining of the uterus is called hyperplasia and it may the reason for her complaint . Other causes include polyps or infections . I will provide her with information leaflet.
c) Cervical smear will be done to detect abnormal cells . Full blood count to detect aneamia . Other investigations will aim to exclude malignancy and hyperplasia of the endometrium . Pelvic U/S trans vaginally (1) done to measure the endometrial thickness and detect ovarian masses (1) . Endometrial thickness if less than 5 mm has a good negative predictive value to exclude endometrial carcinoma . Endometrial sampling done outpatient (1) using Pipelle or Vabra endometrial sampler has high sensitivity around 80 % . This is is nearly equivalent to formal inpatient D&C biopsy but the later requires hospital admission and anaesthesia . The best method for endometrial sampling is hysteroscopic guided biopsy (1) . It has high sensitivity and specifity ( above 90 % ) .
d)Since she is not in need for conservative surgery because of her age the recommended line of treatment is total abdominal hysterectomy with bilateral salpingo oopharectomy (1) . This can be achieved by the abdominal route or vaginal how do you perform ABDOMINAL hysterectomy VAGINALLY?? or laparoscopic assisted vaginal route . Total laparoscopic surgery is also an option with shorter hospital stay and less post operative morbidity (1) EVALUATE – what is the value of TAH + BSO??but needs specials skills and expertise . If hysterectomy is declined the patient may use progestines either high dose oral or levonorgestrel intrauterine system . If this is used she will need follow up and endometrial biopsy every 3-6 month to judge regression or progression of the atypia (1) . Expectant treatment is not recommended because atypical hyperplasia may be associated with foci of malignancy (1) this is the reason for recommending TAH + BSO or may be transformed into frank carcinoma in 40% of cases .
Posted by PAUL A.
A thorough history should be obtained regarding the amount of blood stained vaginal discharge, any associated passage of clots or abdominal pain.
She should be asked whether she is sexually active. If yes, the inquiry should be made regarding postcoital episodes of bleeding\' and any discomfort asociated with coitus such as vaginal dryness leading to dyspareunia (1) .
Also a full cervical smear history (1) should be taken to make sure whether she\'s been having them regularly or not; any problems with the most recent smear should be inquired about.
She should also be inquired whether she is taking HRT (1) or not.If yes, the the duration, type of HRT should be established i.e whether continuos combined, sequential or estrogen only.It is important to confirm the presence of an intact uterus when such questions are asked.
Inquiry about family history of cancers (1) should be asked as well since familial conditions such as hereditary nonpolyposis colonic cancer is associated withan increased risk of CA. endometrium. GI / GU symptoms, weight loss; menstrual Hx!!!

After taking a full history, the patient should be councelled about the likely causes of bleeding which include atrophic vaginitis, atrophic endometritis which are both related to estrogen deficiency. Other possible causes include cervical and endometrial polyps. Other more sinister causes like cervical cancer, premelignant changes in the endometrium such as atypical endometrial hyperplsia and the possibility of endometrial cancer should be explained to her. majority have benign disease. 10% have malignant disease

Investigations include full blood count to assess the degree of blood loss. A transvaginal ultrasound (1) to measure the endometrial thickness. Thickness of < 5mm is reassuring and the patient can be manged conservatively since it rules out the possibility of endometrial hyperplasia and endometrial cancer it does not rule it out and is more suggestive of an atrophic endometrium . If the endometrial thickness is more than 5mmm, it raise the possibility of endometrial hyperplasia and cancer of endometrium and should be investigated by an inpatient hysteroscopy and endometrial biopsy out-patient biopsy should be first line .Alternatively outpatient pipelle biopsy can be undertaken as well (1) .

Atypical hyperplasia on histology of endometrial biopsy is a serious matter and it\'s significance of progression to cancer as well the possibility of co-existent cancer (1) should be explained to the patient you were not asked to explain anything to the patient . The ideal manegement in this case would be a hysterectomy + BSO given possibility of underlying vancer .If thepatient doesn\'t agree to the proposed management, treatment with high dose progesterone (1) and regular hysteroscopy at regular intervals of at least 3 months should be carried out. The risk of progression of cancer in this option should be made clear to her. You were asked to EVALUATE – what is the value of hysterectomy? TAH + BSO / LAVH
Posted by PAUL A.
Mark

a)

I will askdetails of blood stained discharge- the amount,any associated pain or itching or any post coital bleeding.i will ask if there is any hematuria or PR bleeding (1) .i will ask if she has dysparunia, vaginal dryness suggestive of urogenital atrophy (1) . I wll enquire if she has any vague gastric symptoms ot weight loss (1) loss of appetite or abdominal distension.
I will enquire about her past menstrual history (1) - age of menarche, menopause, any oligomenorea or irregularity suggestive of anovulation.I will ask about her obstetric history - parity and long standing infertility.I will ask if she has medical disorders like DM, HT healthy .I will take smear history (1) and if she has taken any treatments for abnormal smears.
Her family history (1) including relatives with colorectal,endometrial or breast cancers will be enquired. I will ask if she is taking any medications like HRT or tamoxifen.

b)
I will tell her that that the bleeding can be from vulva, cervix, vagina or uterus like atrophy,cervical polyp,cancer or endometrial polyp or cancer. It may be due to benign or mailgnant causes .At this age we need to rule out malignant causes.we will need to examine and investigate her for the same. I w ill provide written information on likely causes. majority have benign disease; ~10% have malignant disease

c)
I will collect a pap smear with spatula and endocervical brush if it is due. This is to check for any cervical preinvasive lesions which cannot be seen on examination.she will need colposcopy and biopsy if it is abnormal.
I will ask for a TVS (1) to check for endometrial thickness(ET) ovaries and rule out ascitis.
It is noninvasive quick and with a cut off of 4 mm it gives 100 % negative predictive value to rule out endometrial pathology is there any test which will rule out endometrial pathology with absolute certainty? You must recognise that this statement cannot be accurate .It identifies women( ET more than 4 mm) ET of 3.9mm = no risk of endometrial pathology; 4.1mm = significant risk and further investigation needed. Does this make sense? who need further investigations.However it need trained operator and equipment.
If her ET is more than 4 mm she should be offered endometrial sampling by pipelle vabra or aspiration ? meaning?? What is aspiration? . Pipelle is the most sensitive of all how can it be when it samples a smaller % of the endometrium? 80-87% sensitivity to diagnose endometrial pathology.it is cheap, done in OPD and without anesthesia. How ever it is blind and samples only 7-41% endometrium and may miss few cases of endometrial
Carcinoma.saline infusion sonography can be used to delineate the endometrial ling but it may be uncomfortable in post menopausal women and dosent sample the endometrium hence not recommended.
Out patient hysteroscopy (1) allows direct visualisation of endometrial cavity and targeted endometrial biopsy . it is 100% sensitive if you write this, you must recognise it is wrong – a test which requires someone to take a look, decide which bit to biopsy then take a biopsy cannot ever be 100% sensitive . it need expertise equipment local anesthesia and there is a very small risk of preforation. Hysteroscopy cannot be recommended alone without bipisy as it has high false positive rates due to subjective interobserver variations.
Inpatient hysterscopy and biopsy (1) is gold standard as gives advantages of out patient hysteroscopy plus allows treatment of local causes like polyp and submucous fibroids.

d)
Total abdominal hysterectomy and bilateral salpingo oopherectomy TAH BSO remains the definitive treatment at her age (1) . Atypical hyperplasia may progress to invasive adenocarcinoma in 40% cases in 4 years and may be associated with 35-50% incidence of coexisting adenocarcinoma endometrium (1) . However TAH BSO is associated with serious risks like visceral injuries ,blood transfusion and thromboembolism and frequent risks of wound morbidity , pain and bladder dysfunction what is its value? . Vaginal hysterectomy can be done if there is descent to decrease operative morbidity (1) but ovaries may be difficult to remove. Laproscopically assisted ot total laproscopic hysterectomy with BSO can be done .It reduces wound morbidity,decreases hospital stay ahd facilitates early return to daily activities (1) and has low risk of VTE. However it has higher risk of visceral injuries,longer operating time, need expertise and equipment and GA.
Is she declines surgery the she can beoffered oral high dose progestogens (1) like medroxy progesterone acetate or norethisterone . They regress the hyperplasia in 65-70% cases after 6-18 months atypical hyperplasia?? ? evidence of treatment but are associated with side effects like mastalgia, bloating and depression. Resistant cases will require TAH BSO.
Lng IUS can also be used , it has milder progestogenic side effects but small risks of perforation, expulsion and infection . Both methods need close follow up and hysteroscopy and biopsy afer every 6 months. The exact duration of follow up is not clear and there is a risk of invasive endometrial carcinoma later.

I will provide written information regarding all options and final treatment depends on her wishes and fitness for various modalities not necessary .
Posted by G. K.
dear Dr. Paul:

I wrote in my essay that a normal TVS rules out the possibility of endometrial hyperplasia and Ca endometrium. You said it doesn\'t. I read in \" Gynaecological Oncology\" for the MRCOG and beyond, page no: 110, saying that \"it is highly reliable for detection of endometrial cancer.For women with PMB, it has a negative predictive value approaching 100% in terms of ruling out endometrial caner.\"

The reason I didn\'t ask for GIT symptoms and weight loss because the guestion said \" a healthy 65 year old\".
regards,
Ghazala
Posted by PAUL A.
dear Dr. Paul:

I wrote in my essay that a normal TVS rules out the possibility of endometrial hyperplasia and Ca endometrium. You said it doesn\'t. I read in \" Gynaecological Oncology\" for the MRCOG and beyond, page no: 110, saying that \"it is highly reliable for detection of endometrial cancer.For women with PMB, it has a negative predictive value approaching 100% in terms of ruling out endometrial caner.\"

The reason I didn\'t ask for GIT symptoms and weight loss because the guestion said \" a healthy 65 year old\".
regards,
Ghazala

Approaching 100% IS NOT 100%. A normal endometrial thickness on TVS cannot possibly rule out endometrial cancer given that there is no agreement on the most appropriate cut-off
Posted by PAUL A.
a)History is taken regarding factors associated with increased risk of endometrial cancer , such as age at menarche,parity,age at menopause.Smear history (1) is taken,also any associated vulval or vaginal soreness .Use of HRT (1) and compliance is enquired.Non compliance with HRT is associated with PMB.
History of loss of appetite or weight is taken (1) Detailed menstrual Hx, post-coital bleeding, bowel / urinary symptoms, Family Hx .
b)She should be told that cause of bleeding is most probably benign pathology (1) ,but bleeding in her age should be further investigated to rule out any cancer of uterus or cervix.
c)TVS is done to find the endrometrial thickness (1) . Cut off 3-5mm is taken to detect endometrial cancer does not detect cancer but identifies women for further investigation .It is highly sensitive 80-100%.Endometrial thickness of >5mm would be further investigated by doing endometrial biopsy. Out patient endometrial aspiration biopsy (1) can be done with different devices which sample ,4%- Pipelle,to 41% vabra of endometrium.It is easy to do and successful in 80% of cases. Alternatively out patient hysteroscopy and biopsy (1) may be done using fibreoptic flexible hysteroscope .It is cost effective with high patient acceptability.It avoids anesthetic complications.
If out patient procedures fail to detect any pathology,and she continues to be symptomatic, Hysteroscopy and D&C would be done under general anesthesia (1) .
MRI can detect can detect any tumor and its extent.
d)Atypical endometrial hyperplasia is associated with high risk of progression to endometrial cancer~30-80%.There may be coexistent cancer in about 25-30% of cases (1) .
Treatment options would be ,no treatment – associated with high risk of progression to cancer.Best option for her is Hysterectomy with BSO (1) .This procedure can be abdominal or vaginal.Abdominal hysterectomy has the advantage that BSO is easier and peritoneal washings may be obtained for cytology and staging (1) .But it is associated with higher morbidity , higher risk of hemorrhage ,bowel and bladder injury.
Vaginal hysterectomy has less morbidity,less risk of hemorrhage ,bowel and bladder injury.Removal of ovaries is sometimes difficult with vaginal hysterectomy and Laparoscopic assisstance is required (1) .
If she refuses hysterectomy,high dose progestins (1) may be given but it needs regular follow-up to check progreesion to cancer
Posted by PAUL A.
A)
I will take detailed history of presenting symptom, including nature of bleeding and any precipitating factors (post-coital) , association with pain, excessive vaginal discharge or pruritis vulvae.I will inquire about any rectal bleeding or hematuria (1) . Regarding her past menstrual history will ask about age at menarche and menopause, any history of menstrual irregularity (1) . Obstetrical history i.e. parity, mode of deliveries, and history of miscarriages. Gynecological history including history of polycystic ovaries and cervical smears (1) , any past abnormal smears and treatment received for that. Medical history includes history of diabetes, hypertension, liver disease and thyroid disorders HEALTHY . Drug history including hormone replacement therapy (1) and use of tamoxifen. Past history of breast cancer. Family history (1) of malignancies (eg.endometrial cancer, breast, colon).I will ask about any weight loss, change in bowel habit and anorexia.
b)
I will inform her bleeding is most likely caused by underlying endometrial pathology this includes, a thinning of the uterine lining (endometrial atrophy) most common, and polyps (noncancerous fleshy growths ), Endometrial hyperplasia (a condition in which the lining of the uterus grows too much; if left untreated for a long time, it may lead to cancer) & Endometrial cancer (Cancer of the lining of the uterus).However only 20% of patients has significant underlying pathology (1) .
c)
Principal aim of investigations is to rule out endometrial pathology. Investigation will include CBC, to check for anemia, platelet count, urine routine analysis to look for hematuria, liver functions tests for underlying liver disease, blood sugar level to rule out diabetes. Cervical smear should be taken if routine screening has been missed. Trans-vaginal ultrasound scan (TVS) to measure endometrial thickness (1) , sensitivity for detecting endometrial malignancy is 80-100%, adnexal pathology can also be detected (1) . Out-patient hysteroscopy and directed biopsy (1) is a superior diagnostic tool compared to blind biopsies, especially considering high risk of malignancy in this age group. Has similar efficacy to use of rigid hysteroscope under general anesthesia. May require paracervical block but avoids complications of general anesthesia. Is very cost-effective and has high degree of patient’s acceptability. In-patient hysteroscopy and curettage under anesthesia will be considered in case of failed out-patient (1) .
c)
When significant surgical risk is not an issue presence of cytological atypia with its risk of concomitant carcinoma i.e. 50% (being of higher stage) or highest risk of progression (30%) to carcinoma mandate hysterectomy, with removal of ovaries (1) , as she is menopausal and there is no benefit of leaving them in situ, there is risk of developing ovarian cancer and furthermore there is risk of sub clinical metastases in case of coexisting endometrial carcinoma. Patient will be evaluated carefully for presence of more advance disease prior to planning surgery. Regarding routes of hysterectomy the advantages of the abdominal approach offers good access, visualization and tactile information of the whole pelvis and abdomen and easier adnexectomy. Peritoneal washings can also be obtained (1) . A vaginal hysterectomy (1) would offer a faster recovery and has the advantage of avoiding an abdominal scar. Blood loss is less compared with a laparotomy. Removal of ovaries may be technically difficult and peritoneal washings cannot be obtained .Laparoscopic assisted vaginal hysterectomy and BSO (1) is another option, with shorter hospital stay and less post operative morbidity, peritoneal washings can be obtained, but needs specials skills and expertise. Recovery times are similar to vaginal hysterectomy and the scars are smaller. If significant co morbidities precludes surgery does not apply to the woman in question , or surgery is declined, high dose progestogens or intrauterine progesterone releasing system can be the alternative option, but risk of progression and need for close surveillance and follow up should be explained (1) . In case of persistent symptoms surgery is recommended.
The patient will be provided with written information.

Good answer
Posted by PAUL A.
(a) Which information would you obtain from the history? [7 marks]

History should include details about her vaginal discharge including the amount and frequency and any similar history in the past. A foul smelling discharge, post coital bleeding (1) and passage of fleshy tissues suggests malignancy especially cervical cancer. Other symptoms like loss of appetite, abdominal mass is important. Age of menarche and menopause, parity likely to earn more marks if you deal with these individually and in greater detail. For instance, you need a detailed menstrual Hx and any family history (1) gynecological breast or colonic cancer is to be asked. Cervical smear history, current or past history of HRT (1) and its type and duration of use is to be asked. The timing of bleeding in relation to the progesterone phase is important in evaluating women on cyclical HRT.

(b) What will you tell her about the likely cause of her symptoms? [2 marks]

She should be told that about 90% of women who present with post menopausal bleeding have only minor problems or no specific cause at all (1) . The commonest cause is atrophic vaginitis due to reduced estrogen level after menopause. But it is safer to have further evaluation to find the cause since the remaining 10% may have serious causes like endometrial or cervical cancer (1) .

(c) Justify your investigations given that clinical examination was normal [5 marks]

About 13% of women above 65 years presenting with postmenopausal bleeding might be having an endometrial or cervical cancer. The main aims of investigations are to detect serious causes like cancer and also to reassure the women if the results are normal (1) .

The ideal setting for evaluating such women is a one-stop clinic with access to TVS, outpatient endometrial biopsy and hysteroscopy. If the smear history is normal and up-to-date, and cervix is clinically normal cervical cancer is unlikely. Transvaginal sonography (1) is found to be sensitive initial tool for evaluation postmenopausal bleeding. It can measure the thickness of endometrium and detect endometrial abnormalities like polyps and cancer. If the endometrial thickness is less than 3 mm the chance of having endometrial cancer reduces to 0.6-0.8%. In such a situation further evaluation is needed only if there is recurrence of bleeding. TVS is a simple investigation with minimal patient discomfort and no adverse effects. But it is operator dependent, adequate training is mandatory.

But if the endometrium is thicker than 3 mm or if there are other abnormalities endometrial histology is required. But outpatient endometrial biopsy (1) or dilatation and curettage without hysteroscopy?? both are associated with about 10% false negativity. Hence the ideal step is an out patient hysteroscopy (1) along with an endometrial sampling. It is comparable to an inpatient hysteroscopy and D&C under GA and can be done in most patients without the need for cervical dilatation. Minor causes like endometrial polyps can be treated in the same sitting.

(d) She is found to have atypical endometrial hyperplasia. Evaluate her treatment options [6 marks].

Atypical endometrial, hyperplasia can either simple or complex. The risk of progression to endometrial cancer is about 7% in simple atypical hyperplasia and about 29% in complex atypical hyperplasia. Recent studies have shown that there may foci of associated endometrial cancer in up to 50% case of atypical hyperplasia (1) .

As she is otherwise healthy and there is no need of uterine cincervation for fertility purposes a total hysterectomy with bilateral salpingooophorectomy (1) should be considered the fist option. Because of the possibility of endometrial carcinoma an MRI should be considered to assess the depth of penetration into the myometrium and extension to the cervix as well to rule out pelvic lymphadenopathy. If any of the above factors are present consider referral to a gynecologic oncologist for management as she may need pelvic lymph node sampling as part of staging.

If there was no atypia how could there be no atypia when you are told she has ATYPICAL hyperplasia??? medical treatment with could have been an option for her.
Posted by PAUL A.
prt

a] I would like to enquire about the amount of bleeding with any precipitating factors like post coital bleeding.She should be asked about vaginal dryness and dyspareunia associated with blood stained vaginal discharge (1) .Hx of bleeding from other sites like rectal bleeding or haematuria should be elicited .
Details of menstrual history (1) ,age of menarche and menstruating irregularly suggestive of anovulation needs to be elicited.
Details of obstetric history like number of children is asked.Cervical smear hx (1) should be taken ,whether they have been normal till date.
Any history of weight loss/anorexia (1) or increasing abdominal girth should be elicited to exclude ovarian pathology.
Her personal history of smoking,the number and duration of cigrettes should be found out.
Any hx of taking HRT (1) ;or past hx of taking infertility drugs should be elicited.

b]I would like to tell the woman that in 90% of the cases no pathology may be detected but she need investigations (1) .
There can be a possibility of increased thickening of the lining of her womb,causing blood stained discharge.This is a premalignant condition and needs thourough investigations to rule out malignancy.

c]FBC is done to assess anaemia.Coagulation profile is done if there is hx of bleeding from other sites.
TVS (1) is done to assess endometrial thickness and to rule out adenexal mass (1) .If the endometrial thickness is less than 5mm,then her risk of endometrial cancer is reduced from 10% to 1 %. If endometrial thickness is greater than 4mm then the endometrial sampling should be done. Endometrial biopsy can be done in outpatient by means of Pipelle biopsy (1) . Alternatively outpatient hysteroscopy and biopsy is taken (1) or in patient hysteroscopy with currettage under anasthesia (1) is undertaken.
In case of adenexal mass CA 125 should be checked.
If there is suspicion of cervical pathology then EUA with biopsy should be performed.

d) A typical endometrical hyperplasia has 30% risk of progression to endometrial cancer if untreated (1) might be co-existent carcinoma . Hystrectomy with bilateral salpingo-oophrectome(TAH with BSO) (1) is the treatment of choice for this healthy post menopausal woman. This could be an open surgery which has a benefit of quicker operation than laproscopy and widely available, less likely to involve additional form of surgery. Demerits of traditional surgery are longer inpatient stay and post operative recovery. It also increases the thrombotic event.
Laproscopic hysterectomy with oophrectomy has benefit of quicker recovery (1) and less pain. It carries increased risk of visceral and vascular injury. There is increased risk of conversion to laprotomy.
Vaginal hystrectaomy provides benefit of no abdominal scar and opportunity to repair pelvic floor if required. It does not provide the opportunity to provide other pelvic structures ? meaning . It can be combined with LAVH.
In case patient declines surgery then progestogen therapy oral or injectable can be given along with repeat hysteroscopy and endometrial sampling in 6 months. This option leads to risk of progestogenic side effects like weight gain, acne, oedema. There is uncertainty about the duration of follow up and the risk of disease progression (1) .
Posted by PAUL A.
RonRon
A.
I’ll enquire whether this is a first episode or whether she had similar episodes in the past. I’ll further ask regarding pain / bleeding on intercourse, recent cervical smears and smear history (1) , when she turned menopausal and when she had her menarche need detailed menstrual Hx . I want to know whether she has (ever) used any form of HRT (1) . I’ll ask about her obstetric history and methods of contraception and any previous (gynae) surgery such as removal of endometrial polyps. I want to know whether she noted changes in her weight (1) or abdominal distension / mass. I’ll enquire regarding hypertension and diabetes healthy , history of breastcancer (+ tamoxifen use), as well as a family history of cancer in general and of endometrium or colon in particular (1) .

B.
I’ll acknowledge her anxiety but explain that the majority, up to 90%, of causes for post-menopasual bleeds are relatively innocent such as postmenopausal atrophy or polyps (1) . I will however explain that it is still very important to investigate the complaints, as sometimes the cause is a pre-malignant or even cancerous growth in endometrial lining or cervix. (1)

C.
A transvaginal ultrasound (1) will pick up the majority of problems in the uterine cavity. If the endometrial lining is >4 mm a pipelle endometrial sample will be done (1) . The combination of this investigation has very low false-negative rate for endometrial (pre)cancerous lesions. Those where pipelle sampling is not possible, may have the hysteroscopy as an outpatient (1) , provided they are low risk and a polyp is not expected. An ultrasound finding suggestive for polyp would best be followed up with a hysteroscopy you mean in-patient hysteroscopy D&C?? , as pipelle sampling will often fail to identify the polyp and if there is a polyp it can be removed at the same time.

D.
This is a pre-malignant lesion, which in time will develop into cancer in 30-50% if left untreated (1) risk of co-existent cancer, thus conservative management is not an option. In a younger patient you were asked about a 65 year old woman where fertility is an issue, high-dosed progesterone treatment (medroxy-progesteron 20 mg/day) with reassessment by pipelle or hysteroscopy after 3 months can be tried, but response in atypical hyperplasia is poor with often relapse, as compared to hyperplasia without atypia. Placing a Mirena coil would serve a similar purpose, though its use for this purpose is currently not established practice. Progesterone therapy is not appropriate in menopausal patients where fertility is obviously not an issue, especially since cancerous so what are the treatment options for this woman? Why did you start with an option which you know is unsuitable for the woman in question? For the same space / time, you could have written about TAH + BSO, VH / LAVH and earned 3-4 marks. This could be the difference between a pass / fail
Posted by PAUL A.
(a)A detailed history of postmenopausal bleeding should be taken to know nature frequency precipitating factors and severity of bleeding. Precipitating factors may be following trauma, intercourse or use of hormonal replacement therapy (1) or tamoxifen. Menstrual history is also important to find out high risk factors in form early age of menarche or late menopause Hx suggestive of anovulation . Obstetric history should also be enquired to know whether she is nulliparous. Medical history of diabetes hypertension healthy or other associated illness should also be documented.
Past history of any gynaecological problem or cancer or breast cancer should also be asked. Cervical smear status cervical smear Hx should also asked to rule out any cervical pathology. It is important to ask for associated urinary or bowel symptoms which specific symptoms? to rule out urinary or colon pathology. History of anorexia recent changes in weight (1) or bowel habits should also be enquired. Family history of breast cancer or gynaecological cancer (1) should also be obtained. Personal history of smoking and use of alcohol should also be obtained.

(b) vulval or vaginal causes are atrophic changes, dystrophic, trauma including use of ring pessary and carcinoma.
Cervical causes are cervicitis, atrophic, trauma, cervica polyp or carcinoma.
Uterine causes includes endomteritis, endometrial polyp, hyperplasia and carcinoma.
Uterine leiomyosarcoma
fallopian tube or ovarian cancer
oestrogen producing tumour and use of exogenous oestrogen.
she is unlikely to know what any of this means
(c) trans-vaginal scan for endometrial thickness (1) is non invasive, cheaper with 80 – 98% sensitivity to detect endometrial cancer and a higher acceptability rate. Although it has got higher false positive rate with poor sensitivity to detect endometrial polyp and it may uncomfortable to women.
Sonohysterography is a better alternative to diagnose polyps, however it is not available in most units.
Out-patient biopsy is cheaper and quick option to obtain tissue from endometrium, however availability of tissue obtained depend on the methods use vebra or pipelle (1) .
Out-patient hysterography what is hysterography??? avoids the risks of surgery or anaesthesia, however it may be uncomfortable to women and it has got the limitation to remove big polyps.
Hysteroscopy and D&C has got the advantages of being pain free (1) do women not have post-op pain?, availability of removing big polyps and doing any additional procedures. However it is expensive, risk of perforation, infection and bleeding.

(d) Treatment options depend on women wishes and her suitability for surgery healthy 65 year old?? .
As atypical hyperplasia has tendency to progress to carcinoma in about one third women (1) possibility of co-existent cancer . Hysterectomy ? BSO?? would be the ideal option if she is fit for surgery. Moreover about 50% hysterectomy specimens removed for atypical hyperplasia have histological evidence of endometrial carcinoma. However, it is major surgery and it is associated with anaesthetic and surgical risks of infection, bleeding, need for blood transfusion, damage to bladder, bowel blood vessels or ureters, thrombo-embolism and death. High doses of progestogen would be the other option only if surgery is declined . It would avoid major surgical or anaesthetic risks. However she should be followed up and re-sampling of endometrium should be done. Hysterectomy should be advised if persistence of atypical hyperplasia or progression to endometrial carcinoma. Options are TAH + BSO, VH / LAVH; medical Rx if surgery declined.

See good answer above

Posted by PAUL A.
Hist of pain associated with bleeding,whether the bleeding is associated with clots or is watery.History of age of menarche,menopause need detailed MENSTRUAL hX ,contraceptive history,history of feeling dryness during intercourse,use of HRT (1) (continuous,sequential or unopposed estrogen use),use of Tamoxifen.
Family h/o (1) Do not use appreviations ovarian or breast cancer,colorectal ca.,should be taken.
Cervical smear history (1) & if colposcopic examination was done previously.
H/o loss of appetite,weight (1) ,haematuria or bleeding per rectum.
2)The patient should be told that the most likely cause of her sypmtoms is atrophic cervicitis or vaginitis which is quite common due to her hypoestrogenic state.Whereas, other causes like cervical or endometrial polyps, ca of endometrium,cervix,vagina or fallopian tube should be ruled out. majority have benign disease; about 10% have malignant disease
3) Considering the clinical examination is normal,a cervical smear should be taken & if suspecios a colposcopy should be done.
A TVS scan (1) should be done to asses the endometrial thickening(if >5 cm,further investigations may be required),endometrial polyps may be difficult to diagnose & so a HyCoSy scan may be undertaken ? evidence & availability?? . Asimple trans abd Usg may be also done to r/o any adnexal mass you are writing a post-grad exam. The examiner did not set the question using abbreviations. Why to an abdominal scan after you have done a TV scan? .
An outpatient sampling using vabra or pipelle may be why MAY? When will you do this? performed although sometimes the area with lesion may be missed out.An outpatient hysteroscopy may also help there are clear indications for this investigations and ‘may be done’ / ‘may help’ is not good enough to improve in collecting the sample with the above instruments.Inpatient hysteroscopy under GA & using a rigid hysteroscope may be performed every test you have written MAY BE DONE. How will you decide which test to perform? although larger polyps cannot be aspirated,smaller ones can be removed.
The gold standard is an Hysterscopy & DNC what is this??? which will reveal the the most likely type of endometrial lesion.A informed consent form should be taken prior to any of the above invasive proceedure.
Finally an MRI scan although expensive may be ??? you clearly do not know when these tests should be done required .
4) The diagnosis should be explained to the patient you were not asked to explain anything to the patient. You were asked about the treatment options and their value supported by information leaflets.She should be told that there is a chance of her condition turning to malignancy & considering she is already menopausal,the surgical management should be explained which is Hysterectomy & Bilateral salpingo oopherectomy.
If she declines the surgical option advise regarding the useof Progestrogens in the form of medroxyprogesterone acetate or Levnorgestral containing IUCD(Mirena coil ) can be used.The final treatment of choice is what the patient chooses & it should be considered. you have not answered the question

See good answer above
Posted by PAUL A.
a.I will enquire whether the blood stained discharge is continuous or intermittent ,any provocating factor such as post coital bleeding (1) if present indicates local cervical cause.Previous cervical smears history (1) will be noted. History suggestive of anovulation,PCOS how does the examiner know that you know what Hx suggests anovulation? ,infertility suggestive of hyperestrogenism will be enquired.History of infertility ,ovulation induction may indicate ovarian cause.History of vaginal dryness,dyspareunia is suggestive of atrophic vaginitis (1) as the cause.History of any mass in abdomen bleeding is likely to cause significant anxiety . I will tell her you were asked about Hx only that the symptoms are most likely may indicate ovarian mass.History of use of medications like tamoxifen and HRT (1) will predispose to bleeding. History of any surgeries done before including hysterectomy will be asked.Family (1) and personal history of endometrial,breast and ovarian cancer will be enquired .History of rectal bleeding and hematuria may indicate gastro or urinary cause.History of recent loss of weight (1) and appetite may suggest malignancy.
b. Post menopausal to a benign cause but in 10 % of cases malignancy may be associated which has to be ruled out by investigations (1) poor English.
c.Trans vaginal ultrasound (1) is essential to estimate endometrial thickness. Using a cut off of 4-5 mm ,it has a sensitivity of 80% in detecting endometrial cancer.It can also detect adnexal mass (1) and non invasive..But it has a high false positive rate and fails to detect benign endometrial polyps.Out patient endometrial sampling (1) is possible by vabra and karmaan curette has a sensitivity of 60-80%.This is cost effective and has better patient acceptability.But this may fail to produce sample in 10-20% of cases and cause discomfort and pain. Hysteroscopy and endometrial sampling is the gold standard technique.Out patient hysteroscopy (1) is possible using flexible fibre optic hysteroscope.this can produce endometrial sample but not remove polyp.There may be difficulty in insertion of hysteroscope in nulliparous women. Hysteroscopy and D &C under anaesthesia (1) is the best method which is least likely to miss endometrial cancer and is also able to remove polyps.There are risks associated with the procedure like infection,haemorrhage,uterine perforation.Optimum method may be TVS followed by out patent hysteroscopy in at rsk women.
c.Atypical endometrial hyperplasia has the risk of progression to cancer in 25 % of women and there may be an underlying cancer (1) .Hence expectant management is not an option.Surgicla treatment is the definitive treatment. This includes TAH with BSO (1) and biopsy of any suspicious lesions.The risks what are the benefits? are due to the procedure infection,haemorrhage,anaesthetic risks,VTE.Hysterectomy can be done by vaginal route which has less morbidity but it is difficult to remove ovaries (1) .Lavh with BSO (1) is an option associated with less morbidity, less hospital stay. But this requires expertise and risks of laproscopy.Medical treatment involves medroxy progesterone acetate 100 mg 0d for 6 months followed by endometrial sampling 3 months later can be tried if surgery declined (1) .This requires long follow up and the duration is not clear.


Good answer
Posted by PAUL A.
a) Information about the discharge if malodourous may suggest underlying infection / malignancy.
Associated symptoms like abdominal pain / history of loss of weight (1) and appetite may suggest malignancy.
A history of blood stained discharge post coital (1) may suggest local lesions of cervix or vagina.
Her menstrual history more detailed Hx should be taken as early menarche and late menopause increases risk for endometrial cancer.
History of pregnancies, use of combined oral contraceptive pills should be taken as these may have a protective effect for endometrial cancer.
History of tubal sterilisation may also provide a protective effect on endometrial cancer.
Family history (1) of endometrial cancer, breast cancer, colonic cancer may increase the risk of endometrial cancer.
History of any hormone replacement therapy(HRT) (1) and details of type of HRT should be taken because if on sequential HRT may sometimes attribute to the cause of her current symptoms.
A history of any treatment with coils like Mirena for progesterone arm of HRT may be the cause of discharge.
History of urinary or bowel symptoms should be taken to exclude underlying advanced malignancies.
History of smear (1) , with recent results and any treatment will help in managing with her current symptoms.

b) A likely cause is unknown and needs further investigations to arrive at the diagnosis.
Most likely causes are benign conditions (1) like HRT withdrawl bleed /cervical / endometrial polyps and may only need reassurance or simple treatment.
Serious causes could be like endometrial cancer or cervical cancer which occurs in about 10% of women (1) presenting with post menopausal bleeding and may need treatment depending on their respective stages.

c)Vaginal swabs to exclude infection and FBC to exclude anaemia.
Trans vaginal ultrasound(TVS) (1) is a very useful investigation because an endometial thickness of less than 5mm will exclude underlying endometrial cancer in more than 85% of PMB, but with less sensitivity to detect endometrial polyp.
TVS can also safely minimise the need for invasive procedure like hysteroscopy when a endometrial thickness cut off is used.
Endometrial sampling with pipelle/vibra aspirator (1) is useful investigation and can be done in outpatient setting to detect endometrial pathologies.
Hysteroscopy and directed endometrial biopsy is the gold standard and can be done in outpatient (1) when will you use out / in-patient? and inpatient setting. This provides direct view of endometrial cavity and obtaining endometrial biopsy samples for pathological diagnosis.

d) Atypical endometrial hyperplasia is a diagnosis which merits hysterectomy and bilateral salphingo-oopherectomy(BSO) (1) in her age group. This is because of the significant risk of progression to endometrial cancer and presence of possible occult underlying undiagnosed endometrial cancer (1) .
BSO is recommended in her age group as she has gone through menopase and also completes the treatment if underlying early endometrial cancer and prevents future ovarian pathologies.
The routes of hysterectomy are vaginal/ abdominal / laparoscopic hysterectomy.
Vaginal approach avoids abdominal surgery (1) with quicker recovery compared to abdominal hysterectomy but may pose challenge if no significant uterine descent/ for removal of ovaries.
Abdominal hysterectomy provides easy access for total hysterectomy and BSO but associated with risks of major abdominal surgery.
Laparoscopic hysterectomy (1) may avoid risk of major abdominal surgery but has its own risk of laparoscopic injuries and may not be available in all centres.
If the patient is not willing for surgical intervention, she should be fully counselled regarding the risk of progression and association of undiagnosed endometrial cancer and consider treatment with progestin therapy with GnRH analogue treatment ? logic of using GnRH – she does not have menstrual cycles so what are you trying to achieve? (-1) . This should have regular follow up with 6 monthly Hysterocopy and endometrial directed biopsy.
Posted by PAUL A.
I would ask about her menstrual history, menopause what does this mean? The word on its own does not convey any information . I would ask about post coital bleeding and if her initial symptoms related to local lesion., vaginal or cervical ? mening. Your punctuation makes the sentence meaningless . I would ask about drug history of hormonal replacement therapy (HRT) (1) which may have direct relation for break through bleeding, according to the type of HRT. I would ask about her obstetrical history, infertility and anovulatory cycles, Polycystic ovaries you need a detailed menstrual Hx ?. Family history (1) should be asked, breast, endometrial, colon, prostate…

I would tell that her symptoms are most likely related to HRT or atrophic or hypertrophic endometrial changes, However, the other serious aetiolgy should be excluded. majority of women have benign disease; ~10% have malignant disease

Investigations should be given includes, Pelvic a, transvaginal ultrasound (1) which may rule out ovarian mass, cyst and evaluate endometrial thickness. As, the cut off value is 5mm, though endometrial cancer may be excluded ? meaning . Also, endometrial polyp can be excluded through trans vaginal scan. Otherwise, endometrial biopsy should be offered is this in place of TVS?? . Out patient endometrial sampling using Pipelle catheter this is not a sentence . However, almost 4% of cases can be missed. Hysteroscopy with endometrial sampling is the diagnostic gold standard investigation, outpatient or inpatient (1) . Dilatation and curettage biopsy may miss about 3 % of endometrial pathology.

Atypical endometrial hyperplasia is a precancerous condition as about 30% of cases may change to endometrial ca (1) may be co-existent ca . So, abdominal hysterectomy is the first line of treatment. Bilateral oophrectomy (1) is advised during the procedure as, there is a possibility of concomitant hidden cancerous lesion may be discovered with histopatholoical examination. Other types of hysterectomy can be offered includes, vaginal (1) what is the value of VH? route, however there is technical difficulties with removal of the ovaries. Also, laparoscopic assisted vaginal hysterectomy can be offered with expertise in laparoscopic procedures ? VALUE – YOU WERE ASKED TO EVALUATE . Medical treatment can be offered in case of refusal of surgical option. Progestagen, norethistrone in relatively high dose can be given (1) . However, side effects of progestagen like, breast pain, bloating, distension, headache. Also, this needs regular follow up by repeated ultrasound and endometrial sampling to rule out change to endometrial ca.

You seem to have adequate knowledge. However, your English needs some improvement – this may be achieved by writing simpler sentences
Posted by PAUL A.
a-- I would ask whether her discharge was present daily or associated with postcoital bleeding.Associated features like pruritis,foulsmell,frequency of micturition,dysuria,hematuria and altered bowel habits (1) like blleeding per rectum would also be asked. I would ascertain about previous similar episodes if any, the treatment taken and the outcome. I would ask about her her menarche , menopause need more detailed menstrual Hx ,obstetric history with respect to the number of children ,breastfeeding, and history of HRT (1) intake.Smear history (1) is asked.Family history (1) of thrombosis and cancers of breast, endometrium, ovary and colon asked.Smoking,intake of alcohol and addictive drugs ? relevance in a healthy 65 year old also would be asked.
b -I would tell her that her symptoms are probably benign but the aim would be to rule out sinister pathology like cancers of cervix,ovary,and endometrium before arriving at a conclusion.I would provide her with written information. majority have benign disease. ~10% have malignant disease

c-I would do USS (1) TVto see for the endometrial thickness as more than 4mm warrants futher investigations like outpatient hysteroscopy and directed biopsy (1) . Its advantage is that it helps to visualise the endometrium and take biopsy from suspicious areas and associated polyps if any can be diagnosed.If the expertiese and equipment is unavailable endometrial biopsy is done as it is easy to do,easily available and cheap.Pipell samples ~4% of the endometrium and vabra aspirator samples ~40% of the endometrium (1) .

d--Conservative management with high dose progestogens is an option but it needs longterm follow up with scans and endometrial biopsy so as to diagnose progression of disease and patients compliance is also vital this will NOT be your first option and should only be used if surgery is declined .Hysterectomy with bilateral salpingo oophorectomy is another option (1) this is not just an option – THIS IS THE RECOMMENDED TREATMENT.This is an optimal treatment as it removes the organ with the pathology( because undiagnosed underlying endometrial cancer is present in ~25% of cases (1) ).Hysterectomy can be done either vaginally( less morbidity (1) but can have problems in removing the adnexa) or abdominally(morbidity likely to be more but removal of adnexa is easy) or via laproscopically ? value (needs expertise and equipment and has its entry related risks of visceral injury,and is less morbid ).
Posted by clarice M.
Hi Zakaria,
I am incredibly flattered that you were impressed with my answer to this question.

Well done on getting such good comments.
Posted by PAUL A.
A) I will ask her about the nature and severity of discharge,any foul smell or any associated symptoms like post coital bleeding or dyspareunia.I will ask regarding vaginal pain or symptoms of menopause like vaginal dryness (1) ,hot flushes as atrophic vaginitis may be the cause of her symptoms.
Enquiry is made regarding haematuria and rectal bleeding.
I will also ask her about use of vaginal tampons or pessaries
A detailed menstrual history is taken regarding age of menarche and menopause and regularity of cycle (1) .Early menarche and late menopause are predisposing factors for endometrial carcinoma.
history is taken about any recent Pap smear (1) and the result if available
Enquiry is made regarding use of any contraception
Ask if any treatment has been taken earlier and the effect of treatment.
A note is made of her parity.
History is taken regarding use of any drugs like hormone replacement therapy (1)
I will ask her about presence of any predisposing factors for endometrial carcinoma like diabetes,hypertension HEALTHY or tamoxifen intake


B) Regarding likely cause of her symptom I will explain her that most likely her symptoms may be due to a benign pathology in the genital tract like endometrial/cervical polyp or atrophic vaginitis/cervicitis (1) .However malignancy is a possibility HOW LIKELY IS MALIGNANT DISEASE? at this age and needs to be excluded and investigations will need to be done.I will provide her with written explanation.



C) A FBC is done to assess anaemia.
I will also do a Pap smear particularly as an atrophic cervix is difficult to assess clinically and cervical cancer may be a possibility with a normal looking cervix? .It is difficult to visualise transformation zone in a post menopausal woman and colposcopy may be difficult.An experienced colposcopist is needed if Pap smear report abnormal.
Transvaginal scan (1) will be done to assess the endometrial thickness and see any adnexal mass (1) .It is a non invasive easily available method with good sensitivity in triaging for further endometrial biopsy.However sensitivity is low in detecting endometrial polyps.The cut value for endometrial thickness varies between 3-5 mm in post menopausal women.It is dependant upon the equipment and skill of operator.Sonohysteroscopy is more sensitive than TVS but is not widely available.
If endometrial thickness is more than 5 mm I will do an outpatient endometrial aspiration biopsy (1) or ahysteroscopy and biopsy (1) .Sensitivity of these outpatient procedures is good and they are acceptable and cost effective.The complications of anaesthesia and surgery are avoided.
However if the results are inconclusive or the symptoms persist inspite of a negative result I will do a formal hysteroscopy D&c under general anaesthesia (1) which is considered as gold standard for invesigating post menopausal bleeding.Tissue can be taken for biopsy from suspicius areas and any polyp if seen can be removed simultaneously.Associated with complications of anaesthesia and surgery like uterine perforation and haemorrhage


D)Total abdominal hysterectomy with bilateral salpigo oophorectomy is the most appropriate treatment for her (1) what is its value / use? .However it is associated with morbidity and mortality of major surgery.Complications like haemorrhage,injury to viscera and thromboembolism can occur.
Vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy with bilateral salping oophorectomy (1) is another option with lower morbidity (1) and better cosmetic effects.Laparoscopic surgery needs specialised equipment and a surgeon with additional expertise for the operation.Haemorrhage and post operative recovery are faster.Associated with complications of laparoscopy like visceral and vascular injury.
Ovaries are better removed considering her post menopausal age to reduce the chances of future malignancy.
Hormonal treatment with high dose progesterone Megesterol Acetate is an alternative if the woman declines surgery (1) .Disadvantage is the need to follow up within 6 months with hyseroscopy and endometrial biopsy.Besides the chances of progress to invasive cancer still exists.
Woman would be explained not answering the question – you were asked to evaluate the options not to explain anything to the woman expectant management is not justified considering the premalignant nature of the lesion and the possibility of progress to invasive cancer.She will be explained child bearing is unlikely at her age if fertility is an issue
Womans wishes will be taken into account.
I will provide her with written information and give her contact details of support groups as the finding is associated with considerable anxiety.
Posted by PAUL A.
a) History should include parity, age at menarche and menopause along with use, previous or current, of HRT and it\'s type (1) you have time & space to deal with menstrual Hx, HRT, obs Hx individually and in greater detail . The type of bleeding (fresh red or dark), precipitating events such as intercourse (1) and associated hormonal symptoms including breast tenderness or cramping should be established. Past medical history of diabetes, hypertension healthy , polycystic ovarian syndrome should be elucidated as these all increase the risk of endometrial cancer. Family Hx, bowel / urinary symptoms, weight loss

b) Her symptoms are most likely to be due to a benign condition (1) however a small but significant number of women will have a more sinister cause in the form of endometrial cancer and this must be excluded is this what you will tell her? .

c) Ultrasound scan provides a sensitive method of assessing the endometrium. The transvaginal (1) route is best and cut-offs of 5mm or less and 3mm or less are used for \'normal\' in women with and without HRT respectively. A pipelle endometrial biopsy (1) has 81% sensitivity and 98% specificity for detecting endometrial cancer in spitet of only sampling 4% of the endometrium. Hysteroscopy (1) out-patient / in-patient? is the \'gold standard\' for endometrial assessment, allowing visualisation of the entire cavity and has high sensitivity for endometrial cancers. All 3 tests are acceptable to most women and can usually be performed as out-patients.

d) Atypical endometrial hyperplasia is recognised as a pre-malignant condition. A significant number of cases will progress to endometrial cancer without treatment (1) co-existent ca . Some may regress, but conservative management is not to be recommended. Treatment with progesterone locally (LNG-IUS) or systemically can induce regression to a normal endometrium if this is not first line Rx, why write it first? If you ran out of time / space, you would have earned fewer marks but given her age hysterectomy should be advised. This may be vaginal or abdominal however foci of invasion may exist along with atypical hyperplasia and as such a total abdominal hysterectomy and bilateral salpingo-oopherectomy (1) is the best choice to eradicate disease and reduce recurrence (1) also allows staging. Value of VH, LAVH .

Apologies for any spelling mistakes, the \"t\" button on my keyboard is somewhat unreliable...

See good answers above
Posted by Maayka ..
nellie

a) I would ask her about the duration of her menses, when was menarche to menopause. Her parity is relevant because nulliparous women are at increased risk of endometrial cancer. The use of HRT or probably Tamoxifen (if at least prophylactically with strong family history of breast cancer) is a form of exogenous oestrogens. About the complaint of PMB – I would ask if this was her first episode or had she previously had PMB which was investigated. I want to ensure also that she is not describing any bleeding from the urethra or rectum and there is no associated abdominal pains with distention. If this was so then a history from her of weight loss would suggest a cancerous lesion. I would ask if she is sexually active and if there is postcoital bleeding to consider cervical causes, and at the same time enquire about her last cervical smear result. If she has symptoms of vaginal dryness this may suggest vaginal wall atrophy.

b) I will tell her that it is likely that the cause is a noncancerous one, like simply because of low oestrogen state of the vaginal walls; to a benign cervical /endometrial polyp, (I will explain it is a growth on the mouth of the womb or within). There is about a 10% chance that it may be cancer in the womb lining and it is necessary to rule out any cancers of the ovary as well.

c) To rule out endometrial or ovarian cancer, the following investigations should be done in the event that it may be for either further follow up or management also.
Blood investigations – FBC, U+Es, LFTs – should be done as a baseline and the latter two relevant if there was the possibility of metastatic lesions or the patient will eventually need general anaesthesia- to ensure her kidney/ liver functions are normal. Serum CA125 levels to rule out the possibility of an ovarian carcinoma.
Transvaginal ultrasound (TVS) is a good screening tool to decide who needs subsequent investigation... An endometrial thickness has not been decided upon as standard beyond which carcinoma should be ruled out but 3, 4, 5 mm thickness are suggested. It has good sensitivity for carcinoma but not for benign polyps though. TVS would also detect the presence of ovarian lesions.
Hysteroscopy and endometrial sampling is the gold standard but the TVS report will usually determine if this is warranted. If the PMB is recurrent then this should be done. It allows the entire surface of the endometrium to be visualized before sampling is done. It can be done as an out patient procedure or under general aneasthesia.

d) For her age, a TAH and BSO would be recommended because there is a 25- 50 % chance of co-existent endometrial carcinoma with atypical hyperplasia. she can have the surgery performed abdominally- associated with increased hospital stay, post op analgesia requirement , longer return to normal activities; vaginally – less postop pain and reduced hospital stay with faster return to activity. This can also be done with the aid of the laparoscope – LAVH. Shou d she not be found fit for surgery following pre- operative assessment or she simply requests nonsurgical intervention , then high dose progestogens should be given – as an injectable like Noristerat or orally. Follow up would then be required every 6 months with biopsy via hysteroscopy because of the likelihood of progressions to carcinoma.

Posted by PAUL A.
ah
a)Post menopausal bleeding can be caused by genital tract malignancy in ten percent of cases. The history will serve to identify risk factors and features of malignancy.
Her parity, age at menarche, and menopause need a detailed menstrual Hx will be asked as nulliparity, early menarche and late menopause are risk factors.
A history of polycystic ovary disease, diabetes and hypertension healthy will also be asked as they are associated with endometrial cancer.
The use of unoppsed oestrogen, tamoxifen are strong risk factors; sequential hormone replacement therapy (HRT) (1) is thought to be associated with endometrial cancer and this will be asked.
Precipitating factors for her symptoms will be asked. if related to coitus (1) a cervical or vaginal lesion may be causative. A smear history (1) will be taken, including results and any previous treatment.
bowel symptoms, weight loss, family Hx
b)I would tell her that the most likely cause of her symptoms is atrophy of the genital tract due to a hypo-oestrogenic postmenopausal state most likely cause is benign disease; ~10% have malignant disease .

c)She will be offered transvaginal ultrasound (1) evaluation of the endometium. The endometrial thickness will be measured,because if this is less than 4 millimetrs,she can be reassured that she is unlikely to have endometrial cancer. It has a sensitivity of 80 to 100 percent of detecting endometrial cancer in a woman not on HRT.
It however has a poor sensitivity for endometrial polyps and other benign lesions, and is not reliable if she is taking HRT. However it is non-invasive, cheap and acceptable to patients and results immediately available.
Endometrial sampling can be done in the out-patient (1) department using either a pipelle sampler which is a blind procedure or hysteroscopy and directed biopsy (1) in which case the endometrium can be visualised. These out-patient procedures avoid the use of general anaesthesia and admission. Both are well tolerated in most patients. Only 10 percent complain of severe pain with the Pipelle and local anaesthesia may be required for a small percentage of patients having hysteroscopyand find it painful.Both out-patient hysteroscopy and pipelle are cost-effective and suitable for patients unfit for general anaesthesia does this apply to the woman in question? .
In-patient hysteroscopy and dilatation and curettage (1) is considered the gold standard and is useful if there is a significant area of the endometrim involved. Alternately, hysteroscopy guided biopsy can be done under general anaesthesia if there was difficulty in obtaining a sample in the outpatient setting.

c) Atypical hyperplasia is associated with coexistent malignancy, the lesion tends to progress to malignancy, or persist (1) .
The patient will be couselled you were not asked to counsel her. What are the treatment options and what is their value? about the options and given written information so that she can make an informed decision.
The optimum treatment is hysterectomy and bilateral salpingho-oophorectomy (1) by the general gynaecologist.The specimen can be examined histologically for presence of malignancy and appropriate follow-up implemented. However there is the risk of anaesthesia and surgery and the patient may not be fit for major surgery.
Medical treatment can be offered to these patients not fit for surgery.
High dose oral progestogens or depot medroxyprogesterone acetate can be prescribed for three to six months and the
endometrium re-biopsied to check for regression (1) . If there is no response the dose can be increased.The regression rate is lower than if there was no atypia (50 to 80 percent compared to 90 percent), and associated side-effects are bloatedness and headaches. Alternatively the levonorgestel intrauterine system (Mirena) can be used.
Alternative treatment include the use of Danazol, or goadotrophin releasing analogues what are you trying to achieve? She is post-menopausal. How will GnRH be effective??? (-1) with or without subsequent endometrial resection will you do endometrial resection in a woman with suspected endometrial malignancy??? . The response rates are between 60 to 75 percent in post-menopausal women??? .
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nellie

a) I would ask her about the duration of her menses, when was menarche to menopause ? meaning?? Take a detailed menstrual Hx including age at menarche / menopause, cycle length and regularity… . Her parity is relevant because nulliparous women are at increased risk of endometrial cancer. The use of HRT (1) or probably Tamoxifen (if at least prophylactically with strong family history of breast cancer) is a form of exogenous oestrogens. About the complaint of PMB – I would ask if this was her first episode or had she previously had PMB which was investigated. I want to ensure also that she is not describing any bleeding from the urethra or rectum and there is no associated abdominal pains with distention. If this was so then a history from her of weight loss (1) would suggest a cancerous lesion. I would ask if she is sexually active and if there is postcoital bleeding to consider cervical causes (1) , and at the same time enquire about her last cervical smear result what about previous smears and treatment? . If she has symptoms of vaginal dryness this may suggest vaginal wall atrophy (1) FHx of malignancy.

b) I will tell her that it is likely that the cause is a noncancerous one, like simply because of low oestrogen state of the vaginal walls; to a benign cervical /endometrial polyp, (I will explain it is a growth on the mouth of the womb or within) (1) . There is about a 10% chance that it may be cancer in the womb lining and it is necessary to rule out any cancers of the ovary as well (1) .

c) To rule out endometrial or ovarian cancer, the following investigations should be done in the event that it may be for either further follow up or management also waste of time & space .
Blood investigations – FBC, U+Es, LFTs – should be done as a baseline and the latter two relevant if there was the possibility of metastatic lesions or the patient will eventually need general anaesthesia- to ensure her kidney/ liver functions are normal. Serum CA125 levels to rule out the possibility of an ovarian carcinoma. not necessary – if you make a diagnosis of malignancy, you will have enough time to do this test. Given that only 10% have malignant disease, this is inappropriate
Transvaginal ultrasound (TVS) (1) is a good screening tool to decide who needs subsequent investigation... An endometrial thickness has not been decided upon as standard beyond which carcinoma should be ruled out but 3, 4, 5 mm thickness are suggested. It has good sensitivity for carcinoma but not for benign polyps though. TVS would also detect the presence of ovarian lesions (1) .
Hysteroscopy and endometrial sampling is the gold standard (1) but the TVS report will usually determine if this is warranted. If the PMB is recurrent then this should be done. It allows the entire surface of the endometrium to be visualized before sampling is done. It can be done as an out patient procedure or under general anaesthesia (1) out-patient aspiration biopsy .

d) For her age, a TAH and BSO (1) would be recommended because there is a 25- 50 % chance of co-existent endometrial carcinoma with atypical hyperplasia (1) . she can have the surgery performed abdominally- associated with increased hospital stay, post op analgesia requirement , longer return to normal activities; vaginally – less postop pain and reduced hospital stay with faster return to activity (1) . This can also be done with the aid of the laparoscope – LAVH ? value . Shou d she not be found fit for surgery HEALTHY following pre- operative assessment or she simply requests nonsurgical intervention , then high dose progestogens should be given – as an injectable like Noristerat or orally. Follow up would then be required every 6 months with biopsy via hysteroscopy because of the likelihood of progressions (1) to carcinoma.
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A good candidate should
(a)
• Know the value of menstrual history – LMP, age at menarche, cycle length and regularity (1)
• Precipitating factors for bleeding – post-coital (1)
• Vaginal dryness, dyspareunia if sexually active may indicate vaginal atrophy. Vaginal discharge may suggest infection (1)
• Weight loss, anorexia – suggest malignancy (1)
• Bowel symptoms – PR bleeding, altered bowel habit; urinary symptoms – haematuria (1)
• Cervical smear history (1)
• Drug Hx – use of HRT (1)
• Obstetric Hx. Family Hx of gynaecological malignancy (1)

(b)
• Explain that in the majority of women, PMB is caused by benign conditions such as genital tract atrophy, cervical & endometrial polyps and the effects of HRT (1)
• In about 10% of women, PMB is caused by malignant disease mainly endometrial cancer but also cervical, vulval and vaginal cancer (1)

(c)
• Know that symptoms are suggestive of malignancy (endometrial or cervical) and therefore prompt investigation required. She should be assessed within 2 weeks of referral (1)
• Trans-vaginal ultrasound scan for endometrial thickness – high sensitivity in detecting endometrial cancer but also high false positive rate. Also enables assessment of ovaries (2)
• Should be combined with out-patient endometrial biopsy either using aspiration curettage or out-patient hysteroscopy & biopsy – more cost-effective and avoids complications of GA and potential delays with in-patient investigation. In-patient hysteroscopy D&C if out-patient procedures not possible (2)

(d)
• Know that atypical endometrial hyperplasia is associated with endometrial carcinoma (1)
• TAH + BSO will be the most appropriate treatment. Allows definitive diagnosis / staging and likely to be curative (2)
• Laparoscopic hysterectomy + BSO or LAVH + BSO are alternative approaches and are associated with quicker recovery (2)
• If surgery is declined, treatment with high dose progestogen should be offered but will need repeat endometrial sampling after 3-6 months and may be associated with disease progression (1)
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