Endometrial Flashcards
Postmenopausal bleeding aetiology
Most common cause is atrophy 60-80% Exogenous oestrogen 15-25% Endometrial hyperplasia 10% Endometrial cancer 10% Cervical/Endometrial polyps 2-12% Cervical cancer 1% Other Vaginal trauma Anticoagulants Bleeding from non-gynae sites
Incidence PMB
5% of gynae OPC presentation
4-11% of postmenopausal women will experience bleeding
Investigations PMB
TVUSS
Endometrial biopsy
- pipelle50% of endometrium, 99% sensitive hyperplasia , 81% Ca
- hyst D&C sample 70% cavity
Management atrophy
top estrogen daily 2 weeks, twice weekly thereafter
Endometrial hyperplasia in postmenopausal women
Progesterones or hysterectomy
Lymphatic drainage endometrial ca
Lymphatic drainage
- Infundibulopelvic (uteroovarian) - Parametrial - Presacral ○ They collectively drain into the internal iliac --> external iliac --> common iliac --> presacral --> para-aortic
Metastastatic sites
Ovary
Vagina
Lungs
FIGO Staging
1 - Confined to the uterus 1A <50%myometrial invasion 1B >50% myometrial invasion 2 - Tumour invades cervical stroma, but does not extend beyond the uterus 3 - Local/Regional spread 3A Serosal +/- adnexae invasion 3B Vagina/parametrium invasion 3C Pelvic or para-aortic lymph nodes 4 - Distant invasion 4A Bladder/bowel 4B Distant metastases (abdominal organs, inguinal nodes)
Stage 1
1 - Confined to the uterus
1A <50%myometrial invasion
1B >50% myometrial invasion
Stage 2
2 - Tumour invades cervical stroma, but does not extend beyond the uterus
Stage 3
3 - Local/Regional spread
3A Serosal +/- adnexae invasion
3B Vagina/parametrium invasion
3C Pelvic or para-aortic lymph nodes
Stage 4
4 - Distant invasion
4A Bladder/bowel
4B Distant metastases (abdominal organs, inguinal nodes)
Lifetime risk endometrial Ca
1:45
Cumulative risk endometrial Ca
1.6%
Histopathological types
- Endometrioid carcinoma ○ Adenocarcinoma and variants - Mucinous adenocarcinoma - Serous adenocarcinoma - Clear cell adenocarcinoma - Undifferentiated adenocarcinoma - Neuroendocrine tumours - Mixed carcinoma - Mixed epithelial and mesenchymal tumours - ○ Adenomyoma ○ Adenofibroma ○ Adenosarcoma Carcinosarcomas malignant and aggressive
Histological Grading
GX: Grade cannot be assessed.
G1: Well differentiated.
G2: Moderately differentiated.
G3: Poorly or undifferentiated.
Stage 1 A (Grade 1-2)
Hysterectomy + BSO
no adjuvant therapy required and survival rate 96% at 5years
Stage 1-2 with Grade 3 disease
Hysterectomy + BSO
Radiotherapy reduces pelvic recurrence with no change in survival (vaginal brachytherapy)
Stage 3
Hysterectomy +BSO
Radiotherapy +/- chemotherapy
If not surgically resectable, then primary radiotherapy +/- chemotherapy +/- delayed surgical resection of residual disease
Stage 4
Hysterectomy +BSO Neoadjuvent chemo (platinum based) Doxorubicin (most toxic), cisplatin, carboplatin, paclitaxel (various combinations)
Recurrence
- 75% recurrence is in the vaginal vault.
- 75% recurrence is symptomatic
- Radiotherapy - brachytherapy has replaced external beam radiation as less adverse effects and similar survival
- Usual reason for inoperable is morbid obesity or severe cardiopulmonary disease
○ Uterine brachytherapy in these women can achieve cure in 70%
Chemotherapy is used for serous cancers
Indications for radiotherapy
- To reduce local recurrence after surgical resection
- Neoadjuvant treatment in non-surgically resectable disease
- Palliative treatment - symptomatic control of bleeding
- Treatment of recurrence
Follow up
- Physical examination 3-6monthly for 2-3 years
- CA125 optional
- Imaging as clinically indicated
- Patient information - symptoms of recurrence, sexual health
Treatment of recurrence - MDT
Definition of endometrial hyperplasia
irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium
Endometrial cell growth is stimulated by binding to estrogen receptors in the nuclei of endometrial cells
Risk factors hyperplasia
- AGE!
- Unopposed estrogen
○ Obesity
○ PCOS
○ HRT (estrogen only) or tamoxifen
○ Perimenopause (anovulation like PCOS)
○ Oestrogen secreting ovarian tumours (granulosa cell) - Nulliparity
- Early menarche and late menopause
- T2DM
- Hypertension
- Lynch Syndrome (HNPCC)
- Unopposed estrogen
Protective factors endometrial hyperplasia
-higher age at last birth
- Smoking
- Contraceptive (COC or POP)
- Breastfeeding
- Exercise
Coffee and tea
Investigation TV USS hyperplasia
TV USS thickness <7mm in premenopausal woman- very unlikely hyperplasia
<4mm PMB unlikely hyperplasia (<1%)
Endometrial hyperplasia risk of progression to Ca
<5% over 20 years
Endometrial hyperplasia WITH ATYPIA % risks
43% already concurrent cancer
29% progress to cancer <19years
8% progress to cancer <8years
4% risk concurrent ovarian ca
Management hyperplasia without atypia
- Progesterone
Higher regression rates 89-96% cf observation
i. Mirena – 1st line
ii. Continuous PO progesterone e.g. medroxyprogesterone 10-20mg/day or norethisterone 10/15mg/day - Address risk factors
- Observation with endometrial biopsy surveillance
Regression rate 74.2 – 81%
Management hyperplasia with atypia
Hysterectomy
BSO / BS depending on risk and menopausal status
If atypia and fertility desired
Counsel RE risk of progression to endometrial cancer
Investigations to rule out invasive endometrial Ca or co existing ovarian Ca
Review in MDM
1. Mirena – 1st line
2. PO Progesterone
2. 3 monthly biopsy, once 2x negative then 6-12 monthly until hysterectomy once fertility no longer required
