Gynae: PMB and endometrial cancer

Question 1

PMB: what should you elicit in HxPC?

Answer 1

• Definitely PV bleeding? (i.e. not bowel, urine)
• When did she notice this? Any triggers? (sex/trauma) How long for, and how much?
• When did she go through menopause? Was she on HRT?

Question 2

PMB: what other symptoms should you ask about?

Answer 2

• Menstrual history – Menarche, any problems with her periods when she was menstruating? (PCOS increases risk)
• Bleeding at any other time e.g. after sex?
• Discharge
• Pain at any time? – chronically, dyspareunia?
• Malaise, weight loss, change in appetite, bloating, ascites
• Bowel or urine symptoms? Exercise tolerance, heart/lung problems?

Question 3

PMB: what background Hx should you ask about?

Answer 3

• Past gynae & obs history
  
  • Has she ever had any gynaecological problems or procedures?
  • Has she ever had any infections?
  • Are her smears up to date? Has she ever had an abnormal smear?
  • How many children? All vaginal deliveries?
• Past medical history
  
  • Has she ever had breast or ovarian cancer? Did she use tamoxifen? Colon cancer?
• Past family history
  
  • Any conditions which run in the family?
  • Has anyone in the family ever had any gynaecological problems?
  • Has anyone in the family ever had colon or endometrial cancer?
• Medications
• Smoking, alcohol

Question 4

Define PMB?

Answer 4

PV bleeding more than 12 months after the cessation of menstruation

Question 5

What are some causes of PMB?

Answer 5

• Most common: endometrial carcinoma, endometrial hyperplasia (+/- atypia and polyps), cervical cancer and ovarian cancer.
• Other causes: atrophic vaginitis, cervicitis and cervical polyps.
• Withdrawal bleeds may occur on HRT and do not need to be investigated, provided they are regular.

Question 6

What examinations would you do for a lady presenting with PMB?

Answer 6

• General examination
• Abdominal examination
• Speculum examination
• Bimanual pelvic examination

Question 7

PMB: what Ix would you perform?

Answer 7

• Bloods – FBC (check for anaemia), CA-125, menopause hormone level (low estradiol with high FSH and LH), TFT
• Cervical smear if needed (this may show cervical cancer, but may also show normal CGIN-like cells in endometrial cancer) + triple swabs
• Transvaginal USS to measure endometrial thickness, (normal <4mm), look for any masses or abnormalities in interface between endo and myometrium, and to visualise any free fluid.
• If the endometrial thickness >5mm a hysteroscopy should be performed –allows visualisation of any polyps and also an endometrial biopsy to be taken.
• If endometrial cancer is confirmed, stage with MRI, discuss at MDT, with likely outcome of hysterectomy + BSO. Return to MDT with final histology- does she need adjuvant RT/Chemo?

Question 8

What is endometrial hyperplasia?

Answer 8

• This is abnormal overgrowth of the endometrium, associated with an excess of oestrogen relative to progestogen.
• Simple hyperplasia has around a 1% chance of progressing to endometrial cancer.
• Complex hyperplasia has a 5% chance, while atypical hyperplasia, which is associated with nuclear pleomorphism and mitotic activity, has a 30% chance.

Question 9

What is the pathology of endometrial cancer?

Answer 9

Endometrial cancer is most common genital tract cancer, often in >60yr olds.

• Adenocarcinoma of columnar endometrial gland cells in >90%.
• Adenosquamous 2nd most common.

Question 10

What are the risk factors for endometrial hyperplasia and cancer?

Answer 10

Principal risk is high oestrogen:progesterone ratio.

• Obesity – due to aromatase activity in the peripheral adipose tissue
• Infertility, and a history of anovulatory cycles
• Late menopause
• Prolonged HRT
• Oestrogen-secreting ovarian lesions, including tumours and PCOS
• Tamoxifen

Also: familial syndromes (HNPCC, Cowden syndrome), pelvic irradiation

Question 11

Describe the spread and staging of endometrial cancer

Answer 11

• Spreads through myometrium to cervix and upper vagina.
• Lymphatic spread to pelvic and para-aortic nodes. Blood-borne is late.
• Staging is surgical+ histological (G1-3) + lymph nodes

Question 12

What are the management and prognosis for endometrial cancer?

Answer 12

Management:

• Stage 1 disease can be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy.
• Various RCTs (including the large ASTEC study) have shown no therapeutic benefit from pelvic lymphadenectomy, though it is important in staging.
• EBRT may be used in patients with lymph node involvement, or considered “high risk” (e.g. Stage 2). Vaginal vault radiotherapy can also be used.
• The role of chemotherapy is limited.

Prognosis: generally good.

• While stage-for-stage it is similar to ovarian cancer, it generally presents much earlier (75% at Stage 1). The overall 5YS is around 75%.