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OBG: Functional Gynaecology > Heavy menstrual bleeding > Flashcards

Heavy menstrual bleeding Flashcards

1
Q

What is the definition of heavy menstrual bleeding?

A

Excessive menstrual loss which interferes with a woman’s quality of life - either on its own or in combination with other symptoms

Definition of ‘excessive’ set by woman who presents with the problem

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2
Q

What proportion of women are thought to be affected by heavy menstrual bleeding?

A

3%

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3
Q

Which age group of women with heavy menstrual bleeding are more likely to present to healthcare services?

A

40-51 years

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4
Q

What is heavy menstrual bleeding not related to?

A

Pregnancy or post-menopausal bleeding - occurs during reproductive years only

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5
Q

What is the cause of the majority of cases of HMB and what is this called?

A

40-60%: abnormal uterine bleeding (AUB), i.e. cannot be attributed to any uterine, endocrine, haematological or infective pathology after investigation

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6
Q

What 2 groups can the causes of heavy menstrual bleeding be classified into?

A
  1. Structural causes (PALM)
  2. Nonstructural causes (COEIN)
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7
Q

What are 4 examples of structural causes of HMB?

A
  1. Polyp
  2. Adenomyosis
  3. Leiomyoma (fibroid)
  4. Malignancy and hyperplasia
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8
Q

What are 5 nonstructural causes of heavy menstrual bleeding?

A
  1. Coagulopathy
  2. Ovulatory dysfunction
  3. Endometrial
  4. Iatrogenic
  5. Not yet classified
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9
Q

What are 2 key risk factors for heavy menstrual bleeding?

A
  1. Age (more likely at menarche and approaching the menopause)
  2. Obesity
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10
Q

What are the 3 key clinical features of HMB in the history?

A
  1. Bleeding during menstruation deemed to be excessive for the individual woman
  2. Fatigue
  3. Shortness of breath (if associated anaemia)
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11
Q

What are 5 key things to focus on in the history in a woman with HMB?

A
  1. Menstrual cycle history
  2. Smear history
  3. Contraception
  4. Medical history
  5. Medications - including any taken to reduce menstrual bleeding
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12
Q

What are 4 important things to ask as part of the menstrual cycle history?

A
  1. Frequency - average 28 days (24-38)
  2. Duration - average 5 days (4.5-8)
  3. Volume - average 40ml over course of menses. Flooding and clots
  4. Date of last menstrual period (LMP)
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13
Q

What is the normal frequency of menses and what is considered frequent/ infrequent?

A

average 28 days

<24 days frequent, >38 days infrequent

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14
Q

What is the normal length of menses and what is considered frequent/ infrequent?

A

average 5 days

<4.5 days shortened,, >8 days prolonged

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15
Q

What is the average volume of menstrual blood lost over the course of menses, and what is considered heavy vs light?

A
  • Average: 40ml
  • >80ml heavy (Hb and Ferritin affected), <5ml light
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16
Q

What are 2 elements of the history that can indicate increased volume of bleeding during menses?

A

flooding, clots passed

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17
Q

What are 4 parts that the examination of a patient should include for a patient with HMB?

A
  1. General observation
  2. Abdominal palpation
  3. Speculum
  4. Bimanual examination
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18
Q

What are 9 things that may be present on examination in HMB?

A
  1. Pallor (anaemia)
  2. Palpable uterus - smooth or irregular? (fibroids)
  3. Pelvic mass
  4. Tender uterus
  5. Cervical excitation (adenomyosis/endometriosis)
  6. Inflamed cervix
  7. Cervical polyp
  8. Cervical tumour
  9. Vaginal tumour
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19
Q

What are 9 key differentials for causes of HMB to remember?

A
  1. Pregnancy
  2. Endometrial or cervical polyps
  3. Adenomyosis
  4. Fibroids
  5. Malignancy or endometrial hyperplasia
  6. Coagulopathy (von Willebrand’s disease, anticoagulant use)
  7. Ovarian dysfunction - PCOS, hypothydoidism
  8. Iatrogenic causes e.g. contraceptive hormones, copper IUD
  9. Endometriosis
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20
Q

What are 2 reasons that pregnancy could cause HMB?

A
  1. Ectopic pregnancy
  2. Miscarriage
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21
Q

What type of bleeding can endometrial or cervical polyps cause?

A
  • HMB but not generally associated with dysmenorrhoea
  • Can also cause intermenstrual or post-coital bleeding
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22
Q

What type of malignancy can cause HMB?

A

vaginal or cervical malignancies, or ovarian tumours

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23
Q

What is the most common coagulopathy to cause heavy menstrual bleeding?

A

von Willebrand’s disease

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24
Q

What are 7 features in the history suggestive of von Willebrand’s disease/ coagulopathy causing HMB?

A
  1. HMB since menarche
  2. History of post-partum haemorrhage
  3. Surgical related bleeding or dental related bleeding
  4. Easy bruising
  5. Epistaxis
  6. Bleeding gums
  7. Family history of bleeding disorder
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25
Q

In addition to VWB what could be another cause of coagulopathy causing HMB to consider?

A

anticoagulant use e.g. warfarin

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26
Q

What are the 2 most common causes of ovarian dysfunction causing HMB?

A
  1. Polycystic ovary syndrome
  2. Hypothyroidism
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27
Q

What are 2 iatrogenic causes of HMB?

A
  1. Contraceptive hormones
  2. Copper IUD
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28
Q

What proportion of all heavy menstrual bleeding cases are caused by endometriosis?

A

<5%

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29
Q

What are 3 broad groups of investigations that should be carried out for any cause of heavy menstrual bleeding?

A
  1. Blood tests
  2. Imaging
  3. Histology and microbiology
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30
Q

What are 4 types of blood tests that should be performed for any cause of HMB?

A
  1. Full blood count - anaemia
  2. Thyroid function tests - underactive thyroid
  3. Other hormone testing - e.g. if suspicious of PCOS
  4. Coagulation screen + test for VWB disease
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31
Q

At what point does anaemia tend to present from menstrual blood loss?

A

After menstrual blood loss of 120ml for each period

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32
Q

What type of imaging is most commonly used to investigate HMB and what can it show?

A

Ultrasound pelvis: transvaginal US most clinically useful, to assess endometrium and ovaries

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33
Q

When should imaging in the form of ultrasound pelvic transvaginally be considered for HMB? 2 situations

A
  1. if uterus or pelvic mass plapable on examination
  2. if pharmacological treatment has failed
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34
Q

What are 4 histological/microbiological tests that you may perform if a woman presents with HMB?

A
  1. Cervical smear
  2. High vaginal and endocervical swabs for infection
  3. Pipelle endometrial biopsy
  4. Hysteroscopy and endometrial biopsy
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35
Q

When should pipelle endometrial biopsy be performed? 3 indications

A
  1. persistent intermenstrual bleeding
  2. >45 years old
  3. failure of pharmacological treatment
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36
Q

When is hysteroscopy and endometrial biopsy performed to investigate HMB?

A

when ultrasound identifies pathology or is inconclusive

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37
Q

What 2 groups can the management of HMB be split into?

A
  1. Pharmacological
  2. Surgical
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38
Q

What is the three-tier approach to managing HMB pharmacologically, when there is no suspicion of pathology?

A
  1. Lenonorgestrel-releasing intruterine system (LNG-IUS) e.g. Mirena
  2. Tranexamic acid, mefanamic acid or COCP
  3. Progesterone only: oral norethisterone, depo-provera injection or implant
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39
Q

What is the action of LNG-IUS and how long is it licensed for?

A
  • also acts as contraceptive; thins endometrium and can shrink fibroids
  • licensed for 5 years treatment
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40
Q

What helps decide between tranexamic acid, mefanamic acid or COCP for the second tier of pharmacological management of non-pathological HMB?

A

depends on woman’s wishes for fertility: tranexamic acid and mefanamic acid have no effect on fertility but COCP prevents conception

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41
Q

How is tranexamic acid taken for HMB?

A

taken only during menses to reduce bleeding; is anti-fibrinolytic so encourages clots to form to reduce flow

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42
Q

What is the added benefit of mefanamic acid when treating HMB?

A

is an NSAID so also offers analgesia for dysmenorrhoea

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43
Q

How is oral norethisterone (progesterone only) taken to treat HMB? What is the disadvantage of this?

A

taken day 5-26 of cycle - doesn’t work as contraceptive when taken so other contraceptive methods should be applied

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44
Q

What are the 2 main surgical treatment options for heavy menstrual bleeding?

A
  1. Endometrial ablation
  2. Hysterectomy
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45
Q

What is endometrial ablation?

A

endometrial lining of uterus obliterated, can reduce HMB up to 80%

can be performed in outpatient setting with local anaesthetic

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46
Q

How does endometrial ablation affect ability to conceive?

A

suitable for women who no longer wish to conceive, but will need to continue using contraception

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47
Q

What is the only definitive treatment for HMB?

A

hysterectomy

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48
Q

What are the 2 types of hysterectomy and how do they differ?

A
  • subtotal (partial) - removal of uterus but not cervix
  • total - removal of cervix with uterus

ovaries not removed in either case (unless abnormal)

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49
Q

What are the 2 routes to perform a hysterectomy?

A

abdominal incision or through vagina

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50
Q

What are uterine fibroids (leiomyomata)?

A

benign smooth muscle tumours of the uterus arising from the myometrium of the uterus

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51
Q

What is the estimated incidence of fibroids in women?

A

20-40%

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52
Q

What is the risk of a fibroid becoming malignancy?

A

0.1%

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53
Q

What is the classification of fibroids based upon and what are the 3 classification groups?

A

Classified according to position in uterine wall:

  1. Intramural: confined to myometrium
  2. Submucosal: develop immediately underneath endometrium of uterus, protrude into uterine cavity
  3. Subserosal: protrude into and distort serosal (outer) surface of uterus. May be pedunculated
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54
Q

What is believed to be the cause of fibroids?

A

Poorly understood; thought to be stimulated to grow by oestrogen

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55
Q

What is the most common type of fibroid?

A

Intramural

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56
Q

What are 5 risk factors for developing fibroids?

A
  1. Obesity
  2. Early menarche
  3. Increasing age
  4. Family history: women with first degree relative 2.5x risk
  5. Ethinicity: Afro-Caribbean 3x more likely than Caucasian
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57
Q

What are 5 clinical features of fibroids in the history?

A
  1. Pressure symptoms e.g. urinary frequency or chronic retention
  2. Abdominal distension
  3. Heavy menstrual bleeding
  4. Subfertility - obstructive effect
  5. Acute pelvic pain (rare)
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58
Q

What are 2 reasons why fibroids might cause acute pelvic pain (which is rare with fibroids)?

A
  1. May occur in pregnancy due to red degeneration, where rapidly growing fibroid undergoes necrosis and haemorrhage
  2. Rarely, pedunculated fibroids can undergo torsion
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59
Q

What might be present on examination with fibroids?

A

Solid mass, enlarged uterus may be palpable on abdominal or bimanual examination

Uterus usually non-tender

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60
Q

What are 4 major differentials for uterine fibroids?

A
  1. Endometrial polyp
  2. Ovarian tumours
  3. Leimoyosarcoma - malignancy of myometrium
  4. Adenomyosis (endometrial tissue within myometrium)
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61
Q

What is the key investigation for suspected fibroids?

A

Imaging: pelvic ultrasound

Rarely MRI if sarcoma suspected

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62
Q

When might blood tests be performed in suspected fibroids?

A

reserved for patients when diagnosis unclear, or as pre-operative work-up if surgery indicated

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63
Q

What are the 2 groups of management of fibroids?

A
  1. Medical
  2. Surgical
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64
Q

What are 4 types of medical treatments for fibroids?

A
  1. Tranexamic or mefanamic acid
  2. Hormonal contraceptives: for menorrhagia; COCP, POP, Mirena IUS
  3. GnRH analogues: Zoladex
  4. Selective progesterone recetpro modulators: ulipristal/ esmya
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65
Q

How do GnRH analogues such as Zoladex work to treat fibroids?

A

suppress ovulation, inducing a temporary menopausal state

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66
Q

Under what circumstances are GnRH analogues used to treat fibroids?

A

pre-operatively to reduce fibroid size and lower complications

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67
Q

For how long can GnRH analogues such as Zoladex be used and why?

A

6 months maximum due to risk of osteoporosis

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68
Q

What are 2 examples of selective progesterone receptor modulators used to treat fibroids?

A
  1. Ulipristal
  2. Esmya
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69
Q

How do selective progesterone receptor modulators work to treat fibroids and when are they used?

A

Reduce size of fibroid and reduce menorrhagia

Useful pre-operatively or as alternative to surgery

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70
Q

What are 4 surgical options for the management of fibroids?

A
  1. Hysteroscopy and transcervical resection of fibroid (TCRF)
  2. Myomectomy
  3. Uterine Artery Embolisation (UAE)
  4. Hysterectomy
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71
Q

What type of fibroids is hysteroscopy and trasncervical resection of fibroid (TCRF) particularly useful for?

A

submucosal fibroids

72
Q

In which patients is myomectomy a useful option to treat fibroids?

A

woman who want to preserve uterus

73
Q

Who performs uterine artery embolisation (UAE) as a treatment for fibroids and how?

A

radiologist via femoral artery

74
Q

What are 2 common post-operative complications of uterine artery embolisation (UAE) to treat fibroids?

A
  1. Pain
  2. Fever
75
Q

What is adenomyosis?

A

presence of functional endometrial tissue within the myometrium of the uterus

76
Q

What is thought to cause adenomyosis?

A

When endometrial stroma (connective/ supporting tissue) is allowed to communicate with the underlying myometrium after uterine damage which may be caused by:

  1. pregnancy and childbirth
  2. caesarean section
  3. uterine surgery (e.g. endometrial curettage)
  4. surgical management of miscarriage or termination of pregnancy
77
Q

What are 4 causes of uterine damage that may result in adenomyosis?

A
  1. pregnancy and childbirth
  2. caesarean section
  3. uterine surgery (e.g. endometrial curettage)
  4. surgical management of miscarriage or termination of pregnancy
78
Q

In which part of the uterus is damage leading to adenomyosis most commonly found?

A

posterior wall of uterus

79
Q

What can be seen in the damaged part of the uterus resulting in adenomyosis in hysteroscopy specimens?

A

Extent of invasion is variable, but in severe cases pockets of menstrual blood can be seen in myometrium

80
Q

What can be seen pathologically in histological specimens in adenomyosis?

A

Collection of endometrial glands form grossly visible nodules, described as an adenomyoma

Oestrogen, progesterone and androgen receptors found in ectopic endometrial tissue, making it responsive to hormones

81
Q

What are 4 risk factors for adenomyosis?

A
  1. High parity
  2. Uterine surgery e.g. any endometrial curettage, endometrial ablation
  3. Previous caesarean section
  4. Hereditary occurrence - potential genetic predisposition
82
Q

What are 4 typical presenting symptoms of adenomyosis?

A
  1. Menorrhagia
  2. Dysmenorrhoea
  3. Deep dyspareunia
  4. Irregular bleeding
83
Q

What is the typical nature of the dysmenorrhoea caused by adenomyosis?

A

Progressive, beginning as cyclical pain, but can worsen to daily pain

84
Q

What may be found on examination in adenomyosis?

A

Symmetrical enlarged tender uterus may be palpable - abdominal and bimanual palpation

85
Q

What are 6 differetials for adenomyosis based on the symptoms of dysmenorrhoea and menorrhagia?

A
  1. Endometriosis
  2. Fibroids
  3. Endometrial hyperplasia/ endometrial carcinoma
  4. Endometrial polyps (not usually dysmenorrhoea)
  5. Pelvic inflamatory disease (pelvic pain rather than cyclical)
  6. Hypothyroidism and coagulation disorders (menorrhagia)
86
Q

What is the definitive diagnosis of adenomyosis?

A

histological diagnosis after hysterectomy; recently, sometimes specimens obtained at hysteroscopic biopsy can be used for histology

87
Q

In addition to histology what 2 further forms of investigation can help in the diagnosis of adenomyosis?

A
  1. Transvaginal ultrasound
  2. MRI
88
Q

When is imaging used to aid the diagnosis of adenomyosis?

A

clinically suspected cases - can assist diagnosis

89
Q

What is the limit of using transvaginal ultrasound to diagnose adenomyosis?

A

highly observer dependent (but agreement on signs seen in adenomyosis)

90
Q

What signs are seen on transvaginal ultrasound in adenomyosis? 5 things

A
  1. globular uterine configuration
  2. poor definition of endometrial-myometrial interface
  3. myometrial anterior/posterior asymmetry
  4. intramyometrial cysts
  5. heterogeneous myometrial echo texture
91
Q

What can be seen on MRI in adenomyosis?

A

endo-myometrial junctional zone that can be distinguished from the endometrium and outer myometrium

irregular thickening of this zone = hallmark of adenomyosis

92
Q

What is the main aim in the management of adenomyosis?

A

control dysmenorrhoea and menorrhagia

93
Q

What is the only curative therapy for adenomyosis?

A

Hysterectomy

94
Q

What is the medical therapy available for treatment of adenomyosis?

A
  1. NSAIDs for analgesia
  2. Hormone therapy to reduce bleeding/cycle control
    • COCP
    • progestogens
    • GnRH-agonists,
    • aromatase inhibitors
95
Q

What are 4 types of hormone therapy that can be used to treat bleeding and for cycle control in adenomyosis?

A
  1. Combined oral contraceptives
  2. Progestogens (oral or intrauterine system e.g. Mirena)
  3. Gonadotropin-releasing hormone agonists
  4. Aromatase inhibitors
96
Q

How are hormone therapies thought to work to treat adenomyosis?

A

Proposed that they reduce proliferation of ectopic endometrial cells, therefore reducing their mass and decreasing uterine size and volume of blood loss

97
Q

Which 2 types of hormone therapy have been shown to temporarily induce regression of adenomysosi?

A
  1. Continuous COCP
  2. High dose progestins e.g. subcutaneous depot medroxyprogesterone
98
Q

What are 5 non-hormonal treatments in addition to hysterectomy that can be used to treat adenyomyosis?

A
  1. Uterine artery embolisation
  2. Endometrial ablation
  3. Endometrial resection
  4. Laparoscopic excision
  5. Magnetic resonance-guided focused ultrasound
99
Q

How does uterine artery embolisation work to treat adenomyosis?

A

blocks blood supply to adenomyosis, causing it to shrink

100
Q

What are cervical polyps?

A

benign growth protruding from the inner surface of the cervix, that develops as a result of focal hyperplasia of the columnar epithelium of the endocervix

101
Q

In what proportion of women are cervical polyps estimated to be present in women?

A

2-5%

102
Q

What are 3 suggested causes of cervical polyps?

A
  1. Chronic inflammation
  2. Abnormal response to oestrogen (cervical polyps associated with endometrial hyperplasia)
  3. Localised congestion of the cervical vasculature
  4. More common in multigravidae
103
Q

What is the histology of cervical polyps?

A

focal hyperplasia of columnar epithelium of endocervix (normal epithelial layer shown in image)

104
Q

What is the peak age of incidence of cervical polyps?

A

50-60 years of age

105
Q

What are the clinical features of cervical polyps? 4 things

A
  1. Usually asymptomatic - picked up via routine cervical screening
  2. Abnormal vaginal bleeding (menorrhagia, intermenstrual, post-coital, postmenopausal bleeding)
  3. Increased vaginal discharge
  4. Infertility - if large enough to block cervical canal
  5. Polypoid growths on speculum examination, projecting through the external os
106
Q

What are 7 differential diagnoses for cervical polyps?

A
  1. Cervical ectropion
  2. Cancer e.g. endometrial carcinoma
  3. Sexually transmitted infections
  4. Fibroids
  5. Endometritis
  6. Pregnancy-related bleeding
  7. Endometrial polyp - porjecting through cervical canal
107
Q

What is the most important thing to exclude on discovering a cervical polyp?

A

endometrial carcinoma

108
Q

What is the definitive diagnosis for a cervical polyp?

A

histological examination after removal

109
Q

What are 4 investigations for cervical polyps?

A
  1. Histological exam after removal
  2. Triple swabs
  3. Cervical smear
  4. USS to assess endometrial cavity - if persistent bleeding after removal
110
Q
A
111
Q

When would you perform triple swabs (endocervical and high vaginal) for a suspected cervical polyp?

A

suggestion of infection, such as purulent discharge

112
Q

Why is cervical smear performed in suspected cervical polyp? What issues can arise?

A

rule out cervical intraepithelial neoplasia (CIN)

sometimes polyp can prevent smear being taken, so smear should be repeated after polyp removal

113
Q

What occurs concurrently in a large proportion of women with cervical polyps and what proportion is this?

A

endometrial polyps - 27%

114
Q

In which age group is it particularly for cervical polyps to occur with endometrial polyps?

A

post-menopausal age group

115
Q

When should an ultrasound scan be performed in the case of a suspected cervical polyp?

A

if symptoms of bleeding persist after removal of the polyp

116
Q

What is the risk of malignant transformation of cervical polyps?

A

<0.5%

117
Q

What is the usual management of cervical polyps?

A
  • common to remove whenever identified, even if asymptomatic
    • if small - in primary care
    • if large - colposcopy clinic
  • then sent for histological examination
118
Q

Why are cervical polyps removed whenever identified, even if asymptomatic?

A

due to 0.5% risk of malignant transformation

119
Q

How are small cervical polyps removed?

A
  • in primary care
  • grasped with polypectomy forceps, twisted several times
  • polyp avulsed as pedicle becomes twisted
  • polyp should not be pulled of as will result in more bleeding
  • any bleeding can be cauterised with silver nitrite
120
Q

What is the management of larger polyps?

A

diathermy loop excision can be used in colposcopy clinic, or under general anaesthesia if base of polyp is broad

121
Q

What is the recurrence rate of cervical polyps?

A

6-12%

122
Q

What are three possible complications of cervical polyp removal?

A
  1. Infection
  2. Haemorrhage
  3. Uterine perforation (very rare)
123
Q

What is done to reduce the risk of uterine perforation from cervical polyp removal?

A

only polyps that are visible easily should be removed in outpatient setting - shouldn’t blindly attempt to remove from within cervical canal or that are intrauterine in this setting

124
Q

What is meant by the term cervical ectropion?

A

Occurs when there is eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu

Also known as cervical erosion - no erosion actually occurs

125
Q

What are 3 groups of women in whom cervical ectropion is commonly seen on examination?

A
  1. Adolescents
  2. Pregnancy
  3. Women taking oestrogen containing contraceptives
126
Q

What must be excluded before reassurance to patients with cervical ectropion is offered?

A

cervical cancer and cervical intraepithelial neoplasia (CIN)

127
Q

What is the anatomy of the cervix?

A
  • Composed of two regions: ectocervix and endocervical canal
  • Endocervical canal = more proximal, inner part of cervix
    • lined by mucus-secreting simple columnar epithelium
  • Ectocervix = part of cervix that projects into vagina
    • normally lined by stratified squamous non-keratinised epithelium
128
Q

What happens in terms of histology in cervical ectropion?

A
  • stratified squamous cells of the ectocervix undergo metaplastic change to become simple columnar epithelium (as in the endocervix)
129
Q

How do the histological changes that occur in cervical ectropion explain the symptoms which patients may experience?

A
  • Columnar epithelium, now present on ectocervix, contains mucus secreting glands, so some individuals experience increased increased vaginal discharge
  • Post-coital bleeding as fine blood vessels in epithleium easily broken during intercourse
130
Q

What is thought to cause cervical ectropion?

A

high levels of oestrogen

131
Q

What are 4 risk factors for cervical ectropion?

A
  1. use of COCP
  2. pregnancy
  3. adolescence
  4. menstruating age (uncommon post-menopause)
132
Q

What symptoms may be present in women with cervical ectropion?

A
  1. Post-coital bleeding
  2. Intermenstrual bleeding
  3. Excessive discharge (non-purulent, watery discarge)
133
Q

What can be seen on speculum examination in cervical ectropion?

A

everted columnar epithelium has reddish appearance, usually arranged in a ring around external os

134
Q

What are 4 differentials for cervical ectropion?

A
  1. Cervical cancer
  2. CIN
  3. Cervicitis (usually caused by infection)
  4. Pregnancy
135
Q

What is the purpose of investigations in cervical ectropion?

A

it is a clinical diagnosis of any investigations are to exclude potential diagnoses

136
Q

What are 4 investigations to consider for cervical ectropion?

A
  1. Pregnancy test
  2. Triple swabs- if suggestion of infection e.g. purulent discharge
  3. Cervical smear - rule out CIN
  4. Biopy if frank lesion observed
137
Q

What is the management of cervical ectropion? 4 aspects

A
  1. no treatment unless symptomatic
  2. first line: stop oestrogen-containing medications, most commonly COCP
  3. If doesn’t work: ablation of columnar epithlelium, using cryotherapy or electrocautery
  4. medication to acidify vaginal pH has been suggested such as boric acid pessaries
138
Q

What should you warn patients about who are going to undergo ablation (cryotherapy or electrocautery) for cervical ectropion?

A

it will result in significant vaginal discharge until healing completed

139
Q

How does endometrial cancer compare to other cancers in terms of prevalence in women?

A

it is the 4th most common affecting women in the UK, most common gynaecological cancer in the developed world

140
Q

What is the trend in incidence of endometral cancer and what is this attributed to?

A

risen by approximately 40% in the past 20 years; attributed to increase in obesity

141
Q

What is the peak age of endometrial cancer in the UK?

A

between 65 and 75 years

142
Q

What is the most common histological type of endometrial cancer?

A

adenocarcinoma - neoplasia of epithelial tissue that has glandular origin and/or glandular characteristics

143
Q

What causes most causes of adenocarcinoma in the case of endometrial cancer?

A

most caused by stimulation of the endometrium by oestrogen, without the protective effects of progesterone (termed ‘unopposed oestrogen’)

144
Q

What produces progesterone and how is this thought to be linked to development of endometrial adenocarcinoma?

A
  • progesterone is produced by the corpus luteum after ovulation
  • scenarios in which women have experiences a longer period of anovulation thought to predispose to developing malignancy
145
Q

What condition in addition to endometrial cancer can unopposed oestrogen lead to and how does this link to cancer?

A

endometrial hyperplasia; can predispose to atypia, a precancerous state

146
Q

What are 4 broad risk factors for endometrial cancer?

A
  1. prolonged anovulation
  2. age
  3. obesity
  4. hereditary factors
147
Q

What are 5 examples of states of prolonged anovulation that can predispose to endometrial cancer?

A
  1. early menarche and/or late menopause - at extremes of menstrual age, menstrual cycles more likely to be anovulatory
  2. low parity - 1/3 nulliparous.
  3. PCOS - oligomenorrhoea so cycles more likely to be anovulatory
  4. HRT with oestrogen alone
  5. Tamoxifen use
148
Q

What proportion of endometrial cancer cases are thought to be linked to obesity?

A

40%

149
Q

How is obesity thought to be linked to endometrial cancer?

A

greater the amount of subcutaneous fat, the faster the rate of peripheral aromatisation of andogrens to oestrogen - which increases unopposed oestrogen levels in post-menopausal women

150
Q

What is an example of a genetic condition that predisposs to endometrial cancer?

A

hereditary non-polyposis colorectal cancer (Lynch syndrome)

151
Q

What are 6 possible symptoms of endometrial cancer?

A
  1. Postmenopausal bleeding
  2. Clear or white vaginal discharge
  3. Abnormal cervical smears
  4. Irregular bleeding or intermenstrual bleeding (if pre-menopausal)
  5. Abdominal pain
  6. Weight loss
152
Q

What is the symptom that the majority of patients with endometrial cancer present with and what proportion of patients have this?

A

Postmenopausal bleeding: 75-90%

153
Q

What proportion of patinets with postmenopausal bleeding do not have endometrial cancer?

A

90%

154
Q

What are 4 things to look for on examination in endometrial cancer?

A
  1. Abdominal examination: abdominal or pelvic masses
  2. Speculum examination: evidence of vulval/ vaginal atrophy
  3. Speculum: cervical lesions
  4. Bimanual examination: assess size and axis or uterus prior to endometrial sampling
155
Q

What are 3 groups of differentials for post-menopausal bleeding that could point to endometrial cancer?

A
  1. Vulval causes: vulval atrophy, vulval pre-malignant or malignant conditions
  2. Cervical causes: cervical polyps, cervical cancer
  3. Endometrial causes: hyperplasia without malignancy, benign endometrial polyps, nedometrial atrophy
156
Q

What is the most widely used first-line investigation for endometrial cancer?

A

transvaginal ultrasound

157
Q

In what proportion of women with endometrial cancer will there be evidence on transvaginal ultrasound, and what evidence is this?

A

96%: endometrial thickness of >5mm

158
Q

What should prompt the next step in investigation for endometrial cancer from the transvaginal ultrasound?

A

If endometrial thickness is >4mm - endometrial biopsy should be obtained

159
Q

How can biopsy be performed in suspected endometrial cancer and what should be done following the biopsy?

A

Can be performed at an outpatient appointment, often with Pipelle biopsy

Histology can confirm presence of hyperplasia, with or without atypia, or malignancy

160
Q

When might hysteroscopy be performed to investigation potential endometrial cancer? 4 indications

A
  1. Heavy bleeding
  2. Multiple risk factors
  3. Very thickened endometrium
  4. Patient unable to tolerate outpatient sampling
161
Q

What are the 2 ways in which hysteroscopy with biopsy can be performed for potential endometrial cancer?

A
  1. Outpatient
  2. Under anaesthetic
162
Q

What action can be taken if the endometrium is <4mm on ultrasound and appears normal when investigating for endometrial cancer?

A
  • reasonable to defer endometrial sampling as risk of cancer low
  • however if continue to have abnormal bleeding sampling may be indiated
163
Q

Once endometrial malignancy is confirmed what is the next step in investigations?

A

MRI or CT scan for staging

164
Q

To summarise what are 5 investigations for endometrial cancer?

A
  1. Transvaginal ultrasound - first line
  2. Endometrial biopsy if endometrial thickness >4mm
  3. Hysteroscopy with biopsy if high risk
  4. MRI or CT for staging
  5. Baseline bloods prior to operative interventions (FBC, U+Es, LFTs, Group and Save)
165
Q

What is the most widely used staging system for endometrial cancer?

A

FIGO staging (International Federation of Obstetrics and Gynaecology)

166
Q

What is stage I of the FIGO endometrial cancer staging system?

A

carcinoma confined to within uterine body

167
Q

What is stage II of the FIGO endometrial cancer staging system?

A

carcinoma may extend to cervix but is not beyond uterus

168
Q

What is stage III of the FIGO endometrial cancer staging system?

A

carcinoma extends beyond uterus but is confined to pelvis

169
Q

What is stage IV of the FIGO endometrial cancer staging system?

A

carcinoma involves bladder or bowel, or has metastasised to distant sites

170
Q

What are 2 aspects of the management of endometrial hyperplasia, either simple complex, without atypia?

A
  1. Progestogens e.g. Mirena IUS
  2. Surveillance biopsies to identify progression to atypia or malignancy
171
Q

What is the management of atypical endometrial hyperplasia and why?

A
  • total abdominal hysterectomy + bilateral salpingo-oophorectomy
    • if contraindicated, regular surveillance biopsies
  • due to highest rate of progression to malignancy
172
Q

What is the management of stage I endometrial carcinoma?

A
  • Total hysterectomy and bilateral salpingo-oophorectomy.
  • Peritoneal washings should also be taken.
  • Traditionally, this has been performed as an open procedure, but laparoscopic surgery is increasingly performed.
173
Q

What proportion of women present with endometrial carcinoma at stage 1 and what is the prognosis?

A

75% present with stage I disease

very good 5 year survival rate of 90%

174
Q

What is the management of stage II endometrial carcinoma? 3 aspects

A
  • Radical hysterectomy (whereby vaginal tissue surrounding the cervix is also removed, alongside the supporting ligaments of the uterus),
  • Assessment and removal of pelvic lymph nodes (lymphadenectomy).
  • Women with confirmed carcinoma stage Ic or II may be offered adjuvant radiotherapy.
175
Q

What is the management of stage III endometrial carcinoma?

A
  • maximal de-bulking surgery (if possible)
  • additional chemotherapy usually given prior to radiotherapy
176
Q

What is the management of stage IV endometrial carcinoma?

A
  • Maximal de-bulking surgery (if possible)
  • In many stage IV patients, palliative approach preferred, e.g. low dose radiotherapy, or high dose oral progestogens.
177
Q

What follow up is required following surgery for endometrial carcinoma and why?

A

frequent follow up for 5 years post-operatively

recurrence of treated carcinoma is possible

OBG: Functional Gynaecology (7 decks)

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