JC107 (O&G) - Abnormal vaginal bleeding

Question 1

Ddx benign causes of abnormal vaginal bleeding

Answer 1

Ovaries: Anovulation

Uterus:
 Fibroid, endometrial polyps
 Pregnancy-related
 Hyperplasia
 Dysfunctional uterine bleeding

Cervix:
 Cervical erosion
 Cervical polyp

Vagina:
 Atrophic vaginitis
 Lacerations

Question 2

Ddx malignant causes of abnormal vaginal bleeding

Answer 2

Any part of female genital tract can give rise to malignancy
Must-not miss/ common:
- CA endometrium/ corpus uteri
- CA cervix

Ovarian cancer does not present with bleeding

Question 3

Risk factors of cervical cancer

Answer 3

 Human papillomavirus (HPV)

 Early sex (early exposure to HPV; requires 10 years to progress to cancer)

 Multiple partners (sexual promiscuity)

 Smoking (lowered immunity)

 Lower social-economic class

 OC pills

 Immunosuppression (e.g. SLE)

Question 4

Risk factors of corpus cancer

Answer 4

Postmenopausal women

Excessive endogenous oestrogens

Exogenous oestrogen: Unopposed oestrogen therapy, Tamoxifen therapy (breast cancer)

Others:
 Family history of breast, ovarian and colorectal cancer
 Family/ personal history of Lynch syndrome (lifetime risk 15-60%)
 Diabetes mellitus
 Hypertension

Question 5

Causes of excessive endogenous estrogen

Answer 5

 Early menarche
 Late menopause
 Nulliparity
 Obesity
 Polycystic ovarian syndrome
 Oestrogen secreting tumours (ovarian granulosa cell tumours)
 Endometrial hyperplasia

Question 6

Outline history taking questions for abnormal vaginal bleeding

Answer 6

Age of the patient:

Bleeding pattern/ menstrual history:
 Age of menarche or menopause
 Regular/ irregular bleeding
 Amount
 Intermenstrual bleeding, Postcoital bleeding

Provoking factors
 Trauma (vaginal laceration)
 Stress (hypothalamic amenorrhea)

Associated symptoms
 Abdominal pain, Urinary/ bowel symptoms (infection, genital mass)
 Visual field defect, headache, diplopia (Pituitary causes)
 Symptoms of hypothyroidism, Hyperprolactinemia

Medical/ surgical history
 Include drug history: Anticoagulation, HRT, Tamoxifen, COCP

Contraceptive/ sexual history, cervical smears

Obstetric history: Parous or Nulliparous
Social history
Family history: FHx of Ca ovary/ breast/ colon etc

Question 7

Compare cervical cancer and corpus cancer

• Age of onset
• Bleeding pattern

Answer 7

Cervical: Median age 54
- Post-coital bleeding

Corpus: Median age 55, associated with long estrogen exposure (early menarche, late menopause)

• Change in menstrual pattern
• Prolonged bleeding
• Intermenstrual bleeding
• Post-menopausal bleeding

Question 8

Cervical cancer risk factros

Answer 8

HPV infection 
Early sex, unprotected sex, multiple sex partners
Smoking 
Lower socioeconomic class 
OC pills 
Immunosuppression

Question 9

Corpus cancer risk factors

Answer 9

Corpus cancer:

1. High endogenous estrogen: PCOS, Nulliparity, Early menarche, Late menopause, Estrogen-secreting tumors
2. High exogenous estrogen: E-only HRT, Tamoxifen
3. Others: DM, HTN, Family history of breast/ovarian/CRC, Lynch syndrome

Question 10

Outline P/E for abnormal vaginal bleeding (not exams for primary amenorrhea)

Answer 10

General examination:
 Pallor (heavy menstrual bleeding)
 Bleeding tendency
 Constitutional signs

Abdominal examination:
 Inspection: distention/ scars/ signs of pregnancy? (linea nigra, fetal movement)
 Palpation: mass? Tenderness? peritoneal signs
 Percussion: ascites?
 Auscultation: fetal heart?
 Rectal examination (endometriosis - nodularity in Pouch of Douglas)

Pelvic examination:
 Inspection: any abnormality on vulva?
 Speculum examination: lesion in vagina/ cervix?
 Bimanual examination: uterine size, position, adnexal masses

Question 11

First-line investigations for abnormal vaginal bleeding

Answer 11

Pregnancy - urine or serum hCG

Infection: Endocervical, high vaginal, low vaginal swabs

Cervix: Cervical smear +/- colposcopy or cervical biopsy

Uterus: Hysteroscopy + Endometrial aspirate with samplers (e.g. Pipelle)

Ultrasound:

• Transvaginal USG for post-menopausal bleeding
• Transabdominal USG (E.g. endometrial polyp in uterine cavity)

For plan of management:
 Blood test: CBP, RFT, LFT
 Tumour markers
 Female hormone profile (+ thyroid, prolactin)
 Imaging: CT/ MRI/ PET-CT to assess renal tract/ extent of spread/ lymph node involvement

Question 12

Cervical cancer invasion/ metastasis patterns

Answer 12

Local:
 Laterally to parametrium
 Downward to vagina
 Anteriorly to bladder
 Posteriorly to rectum/ pouch of Douglas/ sacrum

Distal (lymphatic chains):

• Paracervical»obturator»external iliac»common iliac»aortic
• Sacral»internal iliac» common iliac»aortic

Question 13

Corpus cancer invasion. metastasis patterns

Answer 13

Local: vaginal, cervical spread

Lymphatics:
 Internal iliac»para-aortic
 Lateral pelvic

Metastasis:
 Tubal
 Ovarian
 Vaginal

Question 14

Clinical staging system for cervical cancer

Answer 14

FIGO staging

Stage I - Confined to cervix

Stage II - Invades beyond uterus, limited to upper vagina/ surrounding structure (parametrium)

Stage III:

• Involves lower third of vagina and/or extends to pelvic wall
• causes hydronephrosis or non-functioning kidney
• involves pelvic and/or para-aortic lymph nodes

Stage IV: Extends beyond true pelvis, involved (biopsy proven) mucosa of bladder or rectum (i.e. distant metastasis)

Question 15

Clinical staging system for corpus/ endometrial cancer

Answer 15

FIGO staging

Stage I - Tumour confined to uterus

Stage II - Tumour invades cervical stroma, but does not extend beyond the uterus

Stage III - Local and/or regional spread of tumour (i.e. outside uterus)

Stage IV - Tumour invades bladder and/or bowel (rectum) mucosa, and/or distant metastases

Question 16

Treatment options for early and late stages of cervical cancer

Answer 16

early disease (e.g. stage 1):

• cone/ simple hysterectomy (retain fertility)
• Wertheim’s hysterectomy (radical hysterectomy + pelvic lymphadenectomy): upper vagine, uterus, parametria, pelvic LN removal
• Radiotherapy (contraindicated against surgery)

late disease (stage 2 or above): Combination treatment

• Radiotherapy + chemotherapy
• Targeted therapy/ immunotherapy - Bevacizumab

Question 17

Advantages of cone hysterectomy and wertheim’s hysterectomy for early cervical cancer

Answer 17

 Preserve ovarian function (premenopausal women) - less osteoporosis, CVD…

 Avoid long-term morbidities of radiotherapy (e.g. bowel, bladder, vaginal stenosis)

Question 18

Corpus cancer Treatment options

Answer 18

Surgical:

• Abdominal/ laparoscopic Total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO)
• +/- pelvic lymphadenectomy

Radiotherapy + chemotherapy for high risk histological types and LN metastasis:
- Compulsory chemotherapy + External RT
- Brachytherapy +/- chemotherapy