Post-menopausal bleeding Flashcards
Definition of post-menopausal bleeding
vaginal bleeding >12 months after last menstrual period
Causes of post-menopausal bleeding
Neoplastic
Endo/Cervical cancer (20%, must exclude)
Endometrial hyperplasia +- cytological atypia + polyps
Cervical polyps
Ovarian Carcinoma
Non-neoplastic
Cervicitis
Atrophic vaginitis - dx of exclusion
Initial management of PMB?
Most important to exclude malignancy so always do a scan!
Initial:
Bimanual + speculum + smear
Transvaginal US - >5mm endometrial layer is threshold
<5mm = <1% chance of endo cancer
If scan results show >5mm endometrial layer or clinically you have other reason to be suspicious, refer for hysteroscopy
How does the TVUS scan affect our further management?
If scan results show >5mm endometrial layer or clinically you have other reason to be suspicious, refer for BIOPSY + HYSTEROSCOPY
If no signs of malignancy, and nothing on the smears, Rx atrophic vaginitis with topical oestrogen
Endometrial Carcinoma
Briefly describe the pathology
Adenocarcinoma - 95%
Premalignant disease - endometrial hyperplasia with atypia
Most common genital tract malignancy, peak age is 60 years.
Caused most commonly from UNOPPOSED oestrogen (by progesterone)
Endometrial Carcinoma
Risk factors and protective factors
Endo Oestrogen:
PCOS, Obesity
Nulliparity, late menopause
Oestrogen-secreting tumours
Exo Oestrogen:
Unopposed oestrogen treatment,
Tamoxifen
Also indicated (misc):
T2DM
Lynch syndrome
Protective factors:
Pregnancy, combined pill
Endometrial Cancers
Except for PMB, what other clinical features might there be? If the onset is pre-menopausal, what signs and symptoms should you watch out for?
Pre-menstrual
irregular bleeding, IMB, recent onset menorrhagia
Examination is often normal
Endometrial Cancer
Where is it most likely to spread?
Pulmonary
Endometrial Cancer
Treatment?
Surgical
• Total hysterectomy + bilateral salpingo-oophrectomy (BSO) – laparatomy/laparoscopy
Radio
if high risk of lymph node involvement (stage 2/3?)
Overall, 75% 5 year survival
Ovarian Cancer
Briefly go over the pathology
Most common cause of gynae cancer death
Risk relates to number of ovulations in Pts life. Less ovulations = ↑ risk of ovarian cancer
Ovarian Cancer
Risk factors?
↓Ovulations
Early menarche, late menopause, nulliparity
Others: Family history BRCA1, BRCA2, Lynch HRT > 5 years Endometriosis history
Protective factors
Early menopause, OCP, pregnancy and lactation. All stop ovulation.
Ovarian Cancer
Signs and symptoms
Early stage: asymptomatic
Stage 3-4: present late - already have mets
Refer ascites + mass immediately
Bloating, loss of appetite, pelvic pain, PMB
Weight loss, fatigue
Urinary and bowel symptoms - urgency, frequency, change in bowel habit
Age >50, IBS
Ovarian Cancer
Screening?
Not usually offered, however can be done if there is a family history of ovarian cancer orBRCA1 and BRCA2
Genetic testing
Yearly Ca125/TVUS
Can also get prophylactic salpingo-oophrectomy
Ovarian Cancer
Investigations?
CA-125
If raised (35IU/ml), arrange pelvic and abdominal ultrasound scans.
If scan is suggestive of ovarian cancer, refer immediately
Diagnosis is made by laparotomy
Ovarian Cancer
Treatment?
o TAH (total abdominal hysterectomy), BSO (bilateral salpingo-oophrectomy) & partial omentectomy o LN biopsy/removal o Biopsies of peritoneal deposits & random peritoneal biopsies
Oophrectomy alone - young women with borderline disease wanting to maintain fertility
Chemo
stage 1c or greater tumours
Radio
Only in dysgerminomas
