Postmenopausal bleeding Flashcards
1
Q
Definition
A
- Vaginal bleeding following >12 months after the menopause.
2
Q
Most common cause
A
- Atrophy of the genital tract
3
Q
Causes
A
1. Ovary Carcinoma Estrogen secreting tumor 2. Uterine body Submucous fibroid Atrophy of endometrium Polyp Hyperplasia->simple, atypical Ca 3. Cervix Atrophy Malignancy->SCC, adenoCa 4. Vagina Atrophy 5. Urethra Urethral caruncle (prolapse of urethral mucosa) Hematuria 6. Vulva Vulvitis Dystrophies Malignancy
4
Q
History
A
1. Amount of bleeding Atrophy->small 2. Vaginal dryness, soreness, superficial dysparaneunia 3. Pruritis, lump 4. Profuse? Discharge 5. Family history 6. Drug history, HRT 7. Pap smear 8. Complete obstetric and gynaecological history
5
Q
Examination
A
- Iron deficiency
- Abdominal
Ascites
Mass - Genital tract
Vaginal
Bimanual
6
Q
Investigations
A
- USS, pap smear
- D/C w/pipelle, Hysteroscopy
- Endometrial biopsy
- FBE, iron studies depending of duration/severity
If indicated
- Vulval biopsy
- Vervical cytology or colposcopy
- Cystoscopy
- Sigmoidoscopy
- Estradiol
7
Q
What thickness should the endometrium be in post-enopausal
A
- Should be may not always require hysteroscopy, but generally still will do
8
Q
Explaining investigations, and outcomes
A
- Will need a hysteroscopy, examination under anaesthesia and biopsy.
- Done in conjunction with the gynaecological oncologist
- Staging is surgical
- TAH/BSO performed through midline incision, peritoneal washings for cytology and selective LN sampling
- Current treat,ent is usually surgery and radiotherapy
- If confined to the inner half of uterus, TAH and BSO may be only required. Higher stages need radiotherapy.
- If high risk->SCC and clear cell adenocarcinoma.
- Survival 5 year
Stage 1: 90%
Stage 2: 70-85%
Stage 3: 50%
Stage 4: 10-30%
9
Q
Staging endoM Ca
A
1. Stage 1: in body of uterus Endometrium Upper 1/2 Lower 1/2 2. Stage 2: To the cervix 3. Stage 3: Beyond uterus, still in pelvis 4. Stage 4: more distant spread
10
Q
How is the spread of endometrial Ca determined
A
- Spread in uterus
- Degree of myometrial invasion
- Presence of extrauterine spread
11
Q
Types of endometrial cancer
A
1. Type 1 Most common Associated with endometrial hyperplasi 2. Type 2 Poorly differentiated Associated with endometrial atrophy Aggressive, intraperitoneal and lymphatic spread
12
Q
Risk factors for endoM Ca
A
- Obesity
- Diabetes
- Nulliparous
- Early menarche, late menopause
- HTN
- Liver disease
- Age
13
Q
Is COCP a risk or protective in endoM cancer
A
- It is protective
14
Q
Risk factors for ovarian cancer
A
- Null parity
- Gonadal dysgnesis
- Family history
- BRCA1, BRCA2
- Infertility
- Early menarche, late menopause
- Smoking
- Obesity
- Age
- Treatment with ovulation induction
- Higher SES
- HRT
15
Q
Types of ovarian CA
A
1. Surface epithelial Serous (most common) Mucinous Endometroid 2. Germ cell (in young) Teratoma Choriocarcinoma 3. Sex cord stroma 4. Metaplastic from non-carcinoma
16
Q
When suspect ovarian ca, what needs to be excluded
A
- Colonic Ca
- Gastric Ca
- Breast Cancer
- Cervical cancer
17
Q
Investigations in ovarian Ca
A
1. Pelvic USS Multilocular cysts Solid areas Metastases Ascites Bilateral 2. Ca125 3. AFP, bHCG, CA125 in younger suspected of germ cell 4. CT chest/abdo/pelvis
Ultrasound--> multilocular cyst solid areas bilateral lesions ascites intra-abdominal metastases 0= none 1= one abnormality 3= two or more abnormalities Premenopausal =1 Postmenopausal=3/4(RMI2)
18
Q
Staging in ovarian Ca, survival, mx
A
1. Limited to ovaries 80% 5 year survival Surgery 2. Peritoneal deposits in pelvis 60% 5 year survival Surgery then chemotherapy 3. Peritoneal deposits outside pelvis 25% 5 year survival Surgery then chemotherapy 4. Distant metastases 5-10% 5 year survival Surgery for palliation only
19
Q
Risk of malignancy index
A
- Cysts are common
- Need to distinguish
- Looks at USS findings and CA125 to give risk score, if >250 should refer to specialist
RMI¼U x M x CA125 • U¼Ultrasound score • 1 point for each of the following: multilocular cysts, solid areas, metastases, ascites and bilateral lesions • U¼1 If ultrasound score is 0-1 • U¼3 If ultrasound score is 2-5 • M¼Menopausal status • Pre-menopausal¼1 • Post-menopausal¼3 • CA125¼Serum CA125 level
20
Q
Surgery for ovarian Ca
A
- Midline laparotomy
- Peritoneal washings
- TAH/BSO
- Biopsy any suspicious areas
- If mucinous->appendectomy
21
Q
Treatment options ovarian cancer
A
Treatment-->Chemotherapy 1. Adjuvant chemo from stage 1c > Neoadjuvant to acheive debulking then interval cytoreductive surgery followed by adjuvant chemo Paclitaxel + Carboplatin