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Obstetrics and Gynaecology > Tutorial 19: Post-menopausal Bleeding and Endometrial Cancer > Flashcards

Tutorial 19: Post-menopausal Bleeding and Endometrial Cancer Flashcards

1
Q

What are some important facts surrounding menopause?

A
  • Natural end of menstruation and fertility
  • Defined as 12 months after last menstrual period
  • Mean age 51-53yo
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2
Q

What are some perimenopausal symptoms?

A
  • irregular periods
  • vaginal dryness
  • hot flushes
  • night sweats
  • sleep disturbances
  • mood change
  • weight gain
  • loss of breast fullness
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3
Q

What is the definition and incidence of post-menopausal bleeding?

A
  • Defined as uterine bleeding occurring after at least 1 year of amenorrhoea
  • 10% after 1 year of menopause
  • Patients with post-menopausal bleeding have a 10-15% chance of having endometrial carcinoma
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4
Q

What things would you ask when taking the history of a woman with post-menopausal bleeding?

A

Bleeding:

  • Persistent, recurrent or heavy bleeding (EC)
  • Post-coital bleeding (cervical)

Other symptoms

  • Vaginal or vulval irritation
  • Vaginal discharge
  • Ring pessary
  • Abdo/urinary sx

Medications

  • Hormones
  • Anti-coagulant

Risk factors of malignancy

  • Early menarche <10yo
  • Late menopause >55yo
  • Nullliparity
  • Unopposed oestrogen therapy
  • Obesity/diabetes mellitus Screening
  • Smear and mammography FHx
  • Breast, HPNCC, EC
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5
Q

What would you include in your examination of a woman with post-menopausal bleeding?

A
  1. General: Weight loss, Signs of anaemia or severe blood loss
  2. Blood pressure
  3. Abdominal exam
  4. Pelvic exam
    • Visualise cervix and vagina
    • Bimanual exam (uterine mass, adnexal mass)
  5. Smear/swabs
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6
Q

What is a differential for Post-menopausal bleeding?

A
  1. Vulva
    1. Benign: Trauma, dermatitis, dystrophy
    2. Pre-/Malignant: carcinoma
  2. Vagina
    1. Benign: Atrophic vaginitis, trauma, inflammation
    2. Pre-/Malignant: carcinoma
  3. Cervix
    1. Benign: Polyps, atrophic changes, trauma, inflammation
    2. Pre-/Malignant: carcinoma, adenocarcinoma
  4. Uterus
    1. Benign: polyps, endometritis
    2. Pre-/Malignant: Hyperplasia, adenocarcinoma
  5. Fallopian tube
    1. Benign: PID
    2. Pre-/Malignant: carcinoma
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7
Q

What investigations would you perform on a lady with post-menopausal bleeding?

A
  • Bloods: CBC and iron, renal function
  • MSU
  • Ultrasound
  • Endometrial lesions
  1. Transvaginal ultrasound
  2. Endometrial sampling (Pipelle)
  3. Hysteroscopy and endometrial biopsy
  • Smear and Swabs
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8
Q

What are the guidelines surrounding endometrial thickening?

A

PMB –> TVUS + ET

Reassurance if:

  • <3mm postmenopausal/normal
  • <5mm with HRT
  • <15mm pre-menopausal with normal period

Sampling required: (outpatient pipelle or Hysteroscopy & D&C)

  • ET >4mm or
  • recurrent bleeding

Follow up required:

  • ET <4mm unless multiple risk factors
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9
Q

What are the advantages and disadvantages of the investigations used for endometrial lesions/thickeness?

A
  1. Pipelle:
    1. Adv: less pain, quick, cost-effective, well tolerated
    2. Disadv: Insufficient sample, fail to detect lesion (i.e. false negative rate 5-15%)
  2. Endometrial Biopsy:
    1. Adv: relatively safe
    2. Disadv:False negative 10% for fibroid and polyp, less than 1/2 uterine cavity sampled, inpatient, infection, bleeding and uterine perforation
  3. Hysteroscopy (+biopsy^)
    1. Adv: visual directed biopsy, good with focal lesions
    2. Disadv: requires biopsy, outpatient, risk of bleed, infection and uterine perforation
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10
Q

What is the difference between endometrial hyperplasia and endometrial cancer?

A

Exogenous or endogenous unopposed oestrogens are primarily implicated in the pathogenesis of hyperplasia

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11
Q

What are the treatment options for endometrial hyperplasia?

A
  • Progesterone PO
  • Mirena
  • Hysterectomy + bilateral salphingo-oophorectomy
  • Assessment of cytological charcteristics for risk of future malignancy
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12
Q

How are the cytological charcteristics of the endometrial biopsy used to calculate risk of future malignancy?

A

Simple:

  • No atypia: 1%
  • Atypia: 8%

Complex:

  • No atypia: 10-15%
  • Atypia: 20-30%
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13
Q

What are some features of endometrial cancer?

A
  • Common gynaecological cancer: present in up to 80% of post-menopausal women
    • Post-menopausal women has 1/1000 risk of EC per year in USA
    • <5% diagnosed under 40yo
  • No effective screening programme
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14
Q

What is a common presentation of endometrial cancer?

A
  • Post-menopausal bleeding (PMB)
  • Frequent, irregular bleeding in perimenopause
  • Irregular vaginal bleeding before menopause
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15
Q

What is the incidence of endometrial cancer in New Zealand woman?

A
  • 5% of female malignancy
  • EC is 6th highest incidence and 12th highest mortality among cancers in females in 1990s.
  • Incidence = 15 per 100,000 in 1996
  • Mortality = 4 per 100,000 in 1997
  • Māori experienced higher risk
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16
Q

What are some risk factors for endometrial cancer?

A
  • Obesity
  • Diabetes mellitus
  • Nulliparity
  • Late menopause
  • Tamoxifen
  • PCOS
  • Oestrogen secreting tumours
  • Smoking
  • Familial breast/colon/ovary cancer
17
Q

What are some infications for further investigations?

A
  • Abnormal scans
  • Irregular bleeding on tamoxifen
  • Recurrent bleeding
  • Patient concerns + benefit-risk balance
18
Q

What are the most common histological subtypes of endometrial cancer following endometrial biopsy?

A
  • 85% adenocarcinoma
  • 4% adnosquamous
  • 4% squamous carcinoma
  • 3% clear cell carcinoma
19
Q

How do you grade endometrial cancer?

A

Endometrial cancer is graded by its degree of differentiation

  • Grade 1: well differentiated - 92% 5year s.r.
  • Grade 2: moderately differentiated - 90% 5year s.r.
  • Grade 3: poorly differenitated - 81% 5year s.r.
20
Q

How do you stage endometrial cancer?

A

Staging = extent of growth

vs grading: degree of differentiation

  • Stage 1: confined to (the uterus).
    • A: inner half of the uterus
    • B: growth into the outer half of the uterus
      • 90% 5year surivival rate
  • Stage 2: growth extended to the cervix
    • 55% 5 year survival rate
  • Stage 3: Growth extended to:
    • A: serosa/adnexa
    • B: vagina
    • C: pelvic or paraaortic lymph nodes
      • 45% 5year survival rate
  • Stage 4: Growth invaded:
    • A: rectum or bladder
    • B: structures beyond the pelvis
      • 5% 5 year survival rate
21
Q

What is the treatment of endometrial cancer?

A
  • Total abdominal hysterectomy and bilateral salpingo-oophorectomy (BSO)
  • Pelvic and para-aortic lymph nodes removal
  • Radiotherapy (adjunct or palliative)
    • Limited roles of chemotherapy and progesterone
22
Q

What is the prognosis of endometrial cancer dependant on?

A

Prognosis = grading + staging

High risk of spread if

  • Higher grade = poorer prognancy
  • Clear cell or serous papillary carcinoma

“Better prognostic profile” than ovarian and cervical malignancy

23
Q

What are the take home messages regarding endometrial cancer?

A
  • Exclude malignancy in PMB
  • USS+biopsy are investigations of choice
  • Easily dx and rx = good prognosis
  • Be aware of high risk patients i.e.
    • women with syndrome x developing enodmetrial hyperplasia and malignancy
24
Q

Which patients are at high risk fo developing endometrial cancer?

A

Syndrome X

High BMI

  • be aware of these high risk patients!!

Obstetrics and Gynaecology (20 decks)

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