Heavy menstrual bleeding Flashcards
(177 cards)
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
2
Q
What proportion of women are thought to be affected by heavy menstrual bleeding?
A
3%
3
Q
Which age group of women with heavy menstrual bleeding are more likely to present to healthcare services?
A
40-51 years
4
Q
What is heavy menstrual bleeding not related to?
A
Pregnancy or post-menopausal bleeding - occurs during reproductive years only
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
6
Q
What 2 groups can the causes of heavy menstrual bleeding be classified into?
A
- Structural causes (PALM)
- Nonstructural causes (COEIN)
7
Q
What are 4 examples of structural causes of HMB?
A
- Polyp
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy and hyperplasia
8
Q
What are 5 nonstructural causes of heavy menstrual bleeding?
A
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
9
Q
What are 2 key risk factors for heavy menstrual bleeding?
A
- Age (more likely at menarche and approaching the menopause)
- Obesity
10
Q
What are the 3 key clinical features of HMB in the history?
A
- Bleeding during menstruation deemed to be excessive for the individual woman
- Fatigue
- Shortness of breath (if associated anaemia)
11
Q
What are 5 key things to focus on in the history in a woman with HMB?
A
- Menstrual cycle history
- Smear history
- Contraception
- Medical history
- Medications - including any taken to reduce menstrual bleeding
12
Q
What are 4 important things to ask as part of the menstrual cycle history?
A
- Frequency - average 28 days (24-38)
- Duration - average 5 days (4.5-8)
- Volume - average 40ml over course of menses. Flooding and clots
- Date of last menstrual period (LMP)
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
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
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
16
Q
What are 2 elements of the history that can indicate increased volume of bleeding during menses?
A
flooding, clots passed
17
Q
What are 4 parts that the examination of a patient should include for a patient with HMB?
A
- General observation
- Abdominal palpation
- Speculum
- Bimanual examination
18
Q
What are 9 things that may be present on examination in HMB?
A
- Pallor (anaemia)
- Palpable uterus - smooth or irregular? (fibroids)
- Pelvic mass
- Tender uterus
- Cervical excitation (adenomyosis/endometriosis)
- Inflamed cervix
- Cervical polyp
- Cervical tumour
- Vaginal tumour
19
Q
What are 9 key differentials for causes of HMB to remember?
A
- Pregnancy
- Endometrial or cervical polyps
- Adenomyosis
- Fibroids
- Malignancy or endometrial hyperplasia
- Coagulopathy (von Willebrand’s disease, anticoagulant use)
- Ovarian dysfunction - PCOS, hypothydoidism
- Iatrogenic causes e.g. contraceptive hormones, copper IUD
- Endometriosis
20
Q
What are 2 reasons that pregnancy could cause HMB?
A
- Ectopic pregnancy
- Miscarriage
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
22
Q
What type of malignancy can cause HMB?
A
vaginal or cervical malignancies, or ovarian tumours
23
Q
What is the most common coagulopathy to cause heavy menstrual bleeding?
A
von Willebrand’s disease
24
Q
What are 7 features in the history suggestive of von Willebrand’s disease/ coagulopathy causing HMB?
A
- HMB since menarche
- History of post-partum haemorrhage
- Surgical related bleeding or dental related bleeding
- Easy bruising
- Epistaxis
- Bleeding gums
- Family history of bleeding disorder
25
In addition to VWB what could be another cause of coagulopathy causing HMB to consider?
anticoagulant use e.g. warfarin
26
What are the 2 most common causes of ovarian dysfunction causing HMB?
1. Polycystic ovary syndrome
2. Hypothyroidism
27
What are 2 iatrogenic causes of HMB?
1. Contraceptive hormones
2. Copper IUD
28
What proportion of all heavy menstrual bleeding cases are caused by endometriosis?
\<5%
29
What are 3 broad groups of investigations that should be carried out for any cause of heavy menstrual bleeding?
1. Blood tests
2. Imaging
3. Histology and microbiology
30
What are 4 types of blood tests that should be performed for any cause of HMB?
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
31
At what point does anaemia tend to present from menstrual blood loss?
After menstrual blood loss of 120ml for each period
32
What type of imaging is most commonly used to investigate HMB and what can it show?
Ultrasound pelvis: transvaginal US most clinically useful, to assess endometrium and ovaries
33
When should imaging in the form of ultrasound pelvic transvaginally be considered for HMB? 2 situations
1. if uterus or pelvic mass plapable on examination
2. if pharmacological treatment has failed
34
What are 4 histological/microbiological tests that you may perform if a woman presents with HMB?
1. Cervical smear
2. High vaginal and endocervical swabs for infection
3. Pipelle endometrial biopsy
4. Hysteroscopy and endometrial biopsy
35
When should pipelle endometrial biopsy be performed? 3 indications
1. persistent intermenstrual bleeding
2. \>45 years old
3. failure of pharmacological treatment
36
When is hysteroscopy and endometrial biopsy performed to investigate HMB?
when ultrasound identifies pathology or is inconclusive
37
What 2 groups can the management of HMB be split into?
1. Pharmacological
2. Surgical
38
What is the three-tier approach to managing HMB pharmacologically, when there is no suspicion of pathology?
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
39
What is the action of LNG-IUS and how long is it licensed for?
* also acts as contraceptive; thins endometrium and can shrink fibroids
* licensed for 5 years treatment
40
What helps decide between tranexamic acid, mefanamic acid or COCP for the second tier of pharmacological management of non-pathological HMB?
depends on woman's wishes for fertility: tranexamic acid and mefanamic acid have no effect on fertility but COCP prevents conception
41
How is tranexamic acid taken for HMB?
taken only during menses to reduce bleeding; is anti-fibrinolytic so encourages clots to form to reduce flow
42
What is the added benefit of mefanamic acid when treating HMB?
is an NSAID so also offers analgesia for dysmenorrhoea
43
How is oral norethisterone (progesterone only) taken to treat HMB? What is the disadvantage of this?
taken day 5-26 of cycle - doesn't work as contraceptive when taken so other contraceptive methods should be applied
44
What are the 2 main surgical treatment options for heavy menstrual bleeding?
1. Endometrial ablation
2. Hysterectomy
45
What is endometrial ablation?
endometrial lining of uterus obliterated, can reduce HMB up to 80%
can be performed in outpatient setting with local anaesthetic
46
How does endometrial ablation affect ability to conceive?
suitable for women who no longer wish to conceive, but will need to continue using contraception
47
What is the only definitive treatment for HMB?
hysterectomy
48
What are the 2 types of hysterectomy and how do they differ?
* subtotal (partial) - removal of uterus but not cervix
* total - removal of cervix with uterus
ovaries not removed in either case (unless abnormal)
49
What are the 2 routes to perform a hysterectomy?
abdominal incision or through vagina
50
What are uterine fibroids (leiomyomata)?
benign smooth muscle tumours of the uterus arising from the myometrium of the uterus
51
What is the estimated incidence of fibroids in women?
20-40%
52
What is the risk of a fibroid becoming malignancy?
0.1%
53
What is the classification of fibroids based upon and what are the 3 classification groups?
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
54
What is believed to be the cause of fibroids?
Poorly understood; thought to be stimulated to grow by oestrogen
55
What is the most common type of fibroid?
Intramural
56
What are 5 risk factors for developing fibroids?
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
57
What are 5 clinical features of fibroids in the history?
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)
58
What are 2 reasons why fibroids might cause acute pelvic pain (which is rare with fibroids)?
1. May occur in pregnancy due to red degeneration, where rapidly growing fibroid undergoes necrosis and haemorrhage
2. Rarely, pedunculated fibroids can undergo torsion
59
What might be present on examination with fibroids?
Solid mass, enlarged uterus may be palpable on abdominal or bimanual examination
Uterus usually non-tender
60
What are 4 major differentials for uterine fibroids?
1. Endometrial polyp
2. Ovarian tumours
3. Leimoyosarcoma - malignancy of myometrium
4. Adenomyosis (endometrial tissue within myometrium)
61
What is the key investigation for suspected fibroids?
Imaging: pelvic ultrasound
Rarely MRI if sarcoma suspected
62
When might blood tests be performed in suspected fibroids?
reserved for patients when diagnosis unclear, or as pre-operative work-up if surgery indicated
63
What are the 2 groups of management of fibroids?
1. Medical
2. Surgical
64
What are 4 types of medical treatments for fibroids?
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
65
How do GnRH analogues such as Zoladex work to treat fibroids?
suppress ovulation, inducing a temporary menopausal state
66
Under what circumstances are GnRH analogues used to treat fibroids?
pre-operatively to reduce fibroid size and lower complications
67
For how long can GnRH analogues such as Zoladex be used and why?
6 months maximum due to risk of osteoporosis
68
What are 2 examples of selective progesterone receptor modulators used to treat fibroids?
1. Ulipristal
2. Esmya
69
How do selective progesterone receptor modulators work to treat fibroids and when are they used?
Reduce size of fibroid and reduce menorrhagia
Useful pre-operatively or as alternative to surgery
70
What are 4 surgical options for the management of fibroids?
1. Hysteroscopy and transcervical resection of fibroid (TCRF)
2. Myomectomy
3. Uterine Artery Embolisation (UAE)
4. Hysterectomy
71
What type of fibroids is hysteroscopy and trasncervical resection of fibroid (TCRF) particularly useful for?
submucosal fibroids
72
In which patients is myomectomy a useful option to treat fibroids?
woman who want to preserve uterus
73
Who performs uterine artery embolisation (UAE) as a treatment for fibroids and how?
radiologist via femoral artery
74
What are 2 common post-operative complications of uterine artery embolisation (UAE) to treat fibroids?
1. Pain
2. Fever
75
What is adenomyosis?
presence of functional endometrial tissue within the myometrium of the uterus
76
What is thought to cause adenomyosis?
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
What are 4 causes of uterine damage that may result in adenomyosis?
1. pregnancy and childbirth
2. caesarean section
3. uterine surgery (e.g. endometrial curettage)
4. surgical management of miscarriage or termination of pregnancy
78
In which part of the uterus is damage leading to adenomyosis most commonly found?
posterior wall of uterus
79
What can be seen in the damaged part of the uterus resulting in adenomyosis in hysteroscopy specimens?
Extent of invasion is variable, but in severe cases pockets of menstrual blood can be seen in myometrium
80
What can be seen pathologically in histological specimens in adenomyosis?
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
What are 4 risk factors for adenomyosis?
1. High parity
2. Uterine surgery e.g. any endometrial curettage, endometrial ablation
3. Previous caesarean section
4. Hereditary occurrence - potential genetic predisposition
82
What are 4 typical presenting symptoms of adenomyosis?
1. **Menorrhagia**
2. **Dysmenorrhoea**
3. Deep dyspareunia
4. Irregular bleeding
83
What is the typical nature of the dysmenorrhoea caused by adenomyosis?
Progressive, beginning as cyclical pain, but can worsen to daily pain
84
What may be found on examination in adenomyosis?
Symmetrical enlarged tender uterus may be palpable - abdominal and bimanual palpation
85
What are 6 differetials for adenomyosis based on the symptoms of dysmenorrhoea and menorrhagia?
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
What is the definitive diagnosis of adenomyosis?
histological diagnosis after hysterectomy; recently, sometimes specimens obtained at hysteroscopic biopsy can be used for histology
87
In addition to histology what 2 further forms of investigation can help in the diagnosis of adenomyosis?
1. Transvaginal ultrasound
2. MRI
88
When is imaging used to aid the diagnosis of adenomyosis?
clinically suspected cases - can assist diagnosis
89
What is the limit of using transvaginal ultrasound to diagnose adenomyosis?
highly observer dependent (but agreement on signs seen in adenomyosis)
90
What signs are seen on transvaginal ultrasound in adenomyosis? 5 things
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
What can be seen on MRI in adenomyosis?
endo-myometrial junctional zone that can be distinguished from the endometrium and outer myometrium
irregular thickening of this zone = hallmark of adenomyosis
92
What is the main aim in the management of adenomyosis?
control dysmenorrhoea and menorrhagia
93
What is the only curative therapy for adenomyosis?
Hysterectomy
94
What is the medical therapy available for treatment of adenomyosis?
1. NSAIDs for analgesia
2. Hormone therapy to reduce bleeding/cycle control
* COCP
* progestogens
* GnRH-agonists,
* aromatase inhibitors
95
What are 4 types of hormone therapy that can be used to treat bleeding and for cycle control in adenomyosis?
1. Combined oral contraceptives
2. Progestogens (oral or intrauterine system e.g. Mirena)
3. Gonadotropin-releasing hormone agonists
4. Aromatase inhibitors
96
How are hormone therapies thought to work to treat adenomyosis?
Proposed that they reduce proliferation of ectopic endometrial cells, therefore reducing their mass and decreasing uterine size and volume of blood loss
97
Which 2 types of hormone therapy have been shown to temporarily induce regression of adenomysosi?
1. Continuous COCP
2. High dose progestins e.g. subcutaneous depot medroxyprogesterone
98
What are 5 non-hormonal treatments in addition to hysterectomy that can be used to treat adenyomyosis?
1. Uterine artery embolisation
2. Endometrial ablation
3. Endometrial resection
4. Laparoscopic excision
5. Magnetic resonance-guided focused ultrasound
99
How does uterine artery embolisation work to treat adenomyosis?
blocks blood supply to adenomyosis, causing it to shrink
100
What are cervical polyps?
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
In what proportion of women are cervical polyps estimated to be present in women?
2-5%
102
What are 3 suggested causes of cervical polyps?
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
What is the histology of cervical polyps?
focal hyperplasia of columnar epithelium of endocervix (normal epithelial layer shown in image)
104
What is the peak age of incidence of cervical polyps?
50-60 years of age
105
What are the clinical features of cervical polyps? 4 things
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
What are 7 differential diagnoses for cervical polyps?
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
What is the most important thing to exclude on discovering a cervical polyp?
endometrial carcinoma
108
What is the definitive diagnosis for a cervical polyp?
histological examination after removal
109
What are 4 investigations for cervical polyps?
1. Histological exam after removal
2. Triple swabs
3. Cervical smear
4. USS to assess endometrial cavity - if persistent bleeding after removal
110
111
When would you perform triple swabs (endocervical and high vaginal) for a suspected cervical polyp?
suggestion of infection, such as purulent discharge
112
Why is cervical smear performed in suspected cervical polyp? What issues can arise?
rule out cervical intraepithelial neoplasia (CIN)
sometimes polyp can prevent smear being taken, so smear should be repeated after polyp removal
113
What occurs concurrently in a large proportion of women with cervical polyps and what proportion is this?
endometrial polyps - 27%
114
In which age group is it particularly for cervical polyps to occur with endometrial polyps?
post-menopausal age group
115
When should an ultrasound scan be performed in the case of a suspected cervical polyp?
if symptoms of bleeding persist after removal of the polyp
116
What is the risk of malignant transformation of cervical polyps?
\<0.5%
117
What is the usual management of cervical polyps?
* common to remove whenever identified, even if asymptomatic
* if small - in primary care
* if large - colposcopy clinic
* then sent for histological examination
118
Why are cervical polyps removed whenever identified, even if asymptomatic?
due to 0.5% risk of malignant transformation
119
How are small cervical polyps removed?
* 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
What is the management of larger polyps?
diathermy loop excision can be used in colposcopy clinic, or under general anaesthesia if base of polyp is broad
121
What is the recurrence rate of cervical polyps?
6-12%
122
What are three possible complications of cervical polyp removal?
1. Infection
2. Haemorrhage
3. Uterine perforation (very rare)
123
What is done to reduce the risk of uterine perforation from cervical polyp removal?
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
What is meant by the term cervical ectropion?
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
What are 3 groups of women in whom cervical ectropion is commonly seen on examination?
1. Adolescents
2. Pregnancy
3. Women taking oestrogen containing contraceptives
126
What must be excluded before reassurance to patients with cervical ectropion is offered?
cervical cancer and cervical intraepithelial neoplasia (CIN)
127
What is the anatomy of the cervix?
* 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
What happens in terms of histology in cervical ectropion?
* stratified squamous cells of the ectocervix undergo metaplastic change to become simple columnar epithelium (as in the endocervix)
129
How do the histological changes that occur in cervical ectropion explain the symptoms which patients may experience?
* 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
What is thought to cause cervical ectropion?
high levels of oestrogen
131
What are 4 risk factors for cervical ectropion?
1. use of COCP
2. pregnancy
3. adolescence
4. menstruating age (uncommon post-menopause)
132
What symptoms may be present in women with cervical ectropion?
1. Post-coital bleeding
2. Intermenstrual bleeding
3. Excessive discharge (non-purulent, watery discarge)
133
What can be seen on speculum examination in cervical ectropion?
everted columnar epithelium has reddish appearance, usually arranged in a ring around external os
134
What are 4 differentials for cervical ectropion?
1. Cervical cancer
2. CIN
3. Cervicitis (usually caused by infection)
4. Pregnancy
135
What is the purpose of investigations in cervical ectropion?
it is a clinical diagnosis of any investigations are to exclude potential diagnoses
136
What are 4 investigations to consider for cervical ectropion?
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
What is the management of cervical ectropion? 4 aspects
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
What should you warn patients about who are going to undergo ablation (cryotherapy or electrocautery) for cervical ectropion?
it will result in significant vaginal discharge until healing completed
139
How does endometrial cancer compare to other cancers in terms of prevalence in women?
it is the 4th most common affecting women in the UK, most common gynaecological cancer in the developed world
140
What is the trend in incidence of endometral cancer and what is this attributed to?
risen by approximately 40% in the past 20 years; attributed to increase in obesity
141
What is the peak age of endometrial cancer in the UK?
between 65 and 75 years
142
What is the most common histological type of endometrial cancer?
adenocarcinoma - neoplasia of epithelial tissue that has glandular origin and/or glandular characteristics
143
What causes most causes of adenocarcinoma in the case of endometrial cancer?
most caused by stimulation of the endometrium by oestrogen, without the protective effects of progesterone (termed 'unopposed oestrogen')
144
What produces progesterone and how is this thought to be linked to development of endometrial adenocarcinoma?
* 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
What condition in addition to endometrial cancer can unopposed oestrogen lead to and how does this link to cancer?
endometrial hyperplasia; can predispose to atypia, a precancerous state
146
What are 4 broad risk factors for endometrial cancer?
1. prolonged anovulation
2. age
3. obesity
4. hereditary factors
147
What are 5 examples of states of prolonged anovulation that can predispose to endometrial cancer?
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
What proportion of endometrial cancer cases are thought to be linked to obesity?
40%
149
How is obesity thought to be linked to endometrial cancer?
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
What is an example of a genetic condition that predisposs to endometrial cancer?
hereditary non-polyposis colorectal cancer (Lynch syndrome)
151
What are 6 possible symptoms of endometrial cancer?
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
What is the symptom that the majority of patients with endometrial cancer present with and what proportion of patients have this?
Postmenopausal bleeding: 75-90%
153
What proportion of patinets with postmenopausal bleeding do not have endometrial cancer?
90%
154
What are 4 things to look for on examination in endometrial cancer?
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
What are 3 groups of differentials for post-menopausal bleeding that could point to endometrial cancer?
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
What is the most widely used first-line investigation for endometrial cancer?
transvaginal ultrasound
157
In what proportion of women with endometrial cancer will there be evidence on transvaginal ultrasound, and what evidence is this?
96%: endometrial thickness of \>5mm
158
What should prompt the next step in investigation for endometrial cancer from the transvaginal ultrasound?
If endometrial thickness is \>4mm - endometrial biopsy should be obtained
159
How can biopsy be performed in suspected endometrial cancer and what should be done following the biopsy?
Can be performed at an outpatient appointment, often with Pipelle biopsy
**Histology** can confirm presence of hyperplasia, with or without atypia, or malignancy
160
When might hysteroscopy be performed to investigation potential endometrial cancer? 4 indications
1. Heavy bleeding
2. Multiple risk factors
3. Very thickened endometrium
4. Patient unable to tolerate outpatient sampling
161
What are the 2 ways in which hysteroscopy with biopsy can be performed for potential endometrial cancer?
1. Outpatient
2. Under anaesthetic
162
What action can be taken if the endometrium is \<4mm on ultrasound and appears normal when investigating for endometrial cancer?
* reasonable to defer endometrial sampling as risk of cancer low
* however if continue to have abnormal bleeding sampling may be indiated
163
Once endometrial malignancy is confirmed what is the next step in investigations?
MRI or CT scan for staging
164
To summarise what are 5 investigations for endometrial cancer?
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
What is the most widely used staging system for endometrial cancer?
FIGO staging (International Federation of Obstetrics and Gynaecology)
166
What is stage I of the FIGO endometrial cancer staging system?
carcinoma confined to within uterine body
167
What is stage II of the FIGO endometrial cancer staging system?
carcinoma may extend to cervix but is not beyond uterus
168
What is stage III of the FIGO endometrial cancer staging system?
carcinoma extends beyond uterus but is confined to pelvis
169
What is stage IV of the FIGO endometrial cancer staging system?
carcinoma involves bladder or bowel, or has metastasised to distant sites
170
What are 2 aspects of the management of endometrial hyperplasia, either simple complex, without atypia?
1. Progestogens e.g. Mirena IUS
2. Surveillance biopsies to identify progression to atypia or malignancy
171
What is the management of atypical endometrial hyperplasia and why?
* total abdominal hysterectomy + bilateral salpingo-oophorectomy
* if contraindicated, regular surveillance biopsies
* due to highest rate of progression to malignancy
172
What is the management of stage I endometrial carcinoma?
* 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
What proportion of women present with endometrial carcinoma at stage 1 and what is the prognosis?
75% present with stage I disease
very good 5 year survival rate of 90%
174
What is the management of stage II endometrial carcinoma? 3 aspects
* 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
What is the management of stage III endometrial carcinoma?
* maximal de-bulking surgery (if possible)
* additional chemotherapy usually given prior to radiotherapy
176
What is the management of stage IV endometrial carcinoma?
* 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
What follow up is required following surgery for endometrial carcinoma and why?
frequent follow up for 5 years post-operatively
recurrence of treated carcinoma is possible
