Postmenopausal bleeding Flashcards Preview

Obstetrics and Gynaecology > Postmenopausal bleeding > Flashcards

Flashcards in Postmenopausal bleeding Deck (21):
1

Definition

1. Vaginal bleeding following >12 months after the menopause.

2

Most common cause

1. Atrophy of the genital tract

3

Causes

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

History

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

Examination

1. Iron deficiency
2. Abdominal
Ascites
Mass
3. Genital tract
Vaginal
Bimanual

6

Investigations

1. USS, pap smear
2. D/C w/pipelle, Hysteroscopy
3. Endometrial biopsy
4. FBE, iron studies depending of duration/severity

If indicated
1. Vulval biopsy
2. Vervical cytology or colposcopy
3. Cystoscopy
4. Sigmoidoscopy
5. Estradiol

7

What thickness should the endometrium be in post-enopausal

1. Should be may not always require hysteroscopy, but generally still will do

8

Explaining investigations, and outcomes

1. Will need a hysteroscopy, examination under anaesthesia and biopsy.
2. Done in conjunction with the gynaecological oncologist
3. Staging is surgical
4. TAH/BSO performed through midline incision, peritoneal washings for cytology and selective LN sampling
5. Current treat,ent is usually surgery and radiotherapy
6. If confined to the inner half of uterus, TAH and BSO may be only required. Higher stages need radiotherapy.
7. If high risk->SCC and clear cell adenocarcinoma.
8. Survival 5 year
Stage 1: 90%
Stage 2: 70-85%
Stage 3: 50%
Stage 4: 10-30%

9

Staging endoM Ca

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

How is the spread of endometrial Ca determined

1. Spread in uterus
2. Degree of myometrial invasion
3. Presence of extrauterine spread

11

Types of endometrial cancer

1. Type 1
Most common
Associated with endometrial hyperplasi
2. Type 2
Poorly differentiated
Associated with endometrial atrophy
Aggressive, intraperitoneal and lymphatic spread

12

Risk factors for endoM Ca

1. Obesity
2. Diabetes
3. Nulliparous
4. Early menarche, late menopause
5. HTN
6. Liver disease
7. Age

13

Is COCP a risk or protective in endoM cancer

1. It is protective

14

Risk factors for ovarian cancer

1. Null parity
2. Gonadal dysgnesis
3. Family history
4. BRCA1, BRCA2
5. Infertility
6. Early menarche, late menopause
7. Smoking
8. Obesity
9. Age
10. Treatment with ovulation induction
11. Higher SES
12. HRT

15

Types of ovarian CA

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

When suspect ovarian ca, what needs to be excluded

1. Colonic Ca
2. Gastric Ca
3. Breast Cancer
4. Cervical cancer

17

Investigations in ovarian Ca

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

Staging in ovarian Ca, survival, mx

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

Risk of malignancy index

1. Cysts are common
2. Need to distinguish
3. 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

Surgery for ovarian Ca

1. Midline laparotomy
2. Peritoneal washings
3. TAH/BSO
4. Biopsy any suspicious areas
5. If mucinous->appendectomy

21

Treatment options ovarian cancer

Treatment-->Chemotherapy
1. Adjuvant chemo from
stage 1c > Neoadjuvant to acheive
debulking then interval cytoreductive surgery
followed by adjuvant chemo
Paclitaxel + Carboplatin