Postmenopausal bleeding

Question 1

Definition

Answer 1

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

Question 2

Most common cause

Answer 2

1. Atrophy of the genital tract

Question 3

Causes

Answer 3

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

Question 4

History

Answer 4

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

Question 5

Examination

Answer 5

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

Question 6

Investigations

Answer 6

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

Question 7

What thickness should the endometrium be in post-enopausal

Answer 7

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

Question 8

Explaining investigations, and outcomes

Answer 8

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%

Question 9

Staging endoM Ca

Answer 9

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

Question 10

How is the spread of endometrial Ca determined

Answer 10

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

Question 11

Types of endometrial cancer

Answer 11

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

Question 12

Risk factors for endoM Ca

Answer 12

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

Question 13

Is COCP a risk or protective in endoM cancer

Answer 13

1. It is protective

Question 14

Risk factors for ovarian cancer

Answer 14

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

Question 15

Types of ovarian CA

Answer 15

1. Surface epithelial 
Serous (most common)
Mucinous
Endometroid
2. Germ cell (in young)
Teratoma
Choriocarcinoma
3. Sex cord stroma
4. Metaplastic from non-carcinoma

Question 16

When suspect ovarian ca, what needs to be excluded

Answer 16

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

Question 17

Investigations in ovarian Ca

Answer 17

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)

Question 18

Staging in ovarian Ca, survival, mx

Answer 18

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

Question 19

Risk of malignancy index

Answer 19

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

Question 20

Surgery for ovarian Ca

Answer 20

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

Question 21

Treatment options ovarian cancer

Answer 21

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