Post menopausal bleeding-Endometrial Ca

History

Duration after manapause

Duration, amount of bleed, pain

Menapause – stormy/ gradual

Perimenopausal bleeding – Intermenstrual/ HMB/ irregular bleed

Hx of amenorrhoea/ Hx of PCOS

HRT

Vaginal discharge – offensive/ blood

Dry vagina, Dyspareunia, Burning sensation

Post coital bleeding

Risk of endometrial Ca - DM, HTN, Obesity, Nulliparity, Early menarche, Late menapase, OOestrogen
replacement, Endometrial hyperplasia, PCOS, Tamoxifen, Ca breast, FHx, Ovarian tumor, colonic tumor,
Pelvic irradiation, Gout, Depression, Gallbladder Dx.

Risk of cervical Ca – Early marriage, Sexual promiscuity, Increased parity, Young intercourse, Low
socioeconomic status, Smoking, Long term OCP

Cervical Ca screening

Utero vaginal prolapse

Foreign bodies – IUCD, pessary

Trauma

Bleeding Dx, Liver pathology, Anticoagulant drugs

Ix, Tx

Examination

Abdominal Ex – NL (anal changes)

Speculum, Detect

- Atrophic changes/ Senile vagina, cervix-reddish, punctate appearance

- Cervical polyps
- Cervical Ca
- IUCD threads
Bimanual Ex

01. Endometrial Ca – Uterine size atrophied or slightly enlarged

02. UV prolapse + Decubitus ulcer (exclude)
03. Cervical Ca – VE, PR, to determine spread to the parametrium

Investigations

- UFR
- FBC, blood picture
- Fitness for Sx
01. 1st step – TVS to exclude
a) Endometrial polyp
b) Endometrial hyperplasia
c) Endometrial Ca
d) Sub mucous fibroid
e) Pyometron
f) Retained IUCD
g) Hormone secreting ovarian tumor
02. Cervical smear
- If no visible lesion – Cytology, Colposcopy and Biopsy
- If there is visible lesion – Wedge biopsy

01.Biopsy

02. EUA

03. D&C

04. Staging - MRI

DDs

*Surface lesions

a) Cervical polyps
b) Cervical Ca
c) Endometrial Ca
d) Endometrial polyp
e) Senile vaginitis
f) Senile endometritis
g) Irregular use of HRT
h) Foreign bodies- IUCD, Pessary
i) Ovarian granulosa cell tumors
j) Bleeding Dx, Anticoagulants
k) Genital tract trauma
l) Decubitus ulcer
 Endometrial Ca
Endometrial thickness on TVS

<4mm >4mm (<10mm)

No endometrial lesion if bleeding stop Hysteroscopy and Biopsy

- Post menopause - malignant risk- thin endometrium

KUO - If malignant risk -- pipelle

Repeat scan in 3 months - No D&C can miss lesion

Diagnose endometrial Ca type, grade

Histological Ex

Diagnose Endometrial Ca

MRI

01. Extent of myometrial inversion

02. Spread to pelvic LN
-prior to Sx
MRI -myometrial invasion, LN +ve
L

Management options
*Surgery – Rx of choice
1a <50%
Stage 1 - Confined to corpus uteri
1b >50%

01. Low risk

Stage 1a - G1,G2 endometrial tumor

-TAH + BSO
-Peritoneal washing
-LN palpated
-Sample suspicious nodes
02. Intermediate – 1a G3, 1B G1,G2

03. Higher risk – Stage 1B G3 and above all non endometroid

Found on Suergery

Histopath Ex

Adjuvent radiotherapy – oncologist

04.TAH + BSO + Para-aortic LN + Peritoneal washing for cytology

Tx stage 1 with

- G3 tumor
- Papillary, Serous, Clear cell
- >50% myometrial invasion (stage 1B)
- Suspicious LN on CT/MRI

Stage 2 - Invade cervical stroma not beyond uterus

*Stage 2 – Radical Hysterectomy

- BSO

- Pelvic, Para-aortic LN

Stage 3 - Local regional spread---3a- Serosa U/ad

3b- V. Parametrial

3c1- + pelvic LN

3c2- + para-aortic

*Stage 3,4 – Maximum debulking

Stage 4 - Bladder, bowel/distant – Bladder, Bowel

-Distant

*Stage 4B – Only palliative Sx

I⁰ - Adjuvant Radiotherapy

01. Stage 1A G3 tumor

02. Stage 1A papillary, serous, clear Aggressive Ca
 03. Stage 1B and beyond

I⁰ - Debulking + Chemotherapy- Taxanes and platins(cisplatin,carboplatin)

01. Stage 3
02. Stage 4

Hormonal therapy

- Only for certain types with high progesterone receptors

Adverse Prognostic Factors

1. Grade 3 (poor differentiated)

2. Deep myometrial invasion 1B
3. Lymphovascular channel
involvement
4. Positive peritoneal cytology
5. Serous or papillary tumors
6. Clear cell tumors
7. Cervical involvement (stage 2)

Follow up

- Pelvic Ex, USS 5 years after Tx

3-4 months – first 2 years
6 months – next 3 years

How will you Mx this patient?

01. Cervical polyp – Polypectomy, D & C

02. Pyometron – Drain, Currattage--- exclude
endometrial Ca
03. Foreign bodies (IUCD, Pessary) – Remove
04. Tx with HRT – Senile vaginitis after
exclusion other
  Cases asked in Final Exam
PMB

Kapila sir and daffny madam

58yrs old Post menapausal bleeding,hx, speculum examination, ,initial management..

Cervical ca how patients present..ET significance.Atypical hyperplasia how do u mx,

why bso in this patient, preperation for surgery

PMB

Eranthi madam and Alagoda sir

52 year old lady .One year hx of HMB wi clots.No irregular bleeding.anemic features.No

other features.Transfusions done.Polypectomy done.On ex: pale

Bl pitting ankle oedema.No abdominal masses.No hf features on cvs.Questions asked:

Madam asked ques. Alagoda sirta didn't allow to ask much. �

Dds?What is most likely?expected ovulatory dysfunction.How would you

investigate?What is against fibroids?How would you manage if endometrial

hyperplasia?How to prepare for hysterectomy?Asked to do VE and speculum

examination. Had a cystocele. Mama newa but madam asked straight forwrd

madamge pothe stuff. Madam was really really helpful (long live the queen!! )

Postmenopausal bleeding

Ranaraja sir and external

Hx DDs and problems identified .58ys old postmenopausal lady who reached

menopause at the age of 43 presented with postmenopausal bleeding for 7months

Discussion

Possible lesions

How do you approach a patient with cervical ca

Investigations that should be performed to arrive at a diagnosis

Other possibilities in this age group-they expected cervical ca and atrophic vaginitis
Management of endometrial ca- they specifically looked for arranging an MDT meeting

with an oncologist....

HMB

Karunananda sir and external

51yr old mother hmb *7wks. Diagnosed to have endometrial hyperplasia.karunananda

sir interrupted in the middle and ask some questions

Ex_ask about general findings. And ask to do abdominal and speculum ex. Not allowed

to do ve.Mx only ask about ix and mx.both were very good and supportive.. but mama

naawa��

HMB

Eranthi mdm and alagoda sir.

51 yr HMB 2yrs- Hx,Ex,they asked have u done genrl and abdmn while taking histry?

Present! Patient was not willing for VE.so i told madam. ask dd,mx,palm coien,wht to

expect in tvs,what are histologicl changes u wld expect in this patient,ET of

perimenipausl wmn(7mm)lng ius,advises to patient( i dont know wht she expected)

HMB

Chathura sir and karunananda sir

44yr pt with HMB. Had a fibroid. Karunananda sir abd. Examination ivara venakalma

anan manan kivva. He expected a thorough ex. And presentation.But all in all both of

them were ok. Discussion was on initial assessment of pt, differentiating adenomyosis

and fibroid, complications of hysterectomy

HMB

2 external examiners (I think one was Dr. Muhunthan.)

46y old mother of 3, HMB for 1 year duration. No intermenstural, postcoital bleeding.

Secondary dysmenorrhea and dyspareunia. LRT done. 2 NVD + 1 section. Admitted for
TAH. Presented the whole history. Relevant examination findings. Did the abdominal

examination. Asked not to do speculum but to do VE. What would you look for in the

SE? Cervical abnormalities. Gave running commentary in the VE. I couldn't palpate the

uterus in VE. Questions. What is PALM COEIN classification? As the uterus size is

normal what can be the pathology here? DDs. Say Ovulatory dysfunction as one. If so

what are the investigations you do? They wanted me to come up with endometrial

biopsy. What types of biopsy are there? If the biopsy is normal how is it reported?

Why haven’t we done a biopsy in this pt prior to TAH? We have to do. If the biopsy is

also normal how will you treat her? Symptomatic. How? What is the name given for

HMB in the previous classification? What is TAH? What do you remove there? What is

Subtotal hysterectomy? They were good

Gyn

-45 yr obese mother of 2 children. Diagnosed pt with HT & on treatments.HMB for 4months.. Had
regular cycles previously. On progesterone 21 days cycles. Detected uterine mass on USS. Pipelle biopsy
was done and its normal. Planning to do hysterectomy.. On abd ex- I didnt palpate any abdominal
mass... Speculum ex- ectropian bimanual ex

Examiners- Prof.Hemantha Senanayaka (colombo) other external one

Hx, ex

Ask how to advice her regarding diet

Hw her obesity affect to her

How to ix this pt

Management options- I told surgical and medical mx sir specially asked abt LNGIUS

( duration- 5yrs) & myomectomy

Complications due to obesity.. Sir wanted DVT. how to prevent DVT

Gyn

daphne madam and a sir. 40yrs HMB. Hx and summary. Ex-palpate for a pelvic mass. Ix-fbc,tvs,
endometrial assessment. management medical and surgical, endometrial ca mgmt, onco gynae referral,
about LNG Ius, cervical ca screening
Obs-eranthi madam and sir. Past section. Obstructed labour. Prep for Lscs

Post op complications and management, VBAC contraindications and indications