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A 71-year-old gravida 2, para 2 woman presents with vaginal bleeding for one week. The bleeding has been light and dark red in color. She has not been on hormone replacement therapy. She denies pelvic pain, or changes in bowel or bladder function. Her medical and surgical history are non-contributory. There is no family history of breast, uterus, ovarian, or colon cancers. She is not taking medications and has no history of drug allergy.
A 70-year-old nulligravid woman presents with a three-month history of intermittent, painless vaginal spotting. The patient denies any vaginal bleeding or spotting since her last menstrual period 20 years ago. She initially noticed brown staining on her underwear. Currently, she wears a pad which she changes daily. She reports regular bowel movements with no blood in her stools. She had her second colonoscopy four years ago. No abnormalities were noted. She denies any urinary complaints and has not noticed any hematuria. The patient was last sexually active 15 years ago. She denies any prior history of sexually transmitted infections. Her last Pap smear with co-testing was normal at age 65. She has no history of abnormal Pap smears. She has never taken hormone therapy. Her past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus. Her past surgical history is significant for laparoscopic cholecystectomy. She is currently taking lisinopril, atorvastatin, and glyburide and she has no known drug allergies.
The purpose of uterine cavity evaluation is to make an accurate diagnosis of the cause of abnormal uterine bleeding, in order that therapy can be appropriately tailored to the woman. This chapter reviews the accuracy and efficacy of currently available tests used to evaluate the uterine cavity. Uterine size can be assessed on bimanual examination; if the uterus is greater in size than 12 weeks of gestation, it may be palpable abdominally. Women with amenorrhoea (no menstrual bleeding for 6 months) should have a full history and examination. Dilatation and curettage (D&C) used to be the method of choice for assessing the uterine cavity. Other methods for assessing the uterine cavity include hysteroscopy, ultrasound, Doppler ultrasound, and outpatient endometrial biopsy. Women presenting with postmenopausal bleeding require urgent referral for pelvic ultrasound and further testing, with endometrial biopsy and/or hysteroscopy undertaken depending on the initial ultrasound result.
Endometrial hyperplasia can be termed as a premalignant condition of the endometrium. Women presenting with postmenopausal bleeding are at the risk of having endometrial cancer and investigations to confirm or exclude such a possibility should be performed. The standard surgical procedure for the management of endometrial cancer is hysterectomy and bilateral salpingo-oophorectomy by the method for evaluation of the peritoneal cavity. Patients with clear-cell or papillary serous tumours may receive pelvic radiotherapy and adjuvant chemotherapy to try to impact on the possibility of extrapelvic relapse. The optimum management of endometrial cancers requires close coordination between the primary healthcare team, the treatment teams at the cancer unit and cancer centre, the palliative care team and patients and their families. For endometrial cancer, the cancer unit should provide a rapid and appropriate assessment service at the local level for women with postmenopausal bleeding.
The menstrual and urogenital changes associated with perimenopause can be very distressing. Seventy-five percent of postmenopausal women experience atrophic genital changes. Vasomotor symptoms are often the most disruptive perimenopausal symptoms that a woman experiences. These can occur even before she sees any change in her menstrual pattern. There is significant variation in an individual woman's response to these, and the symptoms can be distracting, cause insomnia, and lead to unpleasant social situations. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. Etiologies of abnormal menstrual bleeding include endocrine abnormalities, pregnancy related, infectious (genital and systemic), neoplasms (benign and malignant) of pelvic organs, uterine abnormalities, coagulation disorders, liver disease, medication (iatrogenic), and trauma. Women with life-threatening bleeding need immediate treatment.
This chapter discusses the diagnosis, evaluation, staging and prognosis and treatment of postmenopausal bleeding and endometrial cancer. The primary symptom of endometrial cancer (ECa) is postmenopausal bleeding (PMB). A physical examination of PMB should look for vaginal and cervical abnormalities, polyps, masses, uterine size and symmetry, or ovarian masses. ECa (cancer of the body or corpus of the uterus) is the fourth most common malignancy in women in the USA, and seventh most common cause of cancer deaths in women. Prognostic factors are related to age, race, endocrine status, histological cell type, tumor grade, depth of myometrial invasion, extension beyond the uterus, adnexal metastases, and extrauterine and peritoneal spread. PMB has a variety of causes, one of which is endometrial cancer. Endometrial cancer is usually discovered at an early stage, is curable, and is usually a disease of postmenopausal women.
The endometrium undergoes cellular and structural changes that are essential for its function. These changes are cyclical and controlled by the production of estrogen and progesterone by the ovaries. Drugs with estrogenic or progestogenic modes of action also lead to alterations in the ultrasonographic appearances of the endometrium. This chapter helps the sonographer to interpret the appearances of the endometrium in women. The Committee on Safety of Medicines (CSM) has advised that hormone replacement therapy (HRT) is beneficial for the treatment of menopausal symptoms. Although unscheduled bleeding on HRT requires investigation, the underlying malignancy risk is low. In postmenopausal bleeding, there is a cut off of 4 mm for double-layer endometrial thickness on Transvaginal ultrasound (TVS) but for women on HRT there is no agreed cut-off point. Hormonal contraceptives and intrauterine contraceptive devices (IUCD) have multiple effects leading to their contraceptive action.
Perimenopause is the time in a woman's life when she begins to experience the changes that lead to menopause. Smoking and shorter menstrual cycles can cause earlier menopause, while multigravidity and use of oral contraceptive pills are associated with later menopause. There may be additional factors, including cultural differences that influence the age of menopause. The menstrual and urogenital changes associated with perimenopause can be very distressing. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding, and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. The challenge for the provider is to distinguish between normal and abnormal bleeding. Ultrasonography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding. Hysterectomy is the only way to stop menorrhagia completely.
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