Management Of Postmenopausal Bleeding Research Articles

STUDY TO CORRELATE HISTOPATHOLOGICAL FINDINGS WITH ENDOMETRIAL THICKNESS EVALUATED BY TRANSVAGINAL SONOGRAPHY IN POST MENOPAUSAL BLEEDING

almost ninety percent of post-menopausal females with endometrial cancer report a vaginal bleeding experience. Objectives: To nd correlation of radiological and histopathological ndings so that early evaluation of malignancy can be done. Materials And Methods: The Present Study included 50 Patients with abnormal uterine bleeding in postmenopausal women, aged between 45-70 years. All patients were subjected to transvaginal ultrasonographic evaluation of the endometrium and the results were correlated to the histopathological picture of the endometrium after curettage in an attempt to discriminate normal endometrium from abnormal pathological patterns. Results And Analysis: Thirteen patients (26%) had pathological ndings. There was signicant difference in the mean endometrial thickness of nonpathological and abnormal endometrium in postmenopausal patients with P value <0.001**. Among the thirteen patients with pathological ndings eight had endometrial hyperplasia, two had polyp and three had malignancies. Conclusions: It may be concluded that vaginal sonographic measurement of endometrial thickness is an acceptable less invasive alternative to hysteroscopy and D & C and needs to be popularized as rst line investigation in the management of Postmenopausal bleeding in rural population

Patient acceptance of transvaginal sonographic endometrial thickness assessment compared with hysteroscopy and biopsy for exclusion of endometrial cancer in cases of postmenopausal bleeding.

Available examinations for women with postmenopausal bleeding include transvaginal sonography to measure endometrial thickness (TVS-ET), and invasive endometrial assessment using hysteroscopy/endometrial biopsy. However, selection of the examination method seldom involves consideration of patient preferences. The aim of this study was to examine patient preferences for the method used to investigate postmenopausal bleeding. Women were asked to complete an interviewer-administered structured survey before they underwent clinical investigations at a university gynaecology unit from June 2016 to June 2017. Using the standard gamble approach, women were asked to choose between invasive assessment by hysteroscopy/endometrial biopsy (gold standard) or TVS-ET with a risk of missing endometrial cancer. The risk of missing endometrial cancer during TVS-ET was varied until each woman was indifferent to either option. The median detection rate for endometrial cancer required using TVS-ET was 95% (interquartile range=80%-99.9%). In total, 200 women completed the survey, and 77 (38.5%) women required TVS-ET to have a 99.9% detection rate for endometrial cancer. Prior hysteroscopy experience was the only factor that influenced the women's decisions: a significantly higher detection rate was required by this patient group than by patients without previous hysteroscopy experience (P=0.047). A substantial proportion of women would accept TVS-ET alone for the investigation of postmenopausal bleeding. In the era of patientcentred care, clinicians should incorporate patient preferences and enable women to make informed choices concerning the management of postmenopausal bleeding.

The Correlation of Hysteroscopic Diagnosis with Histopathologic Findings in Patients with Post-Menopausal Bleeding: A Retrospective Cross-Sectional Study

Objective: Abnormal uterine bleeding, namely post-menopausal bleeding (PMB), is the most common symptom of intrauterine pathologies in post-menopausal women. This study aimed to investigate the complementary role of hysteroscopy in the management of PMB and the sensitivity of hysteroscopy compared to histopathologic examination in PMB. Material and Methods: This was a retrospective cross-sectional study including patients undergoing hysteroscopy and endometrial curettage. If a local lesion like polyp or myoma uteri was detected, hysteroscopic resection was performed and the tissue was sent for histopathologic examination. If no local lesion was detected, the endometrial cavity was classified as normal, hyperplastic (thickened, irregular cavity), or atrophic (thin and pale cavity). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of hysteroscopy were calculated for every histopathologic finding. Results: The main hysteroscopic findings were endometrial polyp in 54 (47%) cases, normal cavity in 26 (22.6%), atrophy in 14 (12.1%) cases, hyperplastic endometrium in 11 (9.6%) cases and myoma uteri in 10 (8.7%) cases. The sensitivity, specifity, PPV, NPV and diagnostic accuracy of hysteroscopy for endometrial polyps were 70.0%, 72.0%, 76.0%, 65.0% and 71.0% respectively. In 3 cases, histopathological examination showed endometrial hyperplasia within polyps. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of hysteroscopy for myoma uteri were 87.5%, 96.9%, 70.0%, 99.0% and 97.2% respectively. Conclusion: Hysteroscopy showed lower diagnostic accuracy for endometrial pathologies, especially endometrial cancer, validating the need for histopathologic examination. The diagnosis cannot depend on hysteroscopic assessment alone and histopathologic examination should be performed in all PMB cases.

A PROSPECTIVE STUDY ON TRANSVAGINAL DOPPLER SONOGRAPHY OF ENDOMETRIUM IN WOMEN WITH POSTMENOPAUSAL BLEEDING.

Objectives: This present study was to evaluate the clinical profile and Transvaginal Doppler Sonography findings of endomterium in women with postmenopausal bleeding.
 Methods: Detail history, clinical examinations and relevant investigations were performed to all cases of PMB. BMI was calculated. Transvaginal sonography of the uterus and Doppler analysis of the blood flow were performed using vaginal probe at 5-7.5 megahertz. Endometrial thicknesses as well as other pathologies in the cavity were noted. Resistive index was calculated.
 Results: Data was analyzed by using SPSS version 26 software. One sample statistical methods was used. Mean ± standard deviation was observed. P-value was taken equal to less than 0.05 for significant differences.
 Conclusions: Highest prevalence of PMB was seen in women with age greater than 50 years. Most of the cases had BMI 20-25 kg/m2. Most of the benign and malignant cases had parity status P3-P4 and P1-P2 respectively. Endometrial thickness of malignant PMB cases was significantly greater than benign PMB cases. Resistive index of malignant PMB women was significantly lower than benign PMB women. Hence, promotion of healthy lifestyles and contraceptives in early reproductive life and awareness for the need of early screening should be recommended to reduce the prevalence of PMB. And early diagnosis and management of post menopausal bleeding are needed for prevention from malignancy.
 Key words: Postmenopausal Bleeding, Benign, Malignancy, Transvaginal Doppler Sonography.

Clinicopathological Study of Postmenopausal Bleeding in a Tertiary Care Center

Postmenopausal bleeding (PMB) requires complete assessment in order to ensure the absence of malignancy and to identify and treat high-risk patients such as those with endometrial hyperplasia. To enumerate the age predilection, histopathological diagnosis, incidence of malignancies, and management of postmenopausal bleeding. This is a prospective study done in department of gynecological oncology of a tertiary care center. A total of 50 patients of PMB were included for study. The mean age of reaching menopause was 48.02 years. The age range of study population was between 40 and 70 years. The mean age of patients was 56.26 with peak incidence of malignancy observed in age-group of 55–70 years. The histopathological analysis showed proliferative endometrium (16%), simple hyperplasia (8%), complex hyperplasia with atypia (6%), CIN 3(6%), and carcinoma in situ of cervix (2%). Incidence of cervical, endometrial carcinoma, sarcoma of uterus, and vulval cancer was 48, 8, 2, and 2%, respectively. Conservative management was done in 26% cases in proliferative endometrium, hyperplasia without atypia and cervicitis. Out of 26 cases of cervical cancer, 20 cases were referred to radiotherapy department as they presented in advanced stage and six underwent Wertheim’s hysterectomy. PMB is a sinister complaint. It requires careful and timely assessment to eliminate the possibility of malignancy. The risk of endometrial malignancy increases with age. High cervical cancer preponderance stresses the need for education of patients regarding screening and early diagnosis.

Effects of hormone therapy on lipoprotein in postmenopausal Korean women by route of estrogen administration: Impact of micronized progesterone

s / Maturitas 81 (2015) 144–190 157 experienced any vaginal bleeding. The patient opted to take Evorel Sequi® for 3 months as she wanted to avoid a surgical procedure. She did not experience any vaginal bleeding and after 3 months changed back to Evorel Conti®. The patient was advised to return to clinic if she experienced any vaginal bleeding. Discussion: Guidelines exist for the management of postmenopausal bleeding including the interpretation of endometrial thickness onultrasound scan.However there is no clinical guideline for the management of asymptomatic patients given unopposed oestrogen. A literature review performed explores the evidence on this subject. http://dx.doi.org/10.1016/j.maturitas.2015.02.170

35. Clear cell carcinoma arising within an endometrioma

There is an increasing awareness that malignant transformation of endometriosis is an uncommon but distinct entity. We review one such case of a clear cell carcinoma arising within an endometrioma of a rectus sheath scar. These malignancies have a favourable prognosis, with extra-gonadal disease commonly associated with unopposed estrogen replacement therapy. Presentation A 56-year-old female presented to TQEH for management of post menopausal bleeding. She proceeded to undergo a hysterectomy and bilateral salpingo-oopgerectomy. She underwent a simultaneous excision of an endometrioma arising in a rectus sheath scar in the setting of previous endometritis. Her previous medical history is otherwise unremarkable with no other recorded malignancies or family history of endometrial adenocarcinoma. Findings 5-10% of the endometrium showed complex endometrial hyperplasia with secretory change. There was also a background of early mid-secretory change with corpus luteum formation in the right ovary. There were five intramural and subserosal leiomyomas (5-80mm in diameter) with no evidence of ovarian endometriosis. A single focus of cervical endometriosis was identified. Sectioning through the endometrioma from the rectus sheath showed a clear cell carcinoma arising in the setting of endometriosis. The tumour was ER negative, CK 7 positive, CK 20 negative and CDX2 negative. It measured 12 mm maximally with the closest soft tissue margin 3-4 mm. No origin from the ovaries or endometrium was identified. Conclusion Carcinoma arising in extra-ovarian foci of endometriosis is a rare but recognised phenomenon. Most of these tumours are either endometrioid or clear cell, as in this case. Radiation and/or chemotherapy is offered with favourable prognosis.

Regular menses at 73? A peculiar presentation of postmenopausal bleeding

Post menopausal bleeding is one of the most common conditions referred to gynaecology departments. Up to 5% of these women are found to have malignant, or pre-malignant lesions, with early detection and investigation being crucial for curative treatment. We report on the case of a 73-year-old women referred for having regular menses since 14 years of age and discuss the current investigation and management of post menopausal bleeding.

Editorial

Editorial

Recent advances in evaluation and management of postmenopausal bleeding

Postmenopausal bleeding (PMB) is one of the most common reasons in patients attending gynecological OPD. It is a frequent and alarming sign of endometrial cancer though the commonest cause is an atrophic endometrium. Women with PMB are categorized as those with spontaneous bleeding and those with bleeding whilst on Tamoxifen or HRT. All these patients should be investigated by TVS, hysteroscopy and D&C and accordingly should be managed.Postmenopausal bleeding (PMB) is defined as a bleeding which occurs after 12 months of amenorrhea due to loss of ovarian follicular activity in a woman who is not on hormone replacement therapy (HRT). Women with abnormal postmenopausal bleeding also include:•Women with bleeding after 1 year of continuous combined HRT•Women with unexpected bleeding while receiving cyclic HRT

OP17.02: Use of ultrasound to reduce the need for hysteroscopy in the management of postmenopausal bleeding (PMB): introduction of a ‘one‐stop’ clinic

OP17.02: Use of ultrasound to reduce the need for hysteroscopy in the management of postmenopausal bleeding (PMB): introduction of a ‘one‐stop’ clinic

Transvaginal sonographic assessment of endometrial thickness and endometrial morphology in postmenopausal bleeding

The most common symptom of endometrial cancer is postmenopausal bleeding (PMB). However PMB is associated with endometrial cancer in only 10% of cases. Even if repeatedly performed no noninvasive procedure has been able to replace endometrial biopsy in finding the cause of PMB. This prospective study was conducted to investigate the diagnostic values of endometrial thickness (ET) and endometrial morphology (EM) in the management of PMB in 103 women who fulfilled the following inclusion criteria: no menstrual bleeding for at least 12 months abnormal uterine bleeding and no use of hormone or tamoxifen therapy. All patients underwent a transvaginal sonographic examination and an endometrial biopsy. (excerpt)

Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy

Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy

Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy.

The objective was to determine how postmenopausal bleeding (PMB) is managed in Sweden today, and to relate the findings to a new evidence-based algorithm for the management of PMB. A questionnaire regarding the role of ultrasound and the use of different endometrial biopsy methods in the management of PMB was sent to all 61 gynecologic departments in Sweden. Fifty-nine of the 61 departments (97%) satisfactorily answered the questionnaire. Ultrasound was either always (n = 54, 92%) or most commonly (n = 5, 8%) used in the diagnostic work-up of PMB. In women with endometrial thickness < or =4 mm, 18 of the departments (31%) routinely sampled the endometrium; 12 (15%) followed the women with ultrasound; three (5%) did both sampling and follow-up with ultrasound; and the remaining 29 (49%) used expectant management (i.e. no biopsy or routine follow-up). In women with endometrium > or =5 mm, hydrosonography was performed routinely in two departments (3%), occasionally in 37 departments (63%), and never in 20 departments (34%). In women with endometrium > or =5 mm, endometrial biopsy was obtained routinely by Endorette/Pipelle in 39 departments (66%), while in 26 departments (44%) operative hysteroscopy was never performed. More than one-third of the gynecologic departments in Sweden never perform hydrosonography to rule out focal lesions or operative hysteroscopy for the removal of such lesions. Hydrosonography and hysteroscopy have a central role in the new guidelines for the management of PMB. Therefore, a need exists to broaden the use of hydrosonography and hysteroscopy.

Case-series report: management of post-menopausal bleeding in the presence of an intrauterine device

Post-menopausal bleeding in the presence of prolonged use of an intrauterine device should be investigated with hysteroscopy and endometrial sampling to rule out endometrial pathology. Here, we present two cases of prolonged use of intrauterine contraceptive device (IUCD), both associated with endometrial pathology, to illustrate the importance of these investigations.

Ultrasound in the Management of Postmenopausal Bleeding (PMB)

Ultrasound in the Management of Postmenopausal Bleeding (PMB)

The management of post-menopausal bleeding: a review

Post-menopausal bleeding (PMB) accounts for a significant proportion of gynaecological referrals. The primary aim of management is to exclude endometrial carcinoma. Benign causes are excluded from this review. There are many methods available to examine the endometrium.

The value of outpatient hysteroscopy in the management of postmenopausal bleeding: a review of 862 cases

Objective To evaluate the efficacy, reliability and acceptability of outpatient hysteroscopy in the investigation of postmenopausal bleeding in a major teaching hospital. Design A retrospective descriptive study of 862 women referred with postmenopausal bleeding for outpatient hysteroscopy. Methods Between 1994 and 1997, 862 women were referred to the Women's Endoscopy Unit at Nottingham City Hospital for postmenopausal bleeding. Of these women, 171 were receiving hormone replacement treatment. The endocervical canal and the endometrial cavity were assessed using either a 4-mm rigid or a 3.5-mm flexible hysteroscope according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Pipelle endometrial biopsy was taken when indicated. Results The mean age of patients referred with postmenopausal bleeding was 58 years. Hysteroscopy was completed successfully in 97.2% of all patients. Cervical stenosis and pain were the main reasons for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in one-third of all patients undergoing hysteroscopy. Intrauterine polyps were the commonest finding (13.9%) while submucous fibroids were detected in 10.7%. Endometrial biopsies were taken in 34.7%. Abnormal histological findings were reported in 28 cases, including eight instances of endometrial adenocarcinoma. After hysteroscopic assessment, 81% of patients were discharged while further surgical treatment was warranted in 14.6%. Conclusion Outpatient hysteroscopy is a reliable, safe and well-tolerated diagnostic procedure for investigating endometrial and endocervical pathology in patients with postmenopausal bleeding. Whenever hysteroscopic findings appear suspicious an endometrial biopsy should be taken to exclude endometrial pathology.

Evaluation of a one-stop clinic for the rapid assessment of post-menopausal bleeding

Summary In this study, we evaluated the management of postmenopausal bleeding at our one-stop clinic where the first line investigations were a transvaginal ultrasound scan and a pipelle endometrial biopsy. The records of 212 women seen in this clinic in 1994 were reviewed. One hundred and forty-four women (67.9%) were evaluated and reassured in one visit. The mean waiting period following referral to the clinic by the general practitioner was 36 days (range 6-157 days), and only 45 women (21%) required a hysteroscopy. The commonest diagnosis made was endometrial atrophy or no significant endometrial pathology (130 women (61.3%). Endometrial cancer was diagnosed in 12 women (5.6%), and one case of previously unsuspected ovarian cancer was detected. Our findings show that most women with post-menopausal bleeding can be assessed in one visit, and hysteroscopy is not always necessary in the initial assessment of this complaint.

Transvaginal ultrasound measurement of endometrial thickness and endometrial pipelle sampling as an alternative diagnostic procedure to hysteroscopy and dilatation and curettage in the management of post-menopausal bleeding

Summary In order to evaluate pipelle endometrial sampling combined with ultrasound measurement of endometrial thickness as an initial diagnostic procedure in the assessment of endometrial pathology in patients presenting with postmenopausal bleeding, 50 consecutive patients were studied prospectively. In each patient measurement of endometrial thickness and pipelle endometrial biopsy were performed as an out-patient procedure before hysteroscopy and dilatation and curettage (D&C). The diagnostic sensitivity with pipelle endometrial sampling alone in detecting endometrial pathology was 25% with a specificity of 100%. The measurement of endometrial thickness had a sensitivity of 62% with a specificity of 87.8%. Pipelle sampling combined with endometrial thickness increased the sensitivity to 87.5% with a specificity of 87.8%. Therefore, we suggest that pipelle sampling combined with sonographic measurement of endometrial thickness is an acceptable, less invasive alternative to hysteroscopy and D&C as a first-line investigation in the management of post-menopausal bleeding.