SYB #3Jordan Torok

Class of 2010

December 16th, 2008

Chiefest Complaint 78 year old obese non-smoking woman

with two weeks of post-menopausal bleeding and menstrual-like cramping

Reportedly intermittent over the past 3 to 4 years

Current medications include verapamil & Diovain (HTN), Paxil (depression/anxiety) and omeprazole (PUD)

Causes of PMB Atrophy (59 percent) Polyps (12 percent) Endometrial cancer (10 percent) Endometrial hyperplasia (9.8 percent) Hormonal effect (7 percent) Cervical cancer (less than 1 percent) Other (eg, hydrometra, pyometra,

hematometra: 2 percent) http://www.uptodate.com/online/content/topic.do?topicKey=gen_gyne/15883&selectedTitle=1~20&source=search_result

1st best test for PMB? Must exclude malignancy

Endometrial biopsy

vs

Transvaginal Ultrasound (TVU)

Biopsy vs TVU Recommended initial

test due to its high sensitivity

Low cost Low complication rate Not sensitive for

diagnosing structural abnormalities like polyps

Those who can’t tolerate office biopsy

Centers not equipped to perform biopsy

Women who also require evaluation of the adnexae or myometrium

Not adequate for those on ERT

TVU technique Scanning in the

saggital view Measure endometrial

thickness in an AP dimension from one basalis layer to the other, excluding any fluid within the cavity

TVU: concerning findings Endometrial lining thicker than 5 mm; cancer

becomes more certain as 20 mm is approached Endometrium shows diffuse or focal increased

echogenicity (heterogeneity) Endometrium not well visualized

Concerning findings warrant an endometrial biopsy while a thin, homogenous endometrium can reasonably exclude endometrial cancer

Findings/Impression Findings:

Endometrioma is significantly thickened measuring 2 cm in width with multiple central cysts and internal flow this likely representing neoplasm.

There is a left exophytic uterine mass thought to represent leiomyoma measuring 2 cm x 2.5 cm x 2.4 cm. Otherwise remainder the uterus is unremarkable. Ovaries are unremarkable with the right measuring 2 cm x 1.3 cm x 1.2 cm and the left measuring 1 cm x 5 mm x 1.6 cm.

Impression: Findings extremely worrisome for endometrial carcinoma. Exophytic leiomyoma.

Endometrial biopsy Scant stips of unremarkable glandular

epithelilum, may prepresent lower uterine segment or endometrium

Immature squamous endocervical metaplasia

No features of endometrial hyperplasia or malignancy although sample very small

Operative Note: D&C, hysteroscopy

Normal endocervical canal Atrophic endometrium Very large polyp filling the uterine cavity-

polypectomy performed

Surgical Specimen Endometrial curretage: again shows minute

stromal and glandular tissue, negative for malignancy or hyperplasia

Excised polyp: endometrial polyp, negative for malignancy

Endometrial Polyps Localized hyperplastic overgrowth of endometrial

glands and stroma around a vascular core Sessile or pedunculated projection from the

surface of the endometrium Incidence increases starting at 20, peaks in the 5th

decade and declines after menopause Present primarily as metrorrhagia or PMB Best test for evaluation is sonohysterography

(A) Sagittal transvaginal sonogram shows endometrial polyp (arrows) in fundus. Endometrium appears thick and is difficult to measure. (B) Sagittal sonohysterogram shows single round 1.9-cm echogenic polyp (arrow). Note otherwise thin endometrium (2 mm). Reproduced with permission from Joizzo, JR, Chen, MY, Riccio, GJ, Endometrial Polyps: Sonohysterographic Evaluation. AJR Am J Roentgenol 2001; 176:617. Copyright © 2001 American Journal of Roentgenology.