Abnormaal vaginaal Abnormaal vaginaal bloedverliesbloedverliesDirk Timmerman Dirk Timmerman

UZ KU LeuvenUZ KU Leuven 2de Master Arts, 28 april 20102de Master Arts, 28 april 2010

Postmenopausal bleeding

Is all postmenopausal bleeding caused by Is all postmenopausal bleeding caused by endometrial cancer?endometrial cancer?

NoNo30%30% exogenous estrogensexogenous estrogens

30%30% atrophic endometritis/vaginitisatrophic endometritis/vaginitis

11%11% endometrial cancerendometrial cancer

10%10% endometrial or cervical polypsendometrial or cervical polyps

5%5% endometrial hyperplasiaendometrial hyperplasia

10-10-15%15%

miscellaneous: cerv. ca., uterine miscellaneous: cerv. ca., uterine sarcoma, urethral caruncle, traumasarcoma, urethral caruncle, trauma

Abnormaal bloedverlies Echografie? EndometriumdikteEndometriumdikte Bijkomende informatie: Bijkomende informatie:

MorfologieMorfologie Hydrosonografie (SIS)Hydrosonografie (SIS) Kleuren DopplerKleuren Doppler

Ambulante hysteroscopieAmbulante hysteroscopie

TVS en endometriumdikte:Is dit alles wat we nodig hebben?

PMB: Endometriumdikte

Prevalentie van endo ca: 11%Prevalentie van endo ca: 11%

< 5mm 15 endo ca/ 1113 (1.4%)< 5mm 15 endo ca/ 1113 (1.4%)

>> 5mm 248 endo ca/ 1247 (20%) 5mm 248 endo ca/ 1247 (20%)

(Meta-analysis by Timmerman &Vergote 1997 : 20 studies)(Meta-analysis by Timmerman &Vergote 1997 : 20 studies)

OOnly a normal nly a normal and thin and thin endometrial endometrial line line is informativeis informative

Endometrial thickness at TVS?

Fibroom

Poliep

Limitations of hydrosonography Cost? Double compared to TVS aloneCost? Double compared to TVS alone Time to perform? Extra 5 minutesTime to perform? Extra 5 minutes Side effects: Side effects:

infection: very rare infection: very rare spilling of malignant cells? Yes. spilling of malignant cells? Yes.

Patient discomfort? MinimalPatient discomfort? Minimal Does it change management? SometimesDoes it change management? Sometimes

Adenomyosis uteri

Common gynecologic disorderCommon gynecologic disorder Heterotopic endometrial glands and stroma Heterotopic endometrial glands and stroma

in the myometrium with adjacent smooth in the myometrium with adjacent smooth muscle hyperplasiamuscle hyperplasia

(Rokitansky, 1860)

Adenomyosis: presenting symptoms

Diffusely enlarged uterus withDiffusely enlarged uterus with menorrhagia (40-50%)menorrhagia (40-50%) dysmenorrhea (10-30%)dysmenorrhea (10-30%) metrorrhagia (10-12%)metrorrhagia (10-12%) dyspareunia dyspareunia (typically 1 wk prior menstruation)(typically 1 wk prior menstruation)

dyschezia dyschezia (typically 1 wk prior menstruation)(typically 1 wk prior menstruation)

Adenomyosis: epidemiology

About 1% of female patientsAbout 1% of female patients 5 - 70% of hysterectomy specimens 5 - 70% of hysterectomy specimens (Azziz 1989)(Azziz 1989)

31% if 3 sections; 61% if 6 sections 31% if 3 sections; 61% if 6 sections (Bird 1972)(Bird 1972)

More often in multiparous women More often in multiparous women Fourth – fifth decade of lifeFourth – fifth decade of life

Adenomyosis: morphology

Asymmetrical uterine enlargement Asymmetrical uterine enlargement

(or globular appearing uterus)(or globular appearing uterus)

Adenomyosis

Asymmetrical uterine enlargementAsymmetrical uterine enlargement Ill defined hyperechoic & hypoechoicIll defined hyperechoic & hypoechoic areasareas Small anechoic cystsSmall anechoic cysts

Adenomyosis

Asymmetrical uterine enlargementAsymmetrical uterine enlargement Ill defined hyperechoic & hypoechoicIll defined hyperechoic & hypoechoic areasareas Small anechoic cystsSmall anechoic cysts Indistinct endometrial-myometrial borderIndistinct endometrial-myometrial border

Differential diagnosis

Concentric, roundConcentric, round Sharply definedSharply defined Mass effectMass effect Often calcificationsOften calcifications Color DopplerColor Doppler

EllipticalElliptical Poorly defined bordersPoorly defined borders Lack of mass effectLack of mass effect No calcificationsNo calcifications Color DopplerColor Doppler

FibroidAdenomyosis

Morphology of flow

Fibroid: circular flowFibroid: circular flow

Polyp: pediclePolyp: pedicle

Endometrial cancer: multiple Endometrial cancer: multiple irregular vessels in junctional areairregular vessels in junctional area

Adenomyosis: no clear changes in Adenomyosis: no clear changes in normal flow pattern normal flow pattern

Differential diagnosis

Size 0 - 5 cmSize 0 - 5 cm Concentric, roundConcentric, round Sharply definedSharply defined Degeneration possibleDegeneration possible Often calcificationsOften calcifications Color DopplerColor Doppler

Size 5 - 18 cmSize 5 - 18 cm Inhomogeneous, ovalInhomogeneous, oval Irregular contourIrregular contour Central necrosis commonCentral necrosis common No calcificationsNo calcifications Color Doppler?Color Doppler?

Leiomyoma Leiomyosarcoma

Abnormal bleedingHistory, clin. exam, PAP, TVS +Doppler (SIS only if indicated)

Thick endometrium

Exclusion of adnexal pathology

BiopsyHysteroscopic resection (polyp / myoma)

Focal pathology

No focal pathology

Thin endometrium

DUB

Medic. R/

Surgery