Transcript Endometrium in Postmenopausal

POSTMENOPAUSAL
ENDOMETRIUM
Dr. Sharda Jain
Director: Global Institute of
Gynaecoloy at Pushpanjali
Crosslay Hospital
Secretary general: Delhi
Gynaecologist Forum
Learning objectives
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Menopause
Normal Postmenopausal Endometrium
Pathophysiology: before & after menopause
What warrants investigations
Case Studies
Endomtrial evaluation
Personal Experience
Review of Literature
Menopause
• AFTER 12 MONTHS'
SPONTANEOUS
AMENORRHOEA.
• FSH >30
Postmenopausal
Endometrium
No more than thin line
2.3 mm ± 1.8 mm
(0-10)
PATHOPHYSIOLOGY
PRIOR TO MENOPAUSE:
• Short cycle (↓ proliferative)
• ↑ Moderate Elevation of FSH
• Anovulation – Unapposed oest
- DUB
- Hyperplastic endo.
PATHOPHYSIOLOGY
Once menopause occurs, oestrogen and
progesterone are no longer produced by the
ovaries; nor are they produced in any
appreciable amounts by the liver and fat.
The endometrium regresses to some degree,
and no further bleeding should occur.
If bleeding does resume - endometrium must
be evaluated.
Norms for Endometrial Thickness in
Postmenopausal Women (MM)
AMENORRHEIC + NO HORMONE THERAPY 4.0
SEQUENTIAL HORMONE THERAPY (DAY 5) 4.0
ESTROGEN ALONE/COMBINED
ESTROGEN 5.5
WITH PROGESTERONE
TIBOLONE 5.5
RALOXIFENE 4.0
TAMOXIFEN 8.0
HYPERTENSIVE ON MEDICATION 6.5
WHAT WARRANTS
INVESTIGATION
AND EVALUATION?
NO POST MENOPAUSAL
BLEEDING
Thick Endometrium
Fluid - Anachoic area
↑ Endometrium – Warrants investigation
POST MENOPAUSAL BLEEDING
• PRECANCEROUS / CANCER of cervix & uterus
• Benign conditions – eg. Polyp
• Chronic endometritis- eg. TB
• Disorders of coagulation/ Blood dyscrasias
• Systemic Disease- eg. Hypertension
• Drugs – anticoagulants, Tamoxiphen.
Herbal drugs, HRT
Postmenopausal Bleeding
• Benign conditions are most
frequent causes of PMB but
endometrial cancer is the most
serious potential underlying
cause
• One Should think endo. Ca
untill proven otherwise.
RISK ASSESSMENT
75% of women with
endometrial cancer
are postmenopausal.
RISK FACTORS FOR
ENDOMETRIAL CANCER
are conditions typically associated with chronic
elevations of endogenous estrogen levels or
increased estrogen action at the level of the
endometrium. These include
 OBESITY.
 HISTORY OF CHRONIC ANOVULATION.
 DIABETES MELLITUS.
 ESTROGEN-SECRETING TUMORS.
 EXOGENOUS ESTROGEN UNOPPOSED BY PROGESTERONE .
 TAMOXIFEN USE.
 A FAMILY HISTORY OF LYNCH TYPE II SYNDROME
(HEREDITARY NONPOLYPOSIS COLORECTAL, OVARIAN, OR
ENDOMETRIAL CANCER).
Systemic conditions
Abnormalities of the hematologic system
also must be considered as a possible cause
of postmenopausal bleeding.
On rare occasions, AUB will be the first sign
of leukemia or a blood dyscrasia.
Overuse of anticoagulant medications
such as aspirin, heparin, and warfarin-which
are taken with greater frequency by patients
in this age group-may contribute to
postmenopausal bleeding.
POSTMENOPAUSAL BLEEDING &
HRT
• The occurrence of uterine bleeding or
spotting after the initiation of HRT is
not unusual. More than half of HRT
users will have some spotting or
bleeding at the beginning of therapy.
• Usually such bleeding is lighter than a
menstrual period and lessens with
time; after 6 months, it stops
completely in most women.
ENDOMETRIAL EVALUATION IS
CALLED FOR WHEN :
1. any menopausal woman not taking HRT
develops uterine bleeding after more
than 1 year of amenorrhea.
2. any postmenopausal woman on HRT
for 6 months or more with persistent
uterine bleeding.
3. and any previously amenorrheic woman
on HRT who begins bleeding without
apparent cause.
CASE STUDY - 1
64 years old G2 P2 : 16 years postmenopausal
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Went to physician for pain in abdomen
Ultrasound revealed18 mm endometrial strip
No discharge/ No Bleeding, 70 kg, BMI - 32
Mild hypert, DM controlled.
• EB – Well differentiated Adeno Carcinoma
• Staging laparotmy and pan hysterectomy
• IA- Disease
CASE STUDY-2
68 years
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Menopausal 20 years
3 episodes of bleeding in last 6 weeks
Hypertension/ diabetic/ obese/ BMI-31
TVS – Uterus bulky for age. Endometrial strip is 18
mm.
• Office E.B. well differentiated adeno-carcinoma
• 1 A disease
CASE STUDY - 3
54 years, professor in DU
• Menopause = 48 years
• Single episode of spotting on 13/8/2010
• TVS – 7-8 mm
• HPE – Clear all Endo. Ca.
CASE STUDY - 4
• 54 year old G2 P2
• Had HRT at age 50 for Hot flushes – 6 months
• Presented with 3 episodes of vaginal
bleeding over last 6 weeks (3 years after menopause)
• TVS show endometrial strip of 12 mm, Uterusnormal in size.
• E.B. proliferative endometrium
• Hysteroscopy normal
…. Spotting for 3 months
• Refused Hysterectomy
Uterine Balloon Therapy
CASE STUDY - 5
60 YEARS, UNMARRIED PROFESSOR
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Menopause – 48 years
52 years – Heavy Bleeding
Ultrasound – 3-4 mm Endo. Strip
D&C /Hysterectomy – Simple hyperplasia
of endometrium
- Refused Hysterectomy
Uterine Balloon Therapy
CASE STUDY-6
56 years multi gravida
Pain in lower abdomen + ; No Postmenopausal Bleeding
• Appears well
• BMI < 25, 60 kg
• Normotensive
• General exam unremarkable
• Speculum: CERVICAL POLYP
• Ultrasound - Uterus normal, endometrium 12 mm, Both
ovaries normal
• INFLAMMATORY POLYP AND TUBERCULAR
ENDOMETRITIS
ATT Given
- EB &
- Hysteroscopy
RISK ASSESSMENT
THE DURATION OR AMOUNT
(STAINING VS GROSS) OF BLEEDING
DOES NOT MAKE ANY DIFFERENCE.
IT GIVES NO CLUE TO DIAG.
SAME IS TRUE FOR ENDOMETRIAL
THICKNESS.
DIAGNOSTIC TOOLS
• Vaginal ultrasonography.
• Saline infusion sonography
(Hydrosonography)
• Office Endometrial biopsy.
• Conventional F/C or D/C
• Hysteroscopic guided biopsy.
Sensitivity and specificity are
often used to summarise the
performance of a diagnostic test.
Sensitivity is the probability of
testing positive if the disease is
truly present.
Specificity is the probability of
testing negative if the disease is
truly absent.
VAGINAL ULTRASOUND
VAGINAL ULTRASOUND
Although the test is very
specific , it isn't sensitive. Many
women without endometrial
cancer will have an endometrial
thickness of 4 mm or more
A CUT-OFF THRESHOLD OF 3
MM OR 5MM ?
cut-off point of 3 mm is less likely to
miss cancer than cut-offs of 5 mm.
But unfortunately a lower cut-off means
a greater proportion of women
requiring invasive investigation.
THE PATIENT RISK GROUP
•Low pre-test probability
•On HRT
•On tamoxifen therapy
Cut off threshold 5mm
• High
pre-test
Probability (high risk)
Cut off threshold 3mm
Endometrial polyp in hyperechoic thickened endometrium
SALINE – INFUSION
SONOGRAPHY
The introduction of intrauterine
fluid (saline-infusion sonography)
during transvaginal ultrasound is
one of the most significant
advances in ultrasonography of
the past decade.
SALINE – INFUSION
SONOGRAPHY (SIS)
Uterine fibroids and adenomyomas
generally are apparent on ultrasound.
Uterine polyps may appear as a
thickened endometrial stripe, but these
and submucous myomas can be clearly
identified as filling defects when a SIS is
performed
At transvaginal ultrasonography , the finding of a
thickened central endometrial complex, with or
without cystic changes, is often
nonspecific.
The Thickened endometrium may
be a polyp
CYST
POLYP
With polyps the endometrial-myometrial
interface is preserved
well-defined, homogeneous,
isoechoic to the endometrium
The Thickened endometrium may
be a polyp
catheter
POLYP
With polyps the endometrial-myometrial
interface is preserved
• Office Endometrial Biopsy
A useful suction endomtrial sampling (Probet) with
3.1 mm in outside diameter and no pump or syringe
required.
An endometrial suction sampling with syringe
vacuum
SAMPLING OF THE
ENDOMETRIUM
• OFFICE BIOPSY PROCEDURE (Probet
Endometrial Curette, Vabra aspirator,
Karman cannula) will agree with a D&C
under GA ~95% of the time
• Office biopsy has a 16% false negative
rate when the lesion is a polyp or the
cancer covering less than 5% of the
endometrium
– Guido et al. J Reprod Med. 1995;40:553
DILATATION AND CURETTAGE
“Gold STANDARD”
Preoperative D&C will agree with
diagnosis at hysterectomy - 95% of
the time
The role today of the formal D&C or F/C
probably is very limited because the
diagnosis usually can be made in the
office by endometrial biopsy (95%).
OFFICE HYSTEROSCOPICDIRECTED BIOPSY
Hysteroscopic visualization has several
advantages:
immediate office evaluation,
visualization of the endometrium and
endocervix,
the ability to detect minute focal
endometrial pathology and to perform
directed endometrial biopsies.
ACOG/ CANADIAN (SOGC)
WHAT TO DO?
CLINICAL PRACTICE GUIDELINES
2000
• Endometrium ≥ 4, even if No bleeding
• Abnormal vaginal bleeding after
menopause
↓
• Endometrial Cancer must be ruled out
A SYSTEMATIC REVIEW
OF 90 STUDIES AND META-ANALYSIS
ENDOMETRIAL THICKNESS
MEASUREMENT FOR DETECTING
ENDOMETRIAL CANCER IN WOMEN
WITH POSTMENOPAUSAL BLEEDINg:
Opmeer BC, Khan KS et.al
(Obstet Gyneol 2010;116:160-7)
Meta analysis 90 Studies of
POST MENOPAUSAL BLEEDING
• OVERESTIMATED THE
DIAGNOSTIC ACCURACY OF
ENDOMETRIUM THICKNESS
• CRITICAL THICKNESS – 3 MM TO
R/O ENDOMETRIAL CARCINOMA
Opmeer & Kan
Obsted Gynee 2020
•unexplained
CRITICAL THICKNESS – 3 mm
No Bleeding
TVS
Endometrial
Endometrial
thickness is < 3mm
thickness is > 3mm
If low risk
If high risk
follow
fail to do If
office endometrial
biopsy and SIS
D/C biopsy OR
Hysteroscopy
Or both
But symptoms
persist
IN WOMEN WITH CONTINUED BLEEDING AFTER A NEGATIVE INITIAL
EVALUATION, FURTHER TESTING
WITH HYSTEROSCOPICALLY DIRECTED BIOPSY IS ESSENTIAL,
Post Menopausal Bleeding
TVS
Office Endometrial Biopsy
Unsatisfactory, unable to do
Low Risk for Ca
High Risk for Ca
D&C
(D&C + hysteroscopy)
± Hysteroscopy
POST MENOPAUSAL BLEEDING
(Our Experience)
Etiology
%
Atrophic Endometrium
31
Endo. Hyperplasia (simple
complex, atypical)
Endometrial Ca.
26
Polyp endo/ cervical
6
Proliferative Endo (Exogenous
1
14
Estrogen)
Total (Jan 2007 – till date)
78
Post Menopausal
Endometrium
Endometrium
(mm)
<5
Number of
Patient
32
<10
16
Cervical Polyp- 3,
Endo. Polyp-3,
Cancer – 1,
Simple Hyperplasia-9,
>10
30
Carcinoma- = 12
Submucous fibroid-1,
Simple hyperplasia - 14
Complex hyperplasia-2
Atypical = 1
Total
78
Details
Atrophic-31,
Cancer-1
NORMAL ENDOMETRIUM
ENDOMETRIAL POLYP
POLYP AND ATYPICAL HYPERPLASIA
ENDOMETRIAL CANCER:
TRANSVAGINAL ULTRASOUND SCREENING
< 5 mm Endo strip also showed CA.
ENDOMETRIAL CANCER:
TRANSVAGINAL ULTRASOUND SCREENING
6 – 10 mm Endo strip also showed CA.
ENDOMETRIAL CANCER:
TRANSVAGINAL ULTRASOUND SCREENING
Fluid
Endometrium: Post-menopausal
atrophy
ENDOMETRIAL SIMPLE
HYPERLASIA
ENDOMETRIAL HYPERLASIA COMPLEX
ENDOMETRIAL HYPERPLASIA ATYPICAL
GRADE 1 ENDOMETROID
CARCINOMA
GRADE 3 ENDOMETROID CARCINOMA
ENDOMETRIAL CARCINOMA:
POOR PROGNOSIS CELL TYPES PAPILLARY SEROUS
ENDOMETRIAL CARCINOMA - POOR
PROGNOSIS CELL TYPES CLEAR CELL