Postmenapausal bleding
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This document discusses the assessment and management of post-menopausal bleeding (PMB). Key points: - PMB occurs at least 1 year after menopause and has a 10-15% risk of endometrial cancer. Transvaginal ultrasound (TVS) is used to measure endometrial thickness (ET). - If ET is less than 4mm, the risk of cancer is very low (<1%) and further testing is not needed. If ET is greater than 4mm or there are risk factors, endometrial sampling through pipelle biopsy or hysteroscopy is recommended. - Hysteroscopy has the highest sensitivity and specificity for diagnosing endometrial pathology
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Phimosis is the inability to retract the foreskin over the glans penis. It can be physiologic in infants or pathologic due to scarring. Paraphimosis occurs when the trapped foreskin becomes edematous behind the glans. Peyronie's disease involves fibrosis and curvature of the penis during erection. Carcinoma penis is an uncommon cancer affecting the penis, which is often associated with HPV infection or phimosis. Treatment options for these conditions include topical creams, circumcision, surgery, and
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Endometrial ca medical student
The document discusses endometrial hyperplasia and endometrial cancer. It defines endometrial hyperplasia as a spectrum of abnormalities in the endometrial glands and stroma that can progress to cancer. Risk factors for hyperplasia and cancer include unopposed estrogen stimulation and obesity. Diagnosis involves endometrial biopsy and dilation and curettage. Most cases of endometrial cancer are endometrioid adenocarcinomas found in postmenopausal women presenting with abnormal bleeding. Treatment involves surgery, radiation therapy, and systemic therapy.
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Epithelial Ovarian carcinoma and role of laparoscopy in EOC
This document summarizes guidelines for evaluating and managing ovarian masses. It provides information on:
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- Ultrasound is preferred for evaluation, and CA-125, menopausal status and ultrasound findings can be used to determine risk of malignancy.
- For malignant or high risk masses, optimal surgical staging including lymph node assessment is recommended. Chemotherapy may be given depending on risk factors.
- Advanced stage disease should receive maximal cytoreductive surgery followed by chemotherapy, with the goal of leaving no macroscopic disease larger than 1cm.
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Overview of Gynaecological Malignancies & Management
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1. Sentinel lymph node biopsy (SLNB) can help identify metastatic nodal spread in gynecologic cancers like cervical, endometrial, vulvar and ovarian cancers and reduce the need for full lymphadenectomy.
2. The sentinel lymph node is the first node to receive lymphatic drainage from the tumor and has the highest likelihood of containing metastatic cells. It can be identified using blue dye, radioactive tracer, or both.
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Postmenapausal bleding
- 1. An Assessment of women with post menopausal bleeding Dr.KG Hewawitharana
- 2. What is PMB ? • Uterine bleeding occurring at least 1 year after amenorrhea • Common condition with incidence of 10% just after menopause • PMB pts have 10-15% risk of endometrial CA • It is vital to exclude CA or precancerous lesion of endometrium
- 3. Possible Causes 𝒏𝒂𝒐𝒈 • Prevalence of endometrial hyperplasia & endometrial polyp is about 40% • PMB may related to Vulva- Vagina-Cervix , tubes or Ovarian Pathology
- 4. Endometrial CA • Most common gynecological cancer • Pretest probability is 10% • Risk factors includes Obesity , Unopposed Estrogens , PCOD , Nulliparity , DM , Endometrial Hyperplasia , HTN , NHPCC , Post menopause , Tamoxifen + Breast CA • 90% present with Vaginal bleeding • ECA risk is 1% if Age <50 yrs • ECA risk is 25% if age reaches 80 yrs
- 6. • Non invasive & acceptable • Likelihood of malignancy high if ET increases • Cutoff ET is 4mm when further investigations for PMB is considered • If ET<4mm , endometrial sampling is not recommended
- 7. Evidence on TVS assessment Test sensitivity specificity PPV NPV Pres test probability Post test probability Smith- Bindman metanalysis 96% with 40% false positive value 10% 1% Gupta systematic RV 2.5% Tabor metanalysis 96% 50% with false negative rate 4% Timmerman metanalysis Previous studies have over estimated
- 8. Summery • Sensitivity 96% • Specificity 75% • False positive 40% • False negative 04% • Pre test probability 10% • Post test probability 1-2.5%
- 9. Cont. • Metanalysis were based on ET 5mm • Only one study has considered ET 4mm cutoff with evidence of no CA progression after 1 year follow up for that cutoff (Gull B et al 2000) • ET<5mm pts can be mx without endometrial sampling with high degree of certainty for absence of malignancy • Since meaningful assessment is not always possible if bleeding persists pts may need further investigation methods
- 10. 2018 ACOG committee opinion If ET less than 4mm – NPV for CA is > 99%
- 12. Endometrial sampling when ET is > 4mm or <4mm with Risk factors of Endometrial CA exists D&C Pipelle Hysteroscopy & biopsy sensitivity 65-92% 99.6% postMP 91% preMP 81% for Hpp 96% specificity ????? >98% 100%
- 13. D & C • Outdated as primary investigation form • 60% cases less than 50% endometrial cavity subjected for sampling • 10% false positive results (Gunner et al,1996)
- 15. Pipelle biopsy • failure rate is 8%-10% • Farrell et al showed 20% of pipelle insufficient pts had some sort of Ut pathology in subsequent Ix • 3% of pipelle insufficient pts had endometrial CA • Insufficient sampling is a reason for further investigation & it is slightly higher than D&C • But there is no difference between D&C and Pipelle when compare hysterectomy specimens
- 17. Hysteroscopy • Current gold standard • In patient or out patient basis • Can do target biopsy
- 18. Positive peritoneal cytology after Hysteroscopy • General Prevalence of PPC = 12-15% • More with normal saline distention medium than CO2 • But working with Saline is easy than CO2 • More with high intrauterine pressure thus it should be less than 80 mmHg • Time duration of procedure has a role
- 19. Work-up Plan
- 20. How to mx asymptomatic High ET pts? • Routine invasive tests not required as CA incidence is less in this type of pts • Hysteroscopy if ET>6mm - commonest (75%) pathology Polyp • For atypical hyperplasia or carcinoma TVS cut-off sensitivity specificity 5mm 77 85.5 5.2mm 80.5 86.2 6.75mm 84.3 89.9
- 21. Malignancy risk with Endometrial polyps • When asymptomatic , prevalence for malignancy is 10 times less than symptomatic patients • Polyp diameter is important as it’s the only variable associated with abnormal histology in asymptomatic patients
- 22. Fluid in Endometrial cavity • Good marker for endometrial pathology in post menopausal female with ET >4mm • If <4mm ET, endometrial fluid presence is not an indication for further invasive investigations • Fluid levels should not incorporate to ET
- 23. Tamoxifen & PMB • Weak estrogenic action on endometrium increase endometrial CA incidence by 3-6 fold • PMB should be the primary trigger for further investigation in this group
- 24. Unscheduled bleeding on HRT • Breakthrough bleeding when on cyclical HRT or any bleeding while on continuous combined HRT • It may take about 6 months for amenorrhea with continuous combined HRT • If bleeding present on Continuous combined regimens after first 6 months or once amenorrhea is established , consider as abnormal & investigate
- 25. Reference TOG 2012/2015 ACOG 724