External genital examination is unremarkable speculum

External genital examination is unremarkable. Speculum and bimanual examination are
not performed as she has never been sexually active.
Transvaginal ultrasound was not possible and a transabdominal ultrasound examination
was therefore performed with a full bladder.
Transabdominal ultrasound report : the uterus is normal size and anteverted. The
endometrium could not be clearly visualized. Both ovaries appear normal. Ultrasound view
was restricted by patient adiposity.
Examination under anaesthetic and hysteroscopy : the vagina and cervix appear normal.
Hysteroscopy showed an irregular vascular mass arising from the uterine wall with contact
bleeding. Curettage was performed and products sent for histological examination.
The findings at hysteroscopy are shown in Fig. 22.1.
INVESTIGATIONS
Questions
• What is the likely diagnosis?
• If this is confirmed how would you manage this patient?
Figure 22.1 Hysteroscopy findings. See
Plate 4 for colour image.
55
General gynaecology

ANSWER 22
Postmenopausal bleeding should be considered to be due to endometrial carcinoma until
proven otherwise. In many cases the diagnosis turns out to be benign. However, in this
case early suspicion is raised by the risk factors for endometrial carcinoma:
• type 2 diabetes
• obesity
• nulliparity.
There is also a long history of significant bleeding suggesting a more significant path-
ology. In women who can tolerate the examination, the diagnosis may be made by outpa-
tient endometrial sampling. In this case however, the inability to examine properly meant
it was appropriate to investigate the uterine cavity and the rest of the lower genital tract
under anaesthetic. The diagnosis of endometrial cancer was confirmed on histology report
from the curettage specimen.
Management
Management of endometrial carcinoma is simple total abdominal hysterectomy and bilat-
eral salpingoophorectomy, as 90 per cent of women present with early-stage disease.
Magnetic resonance imaging (MRI) scan prior to the procedure may be carried out to
check for possible lymph node involvement, in which case lymph node biopsy should be
performed at the time of surgery. Cases of stage 2 or greater disease are less common and
need adjuvant radiotherapy.
Histology is needed to stage endometrial cancer:
• stage 1 : confined to the body of the uterus
•
1a limited to the endometrium
•
1b invasion only of the inner half of the myometrium
•
1c invasion to the outer half the of the myometrium
• stage 2 : involving the uterus and cervix only
• stage 3 : extending beyond the uterus but not beyond the true pelvis
• stage 4 : extending beyond the true pelvis or into the bladder or rectum.
The woman should be advised that the prognosis is generally good with over 70 per cent
survival at 5 years for stage 1 disease, though it is only 10 per cent for stage 4 disease.