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External genital examination is unremarkable. Speculum and bimanual examination arenot performed as she has never been sexually active.Transvaginal ultrasound was not possible and a transabdominal ultrasound examinationwas therefore performed with a full bladder.Transabdominal ultrasound report: the uterus is normal size and anteverted. Theendometrium could not be clearly visualized. Both ovaries appear normal. Ultrasound viewwas 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 contactbleeding. Curettage was performed and products sent for histological examination.The findings at hysteroscopy are shown in Fig. 22.1.INVESTIGATIONSQuestions•What is the likely diagnosis?•If this is confirmed how would you manage this patient?Figure 22.1Hysteroscopy findings. SeePlate 4 for colour image.55General gynaecology
ANSWER 22Postmenopausal bleeding should be considered to be due to endometrial carcinoma untilproven otherwise. In many cases the diagnosis turns out to be benign. However, in thiscase 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 meantit was appropriate to investigate the uterine cavity and the rest of the lower genital tractunder anaesthetic. The diagnosis of endometrial cancer was confirmed on histology reportfrom the curettage specimen.ManagementManagement 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 tocheck for possible lymph node involvement, in which case lymph node biopsy should beperformed at the time of surgery. Cases of stage 2 or greater disease are less common andneed 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 centsurvival at 5 years for stage 1 disease, though it is only 10 per cent for stage 4 disease.