External genital examination is unremarkable Speculum and bimanual examination

External genital examination is unremarkable speculum

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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
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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.
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  • Spring '19
  • aneer salor
  • Hysterectomy, endometrial cancer

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