Gynaecology update

Osama Abughazza MRCG, MScConsultant O&G

Royal Surrey County Hospital

• Changes in Colp guidelines• Ovarian Cancer- BMJ paper • Endometrial Ca. Endometrial thickness • EPAU • Hysterectomy for benign indications • Case presentation

Colposcopy

• HR-HPV testing 1. For triage2. Test of cure

• Cost effectiveness

HR-HPV for triage

• HR-HPV triage reduces the need for follow up cytology

• In UK -Borderline 3.8% of all smears (127,367)-mild 2.2% of all smears (74,757)

-must have three negative smears before returning to routine recall

-BNC HR-HPV –ve 46%-Mild dyskaryosis HR-HPV -ve 16.1%

Data from pilot study

• BNC & +ve HR-HPV -CIN2+ 21.5% -Colp neg +/- Bx 45%

• Mild & +ve HR-HPV-CIN2+ 30%-Colp neg +/- Bx 37.10%

• -if colposcopy +/- biopsy is negative then CIN is excluded and women can be returned safely to normal recall

• What is the risk of women developing CIN2+ having returned to normal recall after a negative satisfactory colposcopy and who been initially referred through HR-HPV-Triage??

- Only 4.4% had CIN2 and 2.4% had CIN3 at 3 years after a negative satisfactory colposcopy

-In a screened population the rate of CIN2+ is 1.2%

HR-HPV as test of cure

• Test of cure at 6 months after treatment -90% will be double negative after LLETZ for CIN2+-8% had abnormal cytology (CIN2 13.6%, CIN3 8.3%)-13% were cytology negative/HR-HPV positive (CIN2 2.9%, CIN3 0.4%)

• Cytology of women who were discharged to normal recall after double negative test of cure

-84% had a negative cytology at 3 years recall -7% only had a low grade cytology/HR-HPV negative. -The risk of CIN2+ of women who failed test of cure at three years and negative colposcopy was only 2%

Summary

• HR-HPV triage reduces the need for F/U cytology

• HR-HPV triage allows early diagnosis and treatment of HG CIN and early return to normal recall

• Addition of HR-HPV for test of cure allows women who have been treated for CIN to return to normal recall

Ovarian Cancer • The 7th most common cancer in

women worldwide

• Higher incidence in developed regions

• Incidence is highest in the 50-70 year old group (75% of cases diagnosed in women aged > 55 years).

• UK, 80% of women present with advance disease

• UK, low 5 year survival rate (47%, it is the leading cause of death from gynae. Cancers)

What are the risk factors??• Epidemiological risk factors nulliparity, H/O breast ca, family H of breast or ovarian ca.,

post-menopause and use of HRT.

• Genetic risk factors BRCA1, by age 70 the lifetime risk of ovarian cancer and

breast cancer in women as much as 63% and 85%, respectively.

BRCA2 mutation it is as much as 27% and 84%, respectively

Diagnostic dilemma Non-specific symptoms (abdominal distension, bloating, feeling of fullness or

loss od appetite, pelvic or abdominal pain, increase of urinary urgency or frequency, weight loss, fatigue or changes in bowl habit, IBS).

One in two women between the age of 45 and 70 consult their GPs with these symptoms

Analysis of routes to diagnosis in routinely collected national datasets shows

-almost one third of women with ovarian cancer in the UK receive a diagnosis through emergency department and a further third through cross specialty referrals.

What does NICE recommend? • Measure serum CA125 in primary care in women with symptoms that

suggest ovarian cancer.

• If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis.

• For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:

• assess her carefully for other clinical causes of her symptoms and investigate if appropriate

• if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent.

U/S for ovarian massesB&M rules

• Simple U/S rules were developed to help classify masses as benign (B-rules) or malignant (M)

• Using these rules the reported sensitivity was 95%, specificity 91%, positive likelihood ratio of 10.37 and negative likelihood ratio of 0.06.

• Unilocular cysts (that is, fluid-containing cysts), measuring <5 cm on ultrasonography are reassuring and associated with a less than 1% risk of malignancy.

(Timmerman D, et al; Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008;31:681–90)

B Rules M Rules

Unilocular cysts Irregular solid tumour

Presence of solid components where the largest solid component <7 mm

Ascites

Presence of acoustic shadowing

At least four papillary structures

Smooth multilocular tumour with a largest diameter <100 mm

Irregular multilocular solid tumour with largest diameter ≥100 mm

No blood flow Very strong blood flow

Simple ovarian cyst, consensus from the society of radiologist

• Asymptomatic simple cysts 30–50 mm in diameter do not require follow-up, cysts

• 50–70 mm require follow-up,

• Cysts more than 70 mm in diameter should be considered for either further imaging (MRI) or surgical intervention due to difficulties in examining the entire cyst adequately at time of ultrasound.

vine D et al; Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010;256:943–54.

Endometrial Ca. Risk factors for endometrial cancer

• BMI, DM, HTN, Patients with a past history of hyper-oestrogenism (endogenous or exogenous) - may be indicated by an early menarche and/or late menopause.

• Younger patient with PCOS and obesity may be at risk from endometrial hyperplasia/ cancer at less than 40 years old.

• HRT use:• Older HRT regimens that utilise unopposed oestrogen increase the relative risk of endometrial carcinoma by

around six times after five years of use• newer HRT regimens contain progestogens (10-12 days of cyclical progestogens or continuous combined

regimens) to prevent endometrial hyperplasia and cancer - reduces the relative risk of endometrial cancer to around 1.5

• Tamoxifen use:• increases risk of endometrial cancer by 3-6 fold• risk of endometrial cancer estimated to be substantially higher than 10% in tamoxifen users• risk rises with both the use of higher doses and increasing duration of use (particularly for longer than 5 years)

• Hereditary non-polyposis colorectal cancer (HNPCC):• characterised by a familial aggregation of colorectal cancer in addition to extra-colonic cancers (of which

endometrial cancer is the commonest)• Estimated lifetime risk of developing endometrial cancer in women carrying these mutations is around 42-60%

TVS, Endometrial thickness cut off • The thicker the higher the risk• Debate as to whether 3,4,5mm should be used in PMB• Research• A meta-analysis 6000 women with PMB found that using a cut-off 5mm, the risk of

disease following a normal test (i.e. < 4mm) was reduced by ten-fold to 1% compared with the pre-test risk 10% (the background risk of endo. Ca. in women with PMB)

• This corresponded to an overall sensitivity to detect endometrial ca 96% (95% CI 94-98).• Specificity was lower in those women taking HRT at all endometrial cut-off levels. • At the 5mm cut-off 8% of normal histology had no HRT whereas 23% of where on HRT)

(Smith-Bindman R et al; Endovaginal U/S to exclude endometrial cnacer and other endometrial abnormalities. JAMA 1998, 280:1510-17).

• Using a curettage in 1168 women presenting with PMB when a cut of was < 5mm no single malignancy case was found. (Karlsoon et al; TVS of endometrium in women with PMB: a Nordic multicenter study. Am J Obstet Gynecol 1995; 172: 1488-94))

Early pregnancy complications • Incidence of ectopic pregnancy 11.3/1000 pregnancies (stable since 1988 report)

• Mortality rate is declining (16.9/100 000) was 60/100 000 (1988-1990)

• Ectopic Be aware of unusual presentations -shoulder tip pain, rectal pain, D&V (4 out of 6 who died had D&V in the last triennium) , failing faint. -P/V spotting with no pain please refer to EPAU -Secondary Amenorrhea due to IUS or PCOS- think ectopic or abnormal bleeding on any hormonal contraceptive- think pregnancy.

• Defining Miscarriage NICE recent changes -Mean GS of > 25mm or CRL > 7mm with no FHB on TV U/S-Introducing medical management.

• Recurrent miscarriage -Thrombophilia screen, 3D U/S, role of progesterone (Promise study)

Mean age stratified by hysterectomy approachBenign indications for hysterectomy in England 1998-2009

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 200936.00

38.00

40.00

42.00

44.00

46.00

48.00

50.00

Mean age of women having different routes to hysterectomy 1998-2009

openvaginal laparoscopic

mea

n ag

e

In 1998 mean age was 44.6(SD 8)In 2009 mean age was 47 (SD 8)

19981999

20002001

20022003

20042005

20062007

20082009

0

5

10

15

20

25

30

35

Percentage of hysterectomy by indication from 1998 to 2009

FibroidAbnormal uterine bleeding Prolpase Endometrisis and pelvic painOvarian cyst benign Cx dysplasia/ peri and postmenopausal bleeding PID

%

Benign indications for hysterectomy in England 1998-2009

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

5

10

15

20

25

30

35

Percentage of hysterectomy by indication from 1998 to 2009

FibroidAbnormal uterine bleeding Prolpase Endometrisis and pelvic painOvarian cyst benign Cx dysplasia/ peri and postmenopausal bleed-ing PID

%

Approaches to hysterectomy for menorrhagia in the absence of uterine fibroids or POP

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

10

20

30

40

50

60

70

80

90Methods of hysterectomy for abnormal uterine bleeding

Open Vaginal Laparoscopic Unclassifed

% o

f hys

tere

ctom

ies b

y ap

proa

ch

years

Case presentation• 47yrs old, Asian • Presented to A&E with 2-3 week history of fatigue and shortness of breath• Referred to gynaecology as had on-going P/V bleeding• LMP Feb 2015 – on-going bleeding since, heavy with clots• Saw GP in March

– 2-3/52 hx of SOB/fatigue/metallic taste in mouth– Reduced appetite– Increased urinary frequency– Weight loss of 6-8kg since January– Bloods – Hb 8.7– USS – uterine fibroid (result not available to us)– anaemia secondary to menorrhagia

– ? P2 2 x NVDs 2000 and 20021x STOP 2005 – followed by sterilisation

• Findings– HR 109, BP 111/58, T 36.9, RR 19, Sats 99% OA– Chest clear– Abdomen sot and non tender– VBG – Hb 8.2, lactate 1.1, Gluc 7.1– CRP 93, WCC 10.2, U&Es + LFTs + clotting normal

• Plan– Cross match 2 units– CXR

Chest X-RayThere multiple bilateral confluent non-cavitating airspace opacifications affecting the mid and lower zones mainly. It is difficult to ascertain whether there is an amalgamation of these opacities at the right cardiophrenic angle or just one large mass. No collapse, pleural effusion or cardiomegaly. Malignancy is most likely to explain these findings.

• Urine HCG positive• CT chest-abdo-pelvis • Appearances are those of a likely uterine

tumour, with multiple pulmonary metastases• Imp – GTN ? Choriocarcinoma Stage 4• Immediately referred to Charing Cross• Chemotherapy started• 2 cycles completed, third due this week

(Cisplatin and Atoposide)• Prognosis – 94-95% 5yr survival

Summary

• Think cancer/ectopic

• Reproductive age Urine BHCG Pelvic U/S • Postmenopausal Ca125

• Thank You