SYB #3 Jordan Torok Class of 2010 December 16 th, 2008.
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Transcript of SYB #3 Jordan Torok Class of 2010 December 16 th, 2008.
SYB #3Jordan Torok
Class of 2010
December 16th, 2008
Chiefest Complaint 78 year old obese non-smoking woman
with two weeks of post-menopausal bleeding and menstrual-like cramping
Reportedly intermittent over the past 3 to 4 years
Current medications include verapamil & Diovain (HTN), Paxil (depression/anxiety) and omeprazole (PUD)
Causes of PMB Atrophy (59 percent) Polyps (12 percent) Endometrial cancer (10 percent) Endometrial hyperplasia (9.8 percent) Hormonal effect (7 percent) Cervical cancer (less than 1 percent) Other (eg, hydrometra, pyometra,
hematometra: 2 percent) http://www.uptodate.com/online/content/topic.do?topicKey=gen_gyne/15883&selectedTitle=1~20&source=search_result
1st best test for PMB? Must exclude malignancy
Endometrial biopsy
vs
Transvaginal Ultrasound (TVU)
Biopsy vs TVU Recommended initial
test due to its high sensitivity
Low cost Low complication rate Not sensitive for
diagnosing structural abnormalities like polyps
Those who can’t tolerate office biopsy
Centers not equipped to perform biopsy
Women who also require evaluation of the adnexae or myometrium
Not adequate for those on ERT
TVU technique Scanning in the
saggital view Measure endometrial
thickness in an AP dimension from one basalis layer to the other, excluding any fluid within the cavity
TVU: concerning findings Endometrial lining thicker than 5 mm; cancer
becomes more certain as 20 mm is approached Endometrium shows diffuse or focal increased
echogenicity (heterogeneity) Endometrium not well visualized
Concerning findings warrant an endometrial biopsy while a thin, homogenous endometrium can reasonably exclude endometrial cancer
Findings/Impression Findings:
Endometrioma is significantly thickened measuring 2 cm in width with multiple central cysts and internal flow this likely representing neoplasm.
There is a left exophytic uterine mass thought to represent leiomyoma measuring 2 cm x 2.5 cm x 2.4 cm. Otherwise remainder the uterus is unremarkable. Ovaries are unremarkable with the right measuring 2 cm x 1.3 cm x 1.2 cm and the left measuring 1 cm x 5 mm x 1.6 cm.
Impression: Findings extremely worrisome for endometrial carcinoma. Exophytic leiomyoma.
Endometrial biopsy Scant stips of unremarkable glandular
epithelilum, may prepresent lower uterine segment or endometrium
Immature squamous endocervical metaplasia
No features of endometrial hyperplasia or malignancy although sample very small
Operative Note: D&C, hysteroscopy
Normal endocervical canal Atrophic endometrium Very large polyp filling the uterine cavity-
polypectomy performed
Surgical Specimen Endometrial curretage: again shows minute
stromal and glandular tissue, negative for malignancy or hyperplasia
Excised polyp: endometrial polyp, negative for malignancy
Endometrial Polyps Localized hyperplastic overgrowth of endometrial
glands and stroma around a vascular core Sessile or pedunculated projection from the
surface of the endometrium Incidence increases starting at 20, peaks in the 5th
decade and declines after menopause Present primarily as metrorrhagia or PMB Best test for evaluation is sonohysterography
(A) Sagittal transvaginal sonogram shows endometrial polyp (arrows) in fundus. Endometrium appears thick and is difficult to measure. (B) Sagittal sonohysterogram shows single round 1.9-cm echogenic polyp (arrow). Note otherwise thin endometrium (2 mm). Reproduced with permission from Joizzo, JR, Chen, MY, Riccio, GJ, Endometrial Polyps: Sonohysterographic Evaluation. AJR Am J Roentgenol 2001; 176:617. Copyright © 2001 American Journal of Roentgenology.