Abnormaal vaginaal bloedverlies Dirk Timmerman UZ KU Leuven 2de Master Arts, 28 april 2010

Postmenopausal bleeding Is all postmenopausal bleeding caused by endometrial cancer?  No 30% exogenous estrogens atrophic endometritis/vaginitis 11% endometrial cancer 10% endometrial or cervical polyps 5% endometrial hyperplasia 10-15% miscellaneous: cerv. ca., uterine sarcoma, urethral caruncle, trauma

Abnormaal bloedverlies Echografie? Endometriumdikte Bijkomende informatie: Morfologie Hydrosonografie (SIS) Even more why do I need to take the biopsy side? Last year like Prof Goldstein now I tried to convince you that US is excellent to assess women with abnl bleeding Kleuren Doppler Ambulante hysteroscopie

TVS en endometriumdikte: Is dit alles wat we nodig hebben?

PMB: Endometriumdikte Prevalentie van endo ca: 11% < 5mm 15 endo ca/ 1113 (1.4%) > 5mm 248 endo ca/ 1247 (20%) (Meta-analysis by Timmerman &Vergote 1997 : 20 studies)

Endometrial thickness at TVS? Only a normal and thin endometrial line is informative

Fibroom Poliep

Limitations of hydrosonography Cost? Double compared to TVS alone Time to perform? Extra 5 minutes Side effects: infection: very rare spilling of malignant cells? Yes. Patient discomfort? Minimal Does it change management? Sometimes

Adenomyosis uteri Common gynecologic disorder Heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia First described by Rokitanski (Rokitansky, 1860)

Adenomyosis: presenting symptoms Diffusely enlarged uterus with menorrhagia (40-50%) dysmenorrhea (10-30%) metrorrhagia (10-12%) dyspareunia (typically 1 wk prior menstruation) dyschezia (typically 1 wk prior menstruation) Symptoms are not specific, but may rise attention to the presence of adenomyosis

Adenomyosis: epidemiology About 1% of female patients 5 - 70% of hysterectomy specimens (Azziz 1989) 31% if 3 sections; 61% if 6 sections (Bird 1972) More often in multiparous women Fourth – fifth decade of life The diagnosis strongly relies on patience of the pathologist

Adenomyosis: morphology Asymmetrical uterine enlargement (or globular appearing uterus)

Adenomyosis Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Small anechoic cysts In about 50% of cases small (1-6 mm) anechoic cysts are visualised

Adenomyosis Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Small anechoic cysts Indistinct endometrial-myometrial border Dysruption of endometrial-myometrial interface (EMI)

Differential diagnosis Adenomyosis Fibroid Elliptical Poorly defined borders Lack of mass effect No calcifications Color Doppler Concentric, round Sharply defined Mass effect Often calcifications Color Doppler

Morphology of flow Fibroid: circular flow Polyp: pedicle Endometrial cancer: multiple irregular vessels in junctional area Adenomyosis: no clear changes in normal flow pattern

Differential diagnosis Leiomyoma Leiomyosarcoma Size 0 - 5 cm Concentric, round Sharply defined Degeneration possible Often calcifications Color Doppler Size 5 - 18 cm Inhomogeneous, oval Irregular contour Central necrosis common No calcifications Color Doppler?

Abnormal bleeding History, clin. exam, PAP, TVS +Doppler (SIS only if indicated) Exclusion of adnexal pathology Hysteroscopic resection (polyp / myoma) Focal pathology No focal pathology Thin endometrium Thick endometrium Biopsy DUB Medic. R/ Surgery