1. POST MENOPAUSAL WOMAN RAGINI REDDY CONSULTANT GYNAECOLOGIST

2.  Endometrial cancer  Normal post menopause  Endometrial polyps  Endometrial hyperplasia  HRT  Tamoxifen Introduction

3.  Fourth common cancer in women  Age specific uterine cancer  TVS useful- triaging women  Excellent screening tool  Non invasive  No risks  Training essential  Further diagnostic tests Endometrial cancer

4.  Common cause for rapid access  2 week referral- limited clinics  TV scan and OPD hysteroscopy – early 1990s  PMB/HRT/SCAN incidental finding  Menopause- 52 years Introduction

5.  Obesity doubled in past 25 yrs  2025-40% britons will be obese and 50% by 2050  Independent risk factor  Referral will increase  Capacity in clinics- problems  Training and experience – essential Introduction

6.  Simple atrophy  Endometrial thickening-  Proliferation  Cystic atrophy  Simple or complex or atypical hyperplasia  Endometrial polyps/Submucous fibroids  Endometrial cancer Normal post menopausal endometrium

7.  Rise menopause- 11.8%-PM (5.8% pre menopause)  Tamoxifen use- 30-60% prevalence  Obesity- increase Estrone  Hypertension- link unclear  Asymptomatic-Incidental-2-12% PMB  PMB- no correlation to size/number/location  Co-existing endometrial polyps-24-27% Endometrial polyps

8.  Malignant risk- 0.3% asymptomatic 3% PMB  Atypical hyperplasia 1.2%- Asymptomatic 2.2%- Symptomatic  Polyp more than 18mm-abnormal – odds ratio for abnormal is nearly 7 times more  Colour Doppler/Saline hysteroscopy/Gel Endometrial polyps

9.  Hysteroscopy is gold standard  Risk of malignancy is low if polyp less than 18 mm in asymptomatic women  Risk of perforation in higher in asymptomatic women  Risk of removal -- assess  Summary-  PMB + >18 mm- remove polyp- Myosure Endometrial polyps

10.  15% of PMB  Simple- 142 per 100 000 women  Complex- 213 per 100 000 women  Complex hyperplasia without atypia-2% Ca  Simple or complex with atypia- 23% risk Ca  Initial Dx Complex atypia - 29% Ca Endometrial hyperplasia

11.  Conservative- Age/Cytological atypia Progestogen- 3 months-Oral/Mirena Mirena- 100% normal after 6 months Oral progestogens-96% continuous- 69% cyclical Endometrial hyperplasia

12.  Thicker endometrium  High incidence of bleeding  Unscheduled bleeding- investigate  TVS - Endometrial thickness >8mm  Hysteroscopy and biopsy HRT

13.  Tamoxifen-  Duration of use  Thickness goes up by 0.75 mm per year  After stopping-decreases by 1.27mm a year  Mirena- prevents polyps only  Raloxifine better- estrogen antagonist on endometrium Tamoxifen

14.  After menopause  Asymptomatic  Vulval and Vaginal itching  Vaginal discharge  PMB  TVS- Normal/Thick endometrium/Fluid  Topical estrogens cream- no progestogen  Long term Atrophic endometritis

15.  5 mm endometrial thickness cut off  If endometrium not seen-hysteroscopy  Not seen - ?Cancer- blurring interface  Incidental endo thickness >5mm- Refer  Asymptomatic women-Endo thickness not a screening tool  Screening Asymptomatic women- not necessary/ Increase procedures Conclusions

16.  Routine screening –Asymptomatic women on HRT not recommended  Endo thickness of less than 5mm- No Ca  HRT women have thicker endometrium  HRT – no difference in incidence of Endo ca  HRT and symptoms and > 8mm- Hysteroscopy+Bx  Tamoxifen – If symptoms Conclusions

17.  PMB - Investigate further  TVS – Screening tool  Incidental polyps- No need to remove  Polyp size and clinical background- remove  Risks of procedure versus removal  Asymptomatic women with thick endo- individual decision-Risks/thickness/TVS other findings  Asymptomatic women post menopause- no need to investigate- not efficacious/cost effective Conclusions

18. ? Any questions

19.  2/6/15 PM  ALL DAY 3/6/15  RING 7838 EXTENSION TVS WORKSHOP