Abnormal uterine and post-menopausal bleeding in the acute gynaecology unit
ABSTRACT Abnormal uterine bleeding is one of the most common presentations in the acute gynaecology unit. The general principles of emergency care, including assessment of haemodynamic state, symptomatic relief as well as determination of underlying aetiology, apply to these women. We review different strategies in the diagnosis and investigation of abnormal uterine bleeding in both pre- and post-menopausal women. Transvaginal ultrasound (TVS) with colour Doppler is the cornerstone of initial management. TVS, in experienced hands, can reliably exclude the most common intra-cavitary pathologies including endometrial polyps and submucosal fibroids. Their exclusion, in pre-menopausal women, aids in the diagnosis of dysfunctional uterine bleeding. In post-menopausal women, the endometrial thickness reliably selects those who need further testing. If a thin and regular endometrium is visualised, malignancy is most unlikely. To allow for reliable evaluation of the endometrium, TVS has to be performed before endometrial sampling. Saline infusion sonohysterography (SIS) is most valuable in the detection of focal intra-cavitary lesions. TVS with or without SIS can provide enough information to avoid an unnecessary hysteroscopy. In this review, we will also discuss an evidence-based algorithm for the work-up of women with post-menopausal bleeding.
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ABSTRACT: Our primary aim was to assess how patients' characteristics, bleeding pattern, sonographic endometrial thickness (ET) and additional features at unenhanced ultrasound examination (UTVS) and at fluid instillation sonography (FIS) contribute to the diagnosis of intracavitary uterine pathology in women presenting with abnormal uterine bleeding (AUB). We further aimed to report the prevalence of pathology in women presenting with AUB. 1220 consecutive women presenting with AUB underwent UTVS, colour Doppler imaging (CDI) and FIS. Most women (n = 1042) had histological diagnosis. Mean age was 50 years and 37% were postmenopausal. Of 1220 women 54% were normal, polyps were diagnosed in 26%, intracavitary fibroids in 11%, hyperplasia without atypia in 4% and cancer in 3%. All cancers were diagnosed in postmenopausal (7%) or perimenopausal (1%) women. ET had a low predictive value in premenopausal women (LR+ and LR- of 1.34 and 0.74, respectively), while FIS had a LR+ and LR- of 6.20 and 0.24, respectively. After menopause, ET outperformed all patient characteristics for the prediction of endometrial pathology (LR+ and LR- of 3.13 and 0.24). The corresponding LR+ and LR- were 10.85 and 0.71 for CDI and 8.23 and 0.26 for FIS. About half of the women presenting to a bleeding clinic will have pathology. In premenopausal women, benign lesions are often the cause of AUB. For the prediction of intracavitary pathology ET is of little value in premenopausal women. CDI and FIS substantially improve the diagnostic accuracy.01/2015; 7(1):17-24.
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ABSTRACT: Objective. To develop and test a risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women at risk of intrauterine malignancy. Methods. We prospectively studied 624 postmenopausal women with vaginal bleeding and endometrial thickness > 4 mm undergoing diagnostic hysteroscopy. Patient characteristics and endometrial assessment of women with or without endometrial cancer were compared. Then, a risk-scoring model, including the best predictors of endometrial cancer, was tested. Univariate, multivariate, and ROC curve analysis were performed. Finally, a split-sampling internal validation was also performed. Results. The best predictors of endometrial cancer were recurrent vaginal bleeding (odds ratio (OR) = 2.96), the presence of hypertension (OR = 2.01) endometrial thickness > 8 mm (OR = 1.31), and age > 65 years (OR = 1.11). These variables were used to create a risk-scoring model (RHEA risk-model) for the prediction of intrauterine malignancy, with an area under the curve of 0.878 (95% CI 0.842 to 0.908; P < 0.0001). At the best cut-off value (score ≥ 4), sensitivity and specificity were 87.5% and 80.1%, respectively. Conclusion. Among symptomatic postmenopausal women with endometrial thickness > 4 mm, a risk-scoring model including patient characteristics and endometrial thickness showed a moderate diagnostic accuracy in discriminating women with or without endometrial cancer. Based on this model, a decision algorithm was developed for the management of such a population.BioMed Research International 06/2014; 2014:130569. DOI:10.1155/2014/130569 · 2.71 Impact Factor
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ABSTRACT: Benign uterine disease is a common entity affecting women of all ages. Ultrasound has historically been the predominant imaging method used in the evaluation of benign gynaecological disease, magnetic resonance imaging (MRI) being reserved for use in the staging of malignant uterine and cervical disease. MRI is now increasingly used in the diagnosis of benign uterine disease as well as a tool for problem-solving in cases of diagnostic dilemma. It allows detailed assessment of benign conditions, such as endometrial lesions, leiomyomas, and adenomyosis, and can be helpful in the stratification of patients to different treatment modalities, including surgical resection, uterine artery embolization, and medical therapies. In this article, we review the MRI findings in the common benign uterine diseases.Clinical Radiology 07/2014; DOI:10.1016/j.crad.2014.05.108 · 1.66 Impact Factor