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: 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 01/2014; 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; · 1.66 Impact Factor
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ABSTRACT: To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies. Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies. No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52). Using an endometrial thickness cut-off value ≥4mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.European journal of obstetrics, gynecology, and reproductive biology 04/2014; · 1.97 Impact Factor