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

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Presentation on theme: "Abnormaal vaginaal bloedverlies Dirk Timmerman UZ KU Leuven 2de Master Arts, 28 april 2010."— Presentation transcript:

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

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

3 Abnormaal bloedverlies Echografie? Endometriumdikte Endometriumdikte Bijkomende informatie: Bijkomende informatie:  Morfologie  Hydrosonografie (SIS)  Kleuren Doppler Ambulante hysteroscopie Ambulante hysteroscopie

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

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

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

7 Fibroom Poliep

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

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

10 Adenomyosis: presenting symptoms Diffusely enlarged uterus with 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)

11 Adenomyosis: epidemiology About 1% of female patients About 1% of female patients % of hysterectomy specimens (Azziz 1989) % of hysterectomy specimens (Azziz 1989) 31% if 3 sections; 61% if 6 sections (Bird 1972) 31% if 3 sections; 61% if 6 sections (Bird 1972) More often in multiparous women More often in multiparous women Fourth – fifth decade of life Fourth – fifth decade of life

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

13 Adenomyosis Asymmetrical uterine enlargement Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Ill defined hyperechoic & hypoechoic areas Small anechoic cysts Small anechoic cysts

14 Adenomyosis Asymmetrical uterine enlargement Asymmetrical uterine enlargement Ill defined hyperechoic & hypoechoic areas Ill defined hyperechoic & hypoechoic areas Small anechoic cysts Small anechoic cysts Indistinct endometrial-myometrial border Indistinct endometrial-myometrial border

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

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

17 Differential diagnosis Size cm Size cm Concentric, round Concentric, round Sharply defined Sharply defined Degeneration possible Degeneration possible Often calcifications Often calcifications Color Doppler Color Doppler Size cm Inhomogeneous, oval Irregular contour Central necrosis common No calcifications Color Doppler? LeiomyomaLeiomyosarcoma

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


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