SYB #3 Jordan Torok Class of 2010 December 16 th, 2008

Chiefest Complaint 78 year old obese non-smoking woman with two weeks of post-menopausal bleeding and menstrual-like cramping Reportedly intermittent over the past 3 to 4 years Current medications include verapamil & Diovain (HTN), Paxil (depression/anxiety) and omeprazole (PUD)

Causes of PMB Atrophy (59 percent) Polyps (12 percent) Endometrial cancer (10 percent) Endometrial hyperplasia (9.8 percent) Hormonal effect (7 percent) Cervical cancer (less than 1 percent) Other (eg, hydrometra, pyometra, hematometra: 2 percent) &source=search_result

1 st best test for PMB? Must exclude malignancy Endometrial biopsy vs Transvaginal Ultrasound (TVU)

Biopsy vsTVU Recommended initial test due to its high sensitivity Low cost Low complication rate Not sensitive for diagnosing structural abnormalities like polyps Those who can’t tolerate office biopsy Centers not equipped to perform biopsy Women who also require evaluation of the adnexae or myometrium Not adequate for those on ERT

TVU technique Scanning in the saggital view Measure endometrial thickness in an AP dimension from one basalis layer to the other, excluding any fluid within the cavity

TVU: concerning findings Endometrial lining thicker than 5 mm; cancer becomes more certain as 20 mm is approached Endometrium shows diffuse or focal increased echogenicity (heterogeneity) Endometrium not well visualized Concerning findings warrant an endometrial biopsy while a thin, homogenous endometrium can reasonably exclude endometrial cancer

Findings/Impression Findings: Endometrioma is significantly thickened measuring 2 cm in width with multiple central cysts and internal flow this likely representing neoplasm. There is a left exophytic uterine mass thought to represent leiomyoma measuring 2 cm x 2.5 cm x 2.4 cm. Otherwise remainder the uterus is unremarkable. Ovaries are unremarkable with the right measuring 2 cm x 1.3 cm x 1.2 cm and the left measuring 1 cm x 5 mm x 1.6 cm. Impression: Findings extremely worrisome for endometrial carcinoma. Exophytic leiomyoma.

Endometrial biopsy Scant stips of unremarkable glandular epithelilum, may prepresent lower uterine segment or endometrium Immature squamous endocervical metaplasia No features of endometrial hyperplasia or malignancy although sample very small

Operative Note: D&C, hysteroscopy Normal endocervical canal Atrophic endometrium Very large polyp filling the uterine cavity- polypectomy performed

Surgical Specimen Endometrial curretage: again shows minute stromal and glandular tissue, negative for malignancy or hyperplasia Excised polyp: endometrial polyp, negative for malignancy

Endometrial Polyps Localized hyperplastic overgrowth of endometrial glands and stroma around a vascular core Sessile or pedunculated projection from the surface of the endometrium Incidence increases starting at 20, peaks in the 5 th decade and declines after menopause Present primarily as metrorrhagia or PMB Best test for evaluation is sonohysterography

(A) Sagittal transvaginal sonogram shows endometrial polyp (arrows) in fundus. Endometrium appears thick and is difficult to measure. (B) Sagittal sonohysterogram shows single round 1.9-cm echogenic polyp (arrow). Note otherwise thin endometrium (2 mm). Reproduced with permission from Joizzo, JR, Chen, MY, Riccio, GJ, Endometrial Polyps: Sonohysterographic Evaluation. AJR Am J Roentgenol 2001; 176:617. Copyright © 2001 American Journal of Roentgenology.