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
30%
exogenous estrogens
atrophic endometritis/vaginitis
11%
endometrial cancer
10%
endometrial or cervical polyps 5%
endometrial hyperplasia
10-15%
miscellaneous: cerv. ca., uterine sarcoma, urethral caruncle, trauma

3. Abnormaal bloedverlies Echografie?
Endometriumdikte
Bijkomende informatie:
Morfologie
Hydrosonografie (SIS)
Even more why do I need to take the biopsy side? Last year like Prof Goldstein now I tried to convince you that US is excellent to assess women with abnl bleeding
Kleuren Doppler
Ambulante hysteroscopie

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

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

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

7. Fibroom
Poliep

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

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

10. Adenomyosis: presenting symptoms
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)
Symptoms are not specific, but may rise attention to the presence of adenomyosis

11. Adenomyosis: epidemiology
About 1% of female patients
5 - 70% of hysterectomy specimens (Azziz 1989)
31% if 3 sections; 61% if 6 sections (Bird 1972)
More often in multiparous women
Fourth – fifth decade of life
The diagnosis strongly relies on patience of the pathologist

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

13. Adenomyosis Asymmetrical uterine enlargement
Ill defined hyperechoic & hypoechoic areas
Small anechoic cysts
In about 50% of cases small (1-6 mm) anechoic cysts are visualised

14. Adenomyosis Asymmetrical uterine enlargement
Ill defined hyperechoic & hypoechoic areas
Small anechoic cysts
Indistinct endometrial-myometrial border
Dysruption of endometrial-myometrial interface (EMI)

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

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

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

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