Timothy J. Duncan

Outcome of investigations for postmenopausal vaginal bleeding in women under the age of 50 years

OBJECTIVE The objective of this study is to determine the incidence of endometrial cancer in young postmenopausal women presenting with vaginal bleeding. METHODS Cross-sectional study of postmenopausal women presenting with vaginal bleeding in a gynaecological oncology centre in the United Kingdom. All women underwent transvaginal ultrasound scanning (TVS) as the initial investigation tool to evaluate the endometrium. Endometrial biopsy was performed only in cases where endometrial thickness measured equal to or greater than 5mm. The patients were divided into two groups based on their age: less than 50 years (Group A) and 50 years or older (Group B). RESULTS Over a 57-month period, 4454 women were investigated for postmenopausal vaginal bleeding. Of these, 259 (5.8%) women were diagnosed with endometrial carcinoma. 260 (5.8%) women were younger than 50 years. Endometrial biopsy was not performed in 130 women in Group A that had an endometrial thickness measurement of less than 5mm on ultrasonography. With a median follow-up period of 3 (1-5) years, we found no cases of endometrial cancer in women under the age of 50 that did not undergo endometrial biopsy at the time of initial evaluation. Overall, no cases of endometrial cancer were diagnosed in postmenopausal women under the age of 50 years. CONCLUSIONS We found no cases of endometrial cancer amongst 260 women presenting with postmenopausal vaginal bleeding under the age of 50 years. These women could be investigated on a less urgent basis depending on the available resources.

Comparing the performance of two clinical models in estimating the risk of endometrial cancer in symptomatic postmenopausal women

OBJECTIVE The aim of this study was to internally evaluate the accuracy measures of the two newly developed predictive models, called DEFAB and DFAB, used to estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding. STUDY DESIGN Prospective study including postmenopausal women presenting with vaginal bleeding. RESULTS Over a 46-month-period, 3795 postmenopausal women presented with vaginal bleeding and were included in the study. A total of 221 (6%) women were diagnosed with endometrial carcinoma. The DEFAB predictive model incorporates known risk factors such as presence of Diabetes, Endometrial thickness measurement on transvaginal ultrasonography, Frequency of bleeding, Age, and Body mass index. The DFAB model is based on the above clinical characteristics excluding the ultrasonography result. For the recommended cut-off values, there was no evidence (p-value=0.221) of a difference in the diagnostic ability with respect to sensitivity, specificity, area under receiver operating curve, positive predictive value and negative predictive value. There was strong evidence (p-value<0.0001) to suggest that the diagnostic ability of DEFAB and DFAB agree as evidenced by the excellent Kappa statistic 0.950 (95% CI 0.940-0.960). We found strong evidence (p-value<0.0001) that the variables incorporated in both predictive models simultaneously correctly classify an individual to either having cancer or not having cancer with respect to logistic discriminant analysis. CONCLUSION We recommend that these two predictive models can be used interchangeably.

Management of postmenopausal women with vaginal bleeding when the endometrium can not be visualized

Objective. To determine the risk of endometrial cancer when endometrial thickness is not visualized using ultrasonography. Design. Cross‐sectional study. Setting. Gynecological oncology center in the United Kingdom. Population. All postmenopausal women referred with vaginal bleeding. Methods. All women were investigated using gray‐scale transvaginal ultrasonography. Women were arbitrarily stratified into four groups according to the endometrial thickness measurement. Women with endometrial thickness that was not adequately visualized on ultrasonography were included in a separate group. Main outcome measures. Endometrial cancer diagnosis. Results. Over a 50‐month period, 4454 women were investigated for postmenopausal vaginal bleeding. A total of 259 (6%) of women were diagnosed with endometrial carcinoma. Endometrial thickness measured 5–9.9mm in 1201 (27%), 10–14.9mm in 468 (11%), 15–19.9mm in 209 (5%), and equal to or greater than 20mm in 197 (4%) of women. In 174 (4%) of women, the endometrial thickness was not visualized on transvaginal ultrasonography. For women where the endometrial thickness was not adequately visualized, the final histology included benign endometrium (124), endometrial cancer (26), endometrial polyps (11), endometritis (7), and other pathology (7). The odds of endometrial cancer in women where the endometrial thickness was not visualized were found to be significantly higher than the odds of cancer for women with an endometrial thickness of 5–9.9mm (OR = 5.23, 95%CI 3.10–8.85, p‐value <0.0001). Conclusions. For women presenting with postmenopausal bleeding and where the endometrial thickness cannot be adequately visualized on ultrasonography, hysteroscopic evaluation is recommended.

Postmenopausal vaginal bleeding in women using hormone replacement therapy

Objective To estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding using estrogen–progestogen hormone replacement therapy (HRT) regimens and to assess if the duration of HRT use has an effect on the risk of diagnosing endometrial cancer. Study design Cross-sectional study of consecutive women presenting with postmenopausal vaginal bleeding at a gynaecological oncology centre in the UK. Main outcome measures Endometrial cancer diagnosis. Results Over a 62-month period, 4847 women were investigated for postmenopausal vaginal bleeding. The majority of women (4097, 84.5%) did not use any HRT preparation at the time of initial referral and 750 (15.5%) women were using combined HRT preparations. A total of 298 (6.1%) women were diagnosed with endometrial carcinoma. Women using HRT preparations were significantly less likely to be diagnosed with endometrial cancer compared with women not using HRT (adjusted odds ratio = 0.229, 95% CI 0.116–0.452; P < 0.0001). The longer duration of HRT use did increase the risk of diagnosing endometrial cancer in women presenting with postmenopausal vaginal bleeding, but this was not statistically significant. Conclusions Postmenopausal women presenting with vaginal bleeding and using combined HRT preparations have significantly lower risk of being diagnosed with endometrial cancer when compared with women not using HRT.

Late presentation of metastatic smooth muscle neoplasm of the uterus with low malignant potential

A 48-year-old woman underwent total abdominal hysterectomy with conservation of the ovaries and tubes. Histology showed a well-circumscribed smooth muscle tumor with foci of degeneration (including infarct-type necrosis) but no coagulative tumor cell necrosis and only mild focal cytological atypia. She presented, 24 years later with shortness of breath and abdominal distension and underwent bilateral salpingo-oophorectomy, appendectomy, omental biopsy and para-aortic lymph node sampling. Histology showed bilateral ovarian smooth muscle tumors with no coagulative tumor cell necrosis or significant cellular atypia. The cells were mitotically active. The tumors in both ovaries were most likely secondary to the previous uterine smooth muscle neoplasm. To our knowledge, this case is the first in the literature to describe a benign cellular leiomyoma that subsequently behaved as a smooth muscle tumor of uncertain malignant potential, which recurred 24 years after the initial diagnosis.

Investigation and management of abnormal peri-menopausal bleeding

Abnormal peri-menopausal bleeding is a common clinical problem. Decisions to investigate if the menstrual disorders are related to an underlying pathology or represent physiologic changes are often complex especially as no clear guidance is available. The aim of this review is to present a summary of the current available evidence regarding the investigation tools used to evaluate women with abnormal uterine bleeding during menopausal transition and in the post-menopausal period. In this article, we focus mainly on the investigation and exclusion of endometrial carcinoma, as this represents the most common malignancy diagnosed.

The GELPOINT (Applied Medical) port is a suitable instrument for salpingo-oophorectomy with good rates of patient satisfaction, in particular body image

Laparoscopic single site surgery(LESS) is well established for a number of gynaecological procedures including salpingo-oophorectomy and hysterectomy. There are a number of ports currently available, and although initial reports of cosmesis were mixed [3], there have been reports of greatly improved cosmesis from a small trial from a university hospital in Korea [4, 6]. The method used for analysis of scar appearance was the cosmetic body image score (CBIS) which is a validated body image questionnaire, and the same authors reported good cosmetic outcomes compared to traditional multiport surgery [7]. The same unit provided data suggesting that, for their population, the approach was safe, well tolerated by patients and accepted by surgeons [5]. The GELPOINT single incision port has been used for laparoscopic hysterectomy and bilateral salpingooophorectomy in the USA. According to one case series, similar established methods carry low complication rates of umbilical hernia (0.9 %), conversion to conventional laparoscopy (3 %) or laparotomy (2 %) in the hands of experienced surgeons [1]. A French team have used GELPOINT for para-aortic lymph node dissection and showed the procedure to be safe and feasible [2]. To date, there has been no formal cosmetic assessment of the GELPOINT scars in a European context. We evaluated this type of single incision port which combines the principles of the ALEXIS retractor (Applied Medical) with a gel-based seal system. The specifics of the design obviate the need for reticulated instruments which are often required with many SILS ports. In addition to the surgical feasibility of this novel port in European gynaecological practice, an assessment of patients’ satisfaction with the procedure was included. CBIS was used to evaluate patients post-operatively to determine their satisfaction with their scars (Table 1). In addition, a visual analogue pain score documented their post-operative discomfort. Operative parameters including length of incision, duration of surgery, blood loss and need for addition ports were recorded. Postoperatively, length of stay, blood transfusion and complications (up 6 weeks) were noted.

How to improve training in bowel surgery for gynecological oncologists-experience from a single center in the United kingdom.

Introduction There is now a growing realization of the lack of experience of gynecological oncology trainees in gastrointestinal surgery. Advanced fellowship programs in gastrointestinal surgery have been suggested as a potential solution to this problem. Patients and Methods We present data relating to gastrointestinal procedures performed by the gynecological oncology trainee during a fellowship program over a 3-year period in a single gynecological oncology center in the United Kingdom. Results Over a 36-month period, 369 cases of invasive ovarian cancer were diagnosed in our institute, of which 278 (75.3%) were stage III/IV disease. Bowel surgery was performed in 86 patients (30.9%) with stage III/IV ovarian cancer. A total of 121 gastrointestinal procedures were performed during the study period, as some patients had more than one procedure. We present the procedures the gynecological oncology fellow performed and assisted during this period. Discussion To improve competencies in performing bowel surgery among gynecological oncology trainees, we suggest sustained exposure in bowel surgery over the entire duration of the training program.