A 45 yrs. old lady with presented with dysfunctional uterine bleeding on transvaginal USG thickness of endometrium was found to be 8 mm. What should be the nest step in the management of this patient ?
Ans. is a i.e. Histopathology A 45 years old lady is presenting with DUB Chances of endometrial hyperplasia / neoplasia are high. TVS findings show thickness of endometrium as 8 mm. First lets understand what does this signify -Endometrial thickness has been correlated with endometrial cancer risk in pe and post menopausal women. In postmenopausal females with : Atrophic endometrium Endometrial hyperplasia Endometrial cancer Endometrial thickness is 3.4 + 1.2 mm It is 9.7 + 2.5 mm It is 18.2 + 6.2 mm Sensitvities of 95 - 97% have been repoed using a measurement of < 4 mm for exclusion of endometrial cancer. Women with endometrial thickness > 5 mm warrant additional evaluation with saline infusion sonography (515), or hysteroscopy or endometrial biopsy. Also know : Diagnostic alongrithim to identify endometrial pathology in patient with abnormal uterine bleeding and with no risk factors for endometrial cancer. Figure : Diagnostic algorithm to identify endometrial pathology in paients with abnormal uterine bleeding D&C - dilatation & curettage; EMB=endometrial biopsy; SS = saline-infusion sonography; TVS = transyaginal sonography. 'Endometrium bilayer thickness measurements are used for posmenopausal women. bSIS or hysteroscopy per physician preference. Adequate diagnosis and clinical management should follow. Figure : Diagnostic algorithm to identify endometrial pathology in patients with abnormal uterine bleeding and \\Oh risk factors for endometrial cancer. D&C = dilatation and curettage; EMB = endometrial biopsy; SIS = saline-infusion sonography; TVS = transvaginai sonography. 'TVS or EMB per physican preference. 'Endometrium bilayer > 5 mm (in postmenopausal women) or obvious pathology seen. 'SIS or hysteroscopy per physican preference. 'Adequate diagnosis and clinical management should follow. Extra Edge : Clear cut endometrial thickness giudelines have not been established for premenopausal females. It is generally seen that normal endometrial thickness in premenopausal women does not exceed 4 mm on day 4 of menstrual cycle and 8 mm by day 8. A persistent finding of endometrial thickness > 12 mm independant of cycle day should prompt fuher evaluation in these women, especially in those with risk factors for endometrial carcinoma. Summary of diagnostic procedures in case of DUB if endometrial neoplasia is suspected : - There is is no clear sequence to the use of endometrial biopsy, TVS, SIS and hysteroscopy when evaluating abnormal uterine bleeding. - TVS - as it is well tolerated, cost effective and requires minimal technical skill is the first logical step. It addition TVS can determine whether a lesion is diffuse or focal - If endometrial hyperplasia / neoplasia is suspected - then endometrial biopsy is done. If there is a focal leison - either hysteroscopy or SIS is done.
Histopathology
Hysterectomy
Progesterone
OCP