Diagnostic Imaging Pathways - Bleeding (Post-Menopausal)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult female patients with unexplained postmenopausal bleeding.
Date reviewed: October 2013
Date of next review: 2017/2018
Published: November 2013
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
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Endometrial Polyp
Image 1 (Saline Infusion Sonohysterography): There is a soft tissue structure connected to the endometrium via a thin stalk and supplied by a single blood vessel (arrow). The features are consistent with an endometrial polyp. |
| 2 |  |
Endometrial Polyp
Image 2 : Hysterectomy specimen showing a polyp arising from the fundus of the endometrial cavity. Histological examination confirmed this to be an adenomyoma. |
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Endometrial Cancer Image 3a, 3b (Transabdominal Ultrasound) and 2c (Transvaginal Ultrasound): The uterus is anteverted and measures 77 x 31 x 49mm. There are no signs of fibroids. The endometrium is 17mm thick at the fundus and has a number of cystic spaces within it. No free fluid is seen in the pelvis. Biopsy confirmed endometrial cancer. |
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| 3c |  |
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| 4a |  |
Endometrial Cancer
Image 4a: Hysterectomy showing an extensive endometrioid adenocarcinoma filling the endometrial cavity down to the isthmus. |
| 4b |  |
Image 4b (H&E, x2.5) and 4c (H&E, x10): Uterine curettings showing an endometrioid adenocarcinoma composed of closely packed glands with complex architecture. At high power, the malignant cells are columnar and demonstrate irregular nuclei with prominent nucleoli and occasional mitotic figures. |
| 4c |  |
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Teaching Points
Teaching Points
- Post menopausal bleeding (PMB) is defined as spontaneous vaginal bleeding which occurs more than one year after the date of the last menstrual period
- For women on combined oestrogen/progesterone HRT, investigations are only warranted if the bleeding persists for > 6 months
- Transvaginal ultrasound is the initial imaging modality of choice. It can detect focal abnormalities of the endometrium, as well as measure the endometrial wall thickness which has been correlated with uterine pathology
- Saline infusion sonohysterography involves infusing saline into the endometrial cavity followed by transvaginal ultrasound to improve visualisation of focal endometrial lesions
- Further investigations may include a hysteroscopy and endometrial biopsy
pmb
Post-Menopausal Bleeding
- Defined as spontaneous vaginal bleeding which occurs more than one year after the date of the last menstrual period. For women on combined oestrogen/progesterone HRT, investigations are only warranted if the bleeding persists for > 6 months
us
Transvaginal Ultrasound (TVUS)
- Uses of TVUS include
- To assess focal abnormalities such as polyps and the thickness of the endometrium
- To determine those patients with a thin endometrium who are unlikely to require further investigation 1-4
- In the absence of focal abnormalities, endometrial thickness, morphology and vascularisation as seen with Doppler have been used as markers of endometrial pathology 10
- Endometrium thickness is assessed by measuring the anterior and posterior layers of the endometrium in the sagittal plane and summating the values 11
- This technique has a high reproducibility and high intraobserver and interobserver reliability for experienced radiologists 12,13
- Current recommendations suggest using the same threshold of endometrial thickness for users and non-users of HRT. The risk of endometrial cancer for a thickness < 4mm in users of HRT is 0.1% and in non-users is 1% 14
- With a thickness > 5mm, the sensitivity and specificity of detecting endometrial cancer is 100% and 37-57% respectively 14,15
- The use of transabdominal ultrasound gives a good overall view of the pelvis but is inferior to transvaginal ultrasound for viewing endometrial morphology and measuring endometrial thickness 16
sis
Saline Infusion Sonohysterography (SIS)
- Involves infusing saline into the endometrial cavity followed by transvaginal ultrasound to improve visualisation of focal endometrial lesions
- The sensitivity for detecting endometrial cancer is 96% and for any pathology is 98%. 17 However, it cannot confidently discriminate between benign disease and malignancy 18
- Studies indicate that women prefer this study compared to hysteroscopy 19
haes
Hysteroscopy and Endometrial Sampling
- Based on a meta-analysis of 56 studies, the sensitivity of hysteroscopy for the detection of endometrial cancer is 86.4% with a specificity of 99.2% and positive likelihood ratio of 60.9 20
- Advantages
- Allows for removal of polyps and biopsy of suspicious lesions for histological examination
- Targeted biopsy of a visualised focal lesion is more accurate than blind dilatation and curettage
- Disadvantages
- Invasive procedure and less well tolerated compared to saline infusion sonohysterography 19
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol. 1996;87(3):345-9. (Level II evidence)
- Güner H, Tiras MB, Karabacak O, Sarikaya H, Erdem M, Yildirim M. Endometrial assessment by vaginal ultrasonography might reduce endometrial sampling in patients with postmenopausal bleeding: a prospective study. Aust N Z J Obstet Gynaecol. 1996;36(2):175-8. (Level II evidence)
- Garuti G, Sambruni I, Cellani F, Garzia D, Alleva P, Luerti M. Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding. Int J Gynaecol Obstet. 1999;65(1):25-33. (Level III evidence)
- Wolman I, Sagi J, Ginat S, Jaffa AJ, Hartoov J, Jedwab G. The sensitivity and specificity of vaginal sonography in detecting endometrial abnormalities in women with postmenopausal bleeding. J Clin Ultrasound. 1996;24(2):79-82. (Level II evidence)
- Gupta JK, Chien PFW, Voit D, Clark TJ, Khan KS. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81(9):799-816. (Level II evidence)
- Bree RL, Bowerman RA, Bohm-Velez M, Benson CB, Doubilet PM, DeDreu S, et al. US evaluation of the uterus in patients with postmenopausal bleeding: A positive effect on diagnostic decision making. Radiology. 2000;216(1):260-4. (Level II evidence)
- Gredmark T, Kvint S, Havel G, Mattsson LA. Histopathological findings in women with postmenopausal bleeding. Br J Obstet Gynaecol. 1995;102(2):133-6. (Level II evidence)
- Weiderpass E, Adami HO, Baron JA, Magnusson C, Bergstrom R, Lindgren A, et al. Risk of endometrial cancer following estrogen replacement with and without progestins. J Natl Cancer Inst. 1999;91(13):1131-7. (Level III evidence)
- Curtis RE, Boice JD, Shriner DA, Hankey BF, Fraumeni JF. Second cancers after adjuvant tamoxifen therapy for breast cancer. J Natl Cancer Inst. 1996;88(12):832-4. (Level IV evidence)
- Davidson KG, Dubinsky TJ. Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin North Am. 2003;41(4):769-80. (Review article)
- Scottish Intercollegiate Guidelines Network. Investigation of post- menopausal bleeding: a national clinical guideline. September 2002. (Evidence based guideline). View the reference
- Wolman I, Amster R, Hartoov J, Gull I, Kupfermintz M, Lessing JB, et al. Reproducibility of transvaginal ultrasonographic measurements of endometrial thickness in patients with postmenopausal bleeding. Gynecol Obstet Invest. 1998;46(3):191-4. (Level III evidence)
- Alcázar JL, Zornoza A. Transvaginal ultrasonographic measurement of endometrial thickness: an intra-observer and interobserver reproducibility study. Radiography. 2001;7(2):101-4. (Level II evidence)
- Smith Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280(17):1510-7. (Level I-II evidence)
- Granberg S, Ylostalo P, Wikland M, Karlsson B. Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding. Maturitas. 1997;27(1):35-40. (Level III evidence)
- Mendelson EB, Bohmvelez M, Joseph N, Neiman HL. Gynecologic imaging - comparison of trans-abdominal and trans-vaginal sonography. Radiology. 1988;166(2):321-4. (Level IV evidence)
- Epstein E, Ramirez A, Skoog L, Valentin L. Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm. Ultrasound Obstet Gynecol. 2001;18(2):157-62. (Level III evidence)
- Epstein E, Valentin L. Gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and vascularity as assessed by color Doppler for discrimination between benign and malignant endometrium in women with postmenopausal bleeding. Ultrasound Obstet Gynecol. 2006;28(1):89-95. (Level II evidence)
- Timmerman D, Deprest J, Bourne T, Van den Berghe I, Collins WP, Vergote I. A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen. Am J Obstet Gynecol. 1998;179(1):62-70. (Level II evidence)
- Clark TJ, Voit D, Gupta J, Hyde C, Song F, Khan K. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA. 2002;288(13):1610-21. (Level I-II evidence)
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Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children Saline Infusion Sonohysterography |
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