Postmenopausal bleeding: value of imaging

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Genitourinary Emergencies in Older Adults

Older adults are frequently seen in the emergency department for genitourinary complaints, necessitating that emergency physicians are adept at managing a myriad of genitourinary emergencies. Geriatric patients may present with acute kidney injury, hematuria, or a urinary infection and aspects of how managing these presentations differs from their younger counterparts is emphasized. Older adults may also present with acute urinary retention or urinary incontinence as a result of genitourinary pathology or other systemic etiologies. Finally, genital complaints as they pertain to older adults are briefly highlighted with emphasis on emergent management and appropriate referrals.

Recurrent postmenopausal bleeding: a survey of practice among gynecologists in Scotland

BACKGROUND

The definition and management of recurrent postmenopausal bleeding (PMB) are not well described in the literature, with no consensus among the clinicians and no available contemporary UK evidence-based guidelines. We conducted this survey to examine the practice of gynecologists based in Scotland in relation to recurrent postmenopausal bleeding.

METHODS

A web-based questionnaire was sent to 200 non-training grade gynecologists in Scotland exploring their views on the definition, investigation and management of recurrent PMB. Data were extracted from the 61 responses received.

RESULTS

Seventy-seven percent of responders defined recurrent PMB as two or more episodes of PMB, while 21% defined it after three episodes. A bleed-free interval of 3 and 6 months was needed to identify a recurrence by 46% and 44% of responders, respectively. 70% would investigate recurrent PMB with a combination of transvaginal sonography, hysteroscopy and biopsy. Only 19% would arrange a pelvic MRI routinely, while 43% would never offer one. 72% would consider a hysterectomy at some stage, with 22% of responders offering it after 3 episodes of PMB with negative investigation. 18% would never offer a hysterectomy without an identified pathology. 32% of responders felt that the management of recurrent PMB required an individualized case-by-case approach.

CONCLUSIONS

This survey highlights the need for a clinical guideline to address the wide variation in the management of recurrent PMB.

Evaluation of endometrial precancerous lesions in postmenopausal obese women--a high risk group?

AIM

To evaluate precancerous lesions such as hyperplasia and endometrial polyps in obese postmenopausal women.

MATERIALS AND METHODS

Women who were referred with abnormal uterine bleeding in postmenopausal period or the presence of endometrial cells on cervical cytology in our department were investigated. Anthropometric measurements such as height, weight, body mass index, waist/hip ratio and endometrial thickness were compared between a precancerous lesion (hyperplasia and endometrial polyp) group and a pathologically normal group.

RESULTS

We detected statistically significant thickening of endometrium in patients with precancerous lesions. Moreover patients with precancerous lesions had higher body mass index than the pathologically normal group.

CONCLUSIONS

We found elevated precancerous lesion rates in overweight and obese women in the postmenopausal period, of interest given that the prevalence of obesity is increasing in most parts of the world. Although screening for endometrial cancer is not recommended for the general population, in high-risk populations like obese postmenopausal women, it may be very important.

A pilot evaluation of saline sonohysterography for postmenopausal bleeding with thickened endometrium

The aim of this study was to assess the clinical and cost implications of pilot introduction of saline sonohysterography for postmenopausal bleeding with thickened endometrium (>or= 5 mm), at the Royal Glamorgan Hospital. The investigation was attempted in 48 patients who were found to have a thickened endometrium (>or= 5 mm) on transvaginal ultrasound scanning. The attempt was successful in 45 patients (93.8%). Failures were due to (1) cervical stenosis and (2) leakage of saline from the cervix. Difficult catheterisation of the cervix causing pain was encountered in a minority of cases. Two-thirds of patients were found have focal lesions and were booked for hysteroscopic resection. These patients included 30 with polyps, which were precisely described in all of them. In view of this low complication rate and high accuracy, the technique was integrated as a standard method of investigation for postmenopausal bleeding at the hospital.

Magnetic resonance imaging of benign uterine pathology

Magnetic resonance imaging is commonly used for the identification and characterization of many pelvic abnormalities. Magnetic resonance provides the most comprehensive and detailed view of the uterus of any imaging modality. This article focuses on the magnetic resonance imaging features used to recognize and describe congenital uterine anomalies and benign conditions of the uterus.