Abnormal Vaginal Bleeding and breast cancer

The majority of endometrial polyps are benign; however,  histopathologic evaluation of polyps,  including their base,  is necessary to rule out endometrial malignancy. An estrogen-producing tumor of the ovary may also be the cause of bleeding,  although this situation is rare.

A complete gynecologic examination should be performed as well and should include examination of cytologic material from the ectocervix and endocervix and an endometrial biopsy. In patients who have had previous vaginal deliveries, endometrial tissue samples can be obtained using methods that are easily performed in the outpatient setting. 

In patients who are nulliparous, however, dilatation of the cervix while the patient is under some form of anesthesia may be required.  In our practice,  we have found the endometrial pipelle instrument to be useful for outpatient procedures that do not require anesthesia (Figure 15-1). The larger suction curette permits access to a larger amount of tissue for diagnosis. When a stenotic cervix is encountered, we often use lacrimal dilators in the office to obtain access to the endometrial cavity.

Figure 15-1.  Endometrial pipelle instrument used in gynecologic examinations.

Patients tolerate this procedure well, and if the procedure is successful, it obviates the need for an operative procedure and induction of anesthesia. If the information from the cytologic examination and outpatient endometrial biopsy fails to explain the cause of the bleeding or if the bleeding continues, an examination under anesthesia involving hysteroscopy and diagnostic dilation and curettage may be necessary. This examination is often preceded by vaginal sonography,  which provides useful information on the thickness of the endometrial stripe and the presence and anatomic situation of polyps and sometimes indicates an early carcinoma of the endometrium or endocervix. Vaginal sonography is also useful for evaluating the size and morphologic features of the ovaries.

Depending on the results of diagnostic studies, the patient may require a hysterectomy. Before hysterectomy, hysteroscopy may be performed to confirm the findings on vaginal sonography and determine whether any previous attempt at polyp removal has been successful. The findings on hysteroscopy may suggest that a nonhysterectomy approach is appropriate. In addition, an operative hysteroscopy affords the opportunity to remove polyps with a resectoscope under direct visualization. Whether a bilateral salpingo-oophorectomy is performed in addition to hysterectomy depends on several factors, including the age of the patient, her preferences, and whether her family history indicates an elevated risk of ovarian cancer. If endometrial cancer is detected or if active endometriosis contributes to symptoms, a bilateral salpingo-oophorectomy must be performed. However, because patients who have undergone oophorectomy may experience severe estrogen-deprivation symptoms,  the indications for oophorectomy should be clearly and carefully explained to the patient. The issue of estrogen deprivation is especially important for women who have been diagnosed with breast cancer because systemic estrogen replacement therapy is not considered an option for the majority of these patients-especially for those who have estrogen receptor-positive tumors (see Menopausal Health After Breast Cancer section).  Patients should talk to their breast medical oncologist before starting any hormonal therapy. Elizabeth R. Keeler, Pedro T. Ramirez, and Ralph S. Freedman Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2007 References

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