ULTRASOUND

Pelvic Ultrasound For Postmenopausal Bleeding:
Avoids Biopsy In Many Patients!

Vaginal bleeding in a postmenopausal women is fairly common, bothersome, and always abnormal problem (unless it occurs at the expected time in a woman on sequential hormone replacement therapy). Endometrial atrophy is the most common cause of abnormal postmenopausal bleeding. It is the reason for over half of all cases. The thin atrophic endometrium in postmenopausal women is prone to superficial ulceration that can lead to bleeding. Of course, clinically the most important cause of postmenopausal bleeding is endometrial cancer. It makes up approximately 7% to 30% of cases. It is the fourth most common malignancy in women in the U.S.

Up until recently, women with postmenopausal bleeding always required endometrial sampling. Sampling may be performed via office biopsy, dilatation and curettage (D&C), or, in some cases, hysteroscopically guided biopsy. Each of these techniques has drawbacks. Office biopsy and D&C sample blindly. Less than half the endometrium is sampled in most patients. D&C misses 2% to 6% of endometrial lesions, with even higher miss rates for office biopsy in which less tissue is sampled. Hysteroscopically guided biopsy is superior because tissue can be obtained from abnormal appearing regions. However, it is more expensive and requires considerable physician expertise.

Two developments in ultrasound of the uterus have expanded ultrasound's role for this bothersome symptom. First, the development of transvaginal ultrasound allows excellent visualization of the endometrium. Second, transvaginal sonography after the instillation of saline into the endometrial cavity, sonohysterography, permits detailed visualization of the endometrial surface itself.  These procedures permit a more selective approach to endometrial biopsy in women with postmenopausal bleeding by finding those who truly need to be sampled and directing the choice of the best sampling technique in each individual patient. In many cases, the patient is saved a surgical procedure.

Today, the best approach to diagnosis begins with transvaginal ultrasound. If the double layer endometrial thickness is 4mm or less, bleeding is due to atrophy and the patient undergoes no other procedure. If the thickness is greater than 4mm or cannot be measured, a sonohysterogram (SHG) is performed. The SHG findings can help to decide whether a biopsy is indicated, the cause of the difficulty in endometrial measurement, and the optimum sampling technique if it is indicated. Using this approach, all women with an endometrial thickness of 4mm or less are spared biopsy. One study showed a 46% reduction in biopsy rate! This strategy is expected to miss a small number of cancers, but the number may be less than that missed by office biopsy or D&C.

If you develop this common problem, make sure your gynecologist utilizes this new technique before doing a biopsy. It can be performed, as a simple imaging procedure, at New York Partnership for Women's Health.

27,000 women a year learn that they have cancer of the ovary. More than half eventually die from the disease. Early diagnosis is difficult because warning signs are few. In fact, even as ovarian cancer progresses, its symptoms- indigestion, bloating, nausea, unusual vaginal bleeding, or pelvic or stomach discomfort-can be easily dismissed.

The following are some of the risk factors of ovarian cancer: family history, especially if two or more first degree relatives have had the disease; childbearing, the fewer children that you have had the greater you are at risk; oral contraceptive use, if you have taken birth control pills you are less likely to get the disease; age, risk increases with age with most occurring over the age of 50; and personal medical history, such as colon or breast have an increased incidence of ovarian cancer. Women who have had breast cancer are twice as likely to develop ovarian cancer as are women who have not had breast cancer.

If you have any risk factors for ovarian cancer, talk to your doctor about supplementing annual pelvic exams with regular tests for tumors of the ovary. These tests include ultrasound, specifically transvaginal ultrasound, which may be able to detect cancerous tissue, and a special blood test, called a CA-125 test. Both of these methods are under study. At the present time, they're not reliable enough to be used for screening. Unfortunately, at the present time, there is no screening test for ovarian cancer -nothing comparable to the Pap smear for cervical cancer."

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