Investigation of choice in a 55-years-old post menopausal woman who has presented with postmenopausal bleeding:
1.Pap smear
2.fractional curettage
3.Transvaginal ultrasound
4.CA-125 estimation
sol:
In a woman with postmenopausal bleeding chances of endometrial carcinoma are very high. Therefore such a patient should be evaluated so as to rule out endometrial carcinoma. Hence fractional curettage should be done.
Investigations for endometrial carcinoma - Novak 15th /ed p 1257
i… Endometrial Aspiration Biopsy : “It is the accepted first step in evaluating a patient with abnormal uterine bleeding or suspected pathology. The diagnostic accuracy of an office based endometrial biopsy is 90-98% when compared with subsequent findings at dilatation and curettage (D and C)”. … Novak 15th /ed p 1257
“Endometrial sampling should be performed in any woman with irregular or heavy bleeding older than age 35.Although a formal dilatation and curettage has been the standard technique for diagnosis, outpatient endometrial biopsy has replaced it in most situations” …Devita 8th /ed p 1546
Endometrial biopsy can be performed in outpatient setting and has the advantage of being simple, quick, safe, inexpensive, convenient and avoiding the need of anesthesia.
Dilatation and Fractional Curettage: “Fractional curettage is not only the definite method of diagnosis but can detect the extent of growth.” - Dutta Gynae 5th /ed p 344
Hysteroscopy and biopsy: It is nowadays the investigation of choice for endometrial cancer but most of the cancers are detected easily by endometrial aspiration biopsy and it is reserved for those cases where there is cervical stenosis or patient cannot tolerate endometrial aspiration, bleeding recurs after a negative endometrial biopsy or specimen is inadequate.
Transvaginal ultrasound: May be useful adjunct to endometrial biopsy for evaluating abnormal uterine bleeding and selecting patients for additional testings.
If endometrial thickness is > 4 mm, a polypoidal endometrial mass is present or a collection of fluid is present within the uterus, in postmenopausal females always follow up with histopathological diagnosis.
Pap smear: It is not a reliable test for diagnosis of endometrial carcinoma. Only 30-50% patients with endometrial carcinoma have positive pap test and they are women with advanced disease.
Remember:
First investigations in case of endometrial cancer - Endometrial aspiration biopsy.
Best investigation for diagnosing endometrial cancer - Hysteroscopy and biopsy.