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Missing periods after pap smears. Started spotting. Ultrasound done. What are the chances of endometrial cancer?

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HI DOCTOR

I AM A 57 YEAR OLD FEMALE WHO HAS HAD COMPLETELY NORMAL PAP SMEARS SINCE I WAS IN MY 20'S....I HAVEN'T HAD A "TRUE" PERIOD FOR A COUPLE OF YEARS BUT HAVE BEEN HAVING VERY LITTLE BROWNISH DISCHARGE WHICH SEEMS TO COME WHEN MY PERIOD WOULD HAVE BEEN DUE....HAD A TRANSABDOMINAL & TRANSVAGINAL ULTRASOUND & THE READS AS FOLLOWS: THE UTERUS MEASURES 9.1x5.7x3.8 CM AND IS HETEROGENEOUS IN ECHOTEXTURE. WITHIN THE ANTERIOR UTERINE WALL, THERE IS A HETEREOGENEOUS LESION MEASURING 0.9X0.8X1.3 CM CONSISTENT WITH A FIBROID.THE ENDOMETRIAL COMPLEX MEASURES APPROXIMATELY 0.7 CM WHICH IS UPPER LIMITS OF NORMAL. ON THE TRANSVAGINAL IMAGES, THE RIGHT OVARY MEASURES 2.1X1.5X1.3 CM. THE LEFT OVARY NOT VISUALIZED ON THIS EXAMINATION, SECONDASRY TO OBSCURATION BY NEARBY BOWEL. NO ABNORMAL ADNEXAL MASSES OR FREE FLUID COLLECTION IS NOTED. COULD YOU PLEASE EXPLAIN THIS IN DETAIL TO ME. WONDERING IF THE ENDOMETRIAL STRIPE IS CONSISTENT WITH ENDOMETRIAL CANCER. WHAT ARE THE NORMAL RANGES FOR THIS IN A WOMAN WITH MY FINDINGS. ANXIOUSLY AWAITING TO HEAR FROM YOU. THANK YOU VERY MUCH.
Posted Thu, 8 Nov 2012 in Women's Health
 
 
Answered by Dr. Timothy Raichle 1 hour later
Hello, I would be happy to help you with your question.

First of all, do not panic. The chance of endometrial cancer is very small and it was correct of you to see your doctor for evaluation. The definition of menopause is no period for 12 months. I will assume that you fit this definition. Based on what you are describing, one has to assume that this is postmenopausal bleeding as small amounts of blood often make their way out as a brownish discharge. In your case, the evaluation should proceed with the assumption of "this is cancer until I prove otherwise", BUT the chance of cancer in the setting of postmenopausal bleeding is only about 10-15%.

Now, turning to the ultrasound results. The endometrial lining in a postmenopausal woman with bleeding of <4mm is of absolutely no concern. Your lining was measured at 7mm, which is of low concern but the following MUST occur:

1. You need an endometrial biopsy (this is a simple, in office procedure where a small catheter is passed through the cervix and a sample of the inside of the uterus taken. It is not too painful and very sensitive at picking up pre-cancerous changes if present)
2. If the biopsy is normal and the bleeding continues, then you need an ultrasound performed where a small amount of fluid is introduced into the uterus - called a sonohysterogram. This is an excellent way to evaluate if polyps are present.
3. If you make it to #2 and there ARE polyps present, then these can be removed and problem solved.
4. If the biopsy is normal, and the sonohysterogram is negative and the bleeding continues, then you need a hysteroscopy with D&C. This is a procedure performed in an operating room setting with you comfortable. A camera is introduced and the lining is visualized and then samled. It is the ultimate way to evaluate the lining for cancerous changes or polyps

The comments about your ovaries are of no concern. I hope this helps to alleviate your anxiety. Certainly let me know if you have more questions or need clarification. - DR XXXXXXX
Above answer was peer-reviewed by
 
Follow-up: Missing periods after pap smears. Started spotting. Ultrasound done. What are the chances of endometrial cancer? 5 hours later
HI DR. XXXXXXX

I AM STILL HAVING QUITE A BIT OF ANXIETY AFTER YOUR ANSWER. YOU TOLD ME NOT TO PANIC BUT IT SEEMS LIKE Y0U ARE TELLING ME MY PROBLEM COULD BE ENDOMETRIAL CANCER. WOULD THE TRANSVAGINAL ULTRASOUND GIVE ANY INKLING OF CANCER BEING POSSIBLE. I, INITIALLY, ONLY HAD AN ABDOMINAL ULTRASOUND AND MY ENDOMETRIAL STRIPE WAS SAID TO BE 3CM, BUT THE TRANSVAGINAL ULTRASOUND IS SAYING 7, WHY IS THERE SUCH A BIG DIFFERENCE. AND ALSO WOULDN'T THE ULTRASOUND SHOW A POLYP. WHAT IS YOUR OPINION ON HETEROGENEOUS UTERUS AND ME ALSO HAVING A LESION THAT RESEMBLES A FIBROID. CAN A FIBROID CAUSE THIS BLEEDING. AGAIN, THANKS SO MUCH AND ANXIOUSLY AWAITING TO HEAR FROM YOU.
 
 
Answered by Dr. Timothy Raichle 9 hours later
Well I am sorry about the delay. Thanks for the followup.

1. In the setting of postmenopausal bleeding, cancer has to be a consideration but it is uncommon. It must be "ruled out" in the manner that I described.
2. Ultrasound can only "rule out" cancer if the lining is <4mm. Anything over 4mm MUST be biopsied. At 7mm, there is low concern, but it is not normal.
3. Transvaginal scan is the BEST way to look at the lining - ignore the transabdominal comments
4. No, the ultrasound cannot always see a polyp without the fluid introduced into the cavity (as with a sonohysterogram)
5. Comments about the uterine wall appearing heterogeneous are not unusual and probably related to fibroids / fibroid like changes (that are always benign)
6. Yes a fibroid can cause abnormal bleeding.

I hope this helps.
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Follow-up: Missing periods after pap smears. Started spotting. Ultrasound done. What are the chances of endometrial cancer? 23 hours later
HI DR. XXXXXXX

I FEEL A BIT BETTER BUT I'M REALLY SCARED ABOUT RESULTS OF THIS ENDOMETRIAL BIOPSY....MY REPORT STATED THE ENDOMETRIAL COMPLEX MEASURES APPROXIMATELY 0.7 CM WHICH IS UPPER LIMITS OF NORMAL.....MAY I ASK WHAT THE RANGES OF NORMAL ARE....FORGOT TO TELL YOU IN MY PREVIOUS QUESTION THAT MY FSH WAS 38, WHAT DOES THAT TELL YOU...AGAIN, ANXIOUSLY AWAITING TO HEAR FROM YOU.
 
 
Answered by Dr. Timothy Raichle 5 hours later
I understand your concern and fear.

With regard to the comments about the "endometrial complex", which measures 7mm, that which would be considered normal is up to about 6mm in a woman taking hormone replacement therapy.

Your FSH being elevated just means that you are post-menopausal - it is completely useless in terms of sorting out what is going on. It reflects the lack of estrogen in your system that would be expected in a woman who has not had a period for over 12 months.

I hope this helps!
Above answer was peer-reviewed by
 
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