Notes

presence of complex atypical hyperplasia (CAH) on endometrial biopsy. If left untreated, this process has approximately a 28% chance of progressing to an invasive cance
Risk factors for endometrial cancer include late menopause, unopposed estrogen therapy, nulliparity, obesity, Tamoxifen therapy and diabetes mellitus.
Once a pathologic diagnosis is confirmed by biopsy, a basic clinical assessment should ensue in all patients to help define the extent of the disease. If a careful history and clinical gynecologic exam suggests that the carcinoma is likely of an early stage, minimal pre-treatment evaluation is necessary. Routine evaluation in this setting should include a chest x-ray as the lungs are the most common site of distant spread. A pelvic ultrasound is not indicated once a pathologic diagnosis has been established, although one may have been obtained as part of the initial evaluation of postmenopausal bleeding. When there is a low suspicion for advanced disease, a CT scan, MRI, PET scan, and other invasive and costly tests are not indicated. A CA-125 may be helpful in predicting those patients that may have extrauterine spread, but is not absolutely necessary.
The finding of an adnexal mass in a perimenopausal woman raises the suspicion of a neoplastic process. Because of the new onset of irregular bleeding and the finding of hyperplasia, the most likely explanation would be that of a granulosa cell tumor, an estrogen-secreting tumor.
The most common causes of postmenopausal bleeding are atrophy of the endometrium (60-80%), hormone replacement therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and hyperplasia (5-10%).
Tamoxifen is known to increase the risk of endometrial cancer. However, diagnostic studies, such as endometrial biopsy, are reserved for when the patient develops symptoms of bleeding or abnormal vaginal discharge. Ultrasound is not helpful because Tamoxifen is known to cause changes to the endometrium, including thickening. Endometrial biopsy is not indicated as a screening tool for endometrial cancer.
Smoking has not been demonstrated to be associated with an increased risk of ovarian cancer.
A woman’s risk for development of ovarian cancer during her lifetime is approximately 1%. Factors associated with development of ovarian cancer include low parity and delayed childbearing. Long-term suppression of ovulation appears to be protective against the development of ovarian cancer. Oral contraceptives that cause anovulation appear to provide protection against the development of ovarian cancer. Five years cumulative use decreases the lifetime risk by one-half.
Functional ovarian cysts are a result of normal ovulation. They may present as an asymptomatic adnexal mass or become symptomatic. Ultrasound characteristics include a unilocular simple cyst without evidence of blood, soft tissue elements or excrescences. An endometrioma is an isolated collection of endometriosis involving an ovary. This would not classically appear as a simple cyst on ultrasound. Serous cystadenomas are generally larger than functional cysts and patients may present with increasing abdominal girth. Mucinous cystadenomas tend to be multilocular and quite large. Dermoid tumors usually have solid components or appear echogenic on ultrasound, as they may contain teeth, cartilage, bone, fat and hair.
The most likely diagnosis of the adnexal mass that would also explain the finding of endometrial hyperplasia would be a granulosa cell tumor (sex-cord stromal tumor). GCT are functional tumors that secrete high levels of estrogen, which can ultimately stimulate the endometrium to undergo hyperplastic changes and even lead to endometrial cancer. Approximately 25-50% of women with GCT will have endometrial hyperplasia on biopsy, and 5-10% will have endometrial cancer. Granulosa cell tumors represent 70% of sex-cord stromal tumors and typically affect women in their 50’s (most common type is the adult GCT – 95%; the juvenile type affects females before puberty). The three main histologic sub-types of ovarian cancer include germ cell tumors (5%), sex-cord stromal tumors (1-2%), and epithelial tumors (90%). Germ cell tumors typically affect women of younger age groups (ages 10-30), comprise 20-25% of ovarian neoplasms overall (benign and malignant) and account for 70% of tumors in this age group. Epithelial ovarian tumors are the most common and can affect women of all ages, but typically the malignant types occur in women in their sixth decade of life.
The most common tumor found in women of all ages is the dermoid. The median age of occurrence is 30 years, and 80% occur during the reproductive years. Dermoids may contain differentiated tissue from all three embryonic germ layers. Dermoid tumors can contain teeth, hair, sweat and sebaceous glands, cartilage, bone, and fat.