COMMENT:

And since most of my patients are frozen and also I'm not a
gynecologist, there's little I can add to that. Uterine cancer can be
anywhere, and you don't always biopsy through it. So the biopsy is
sepecific but not sensitive. If it's not in the area where you
biopsied, it might not show.

There's argument about whether or not endometrial polyps _per se_ even
predispose to cancer-- they aren't like colon polyps. Hyperplasia is a
risk factor for cancer, but far more important is age and endometrial
thickness-- if it's less than 5 or 6 mm, usually you can avoid the
reflex hysterectomy. Age (>70), diabetes and no childbearing history
are also important risk factors for uterine cancer in post menopausal
bleeding.

Complex hyperplasia in women of childbearing years who want to preserve
the uterus is sometimes treated with high dose progestins. This is
often successful but not always. If it was, everybody could avoid
hysterectomy. Since most women with complex hyperplasia and bleeding
who are > 10 years from menopause just get the hysterectomy, there's
not a lot of experience treating this any other way.

I recommend take it out. You can't get cancer in an organ that has been
removed. Progestins like Provera aren't completely benign, and do bad
things to blood lipids. I would encourage natural progesterone if a
women insisted on going that route.

SBH

1: Acta Obstet Gynecol Scand. 1985;64(8):653-9.

Endometrial polyps and hyperplasia as risk factors for endometrial
carcinoma. A
case-control study of curettage specimens.

Pettersson B, Adami HO, Lindgren A, Hesselius I.

As part of a comprehensive case-control study, the impact of previous
endometrial pathology on the risk of developing endometrial carcinoma
was
investigated. The study comprised 254 consecutive women with
histopathologically
confirmed cancer of the uterine body in a well-defined population, and
their
age-matched controls. Ninety-eight (39%) of the patients and 81 (32%)
of the
controls had previously undergone endometrial curettage. More than one
previous
curettage was positively associated with endometrial carcinoma (odds
ratio =
2.5; 95% CL = 1.4-4.5). Endometrial abnormalities in previous curettage
specimens occurred significantly more often among carcinoma patients
(57%) than
among controls (25%) (odds ratio = 4.0; 95% CL = 2.0-8.0). Twelve
patients, but
no controls, had adenomatous hyperplasia and this hyperplasia antedated
the
cancer diagnosis by a mean of 4.6 years. Endometrial polyps were
present
significantly more often in patients (20%) than in controls (10%) (odds
ratio =
3.4; 95% CL = 1.3-9.3). The present results suggest that both of these
conditions are risk factors for endometrial carcinoma. Among women who
had
undergone endometrial curettage more than 4 years after the menopause,
19 out of
30 patients, but none out of 7 controls, showed abnormality in the
curettage
specimens. Postmenopausal women with endometrial abnormality should
thus be
regarded as being at risk of developing endometrial carcinoma.

PMID: 3832756 [PubMed - indexed for MEDLINE]

2: J Clin Ultrasound. 2004 Jun;32(5):219-24.

Combination of endometrial thickness and time since menopause in
predicting
endometrial cancer in women with postmenopausal bleeding.

Bruchim I, Biron-Shental T, Altaras MM, Fishman A, Beyth Y, Tepper R,
Aviram R.

Department of Obstetrics and Gynecology, Sapir Medical Center, 59
Tchernichovsky
Street, Kfar Saba, 44281, Israel.

PURPOSE: This study was conducted to assess the combination of
endometrial
thickness, as measured by transvaginal sonography, and time since
menopause, in
predicting the presence of endometrial cancer in women with
postmenopausal
bleeding. METHODS: The study group consisted of 95 women with
postmenopausal
bleeding who underwent sonographic measurement of endometrial thickness
followed
by endometrial biopsy. No patient had ever received hormone replacement
therapy.
RESULTS: The mean endometrial thickness was significantly lower in the
absence
of endometrial carcinoma (6.9 +/- 4.3 mm) than in its presence (13.5
+/- 7.7 mm)
(p < 0.005). The incidence of endometrial carcinoma increased with
increases in
endometrial thickness and the number of years since menopause. No
patient had
carcinoma when the endometrium was less than 5 mm thick, but 18.5% did
when the
thickness exceeded 9 mm. The incidence of cancer was 2.6% in women who
had
undergone menopause less than 5 years earlier but was 21.4% in women
who had
undergone menopause more than 15 years prior. Multiple logistic
regression
analysis showed that time since menopause and endometrial thickness
were
statistically significant predictors of endometrial carcinoma.
CONCLUSIONS: Time
since menopause and endometrial thickness together define cutoff points
for the
diagnostic biopsy of tissue samples for endometrial carcinoma; that is,
within a
particular time interval, sampling should not be performed if the
thickness is
below a given value. When using cutoff points of 6 mm of endometrial
thickness
for women experiencing menopause 5-15 years prior and 5 mm in those
going
through menopause 15 or more years prior, approximately 60% of invasive
procedures may be avoided. In addition, models derived by multiple
logistic
regression can be used to calculate a patient's risk of cancer based on
her age
and endometrial thickness. Copyright 2004 Wiley Periodicals, Inc.

Publication Types:
   Clinical Trial
   Controlled Clinical Trial

PMID: 15124187 [PubMed - indexed for MEDLINE]

3: Ann Chir Gynaecol. 1983;72(5):274-7.

Endometrial findings following curettage in 2018 women according to age
and
indications.

Holst J, Koskela O, von Schoultz B.

A retrospective study on 2018 Scandinavian women undergoing
conventional and
aspiration curettage was performed. The outcome in terms of endometrial
pathology was analyzed against age and indications. A large number of
operations
(38.2%) were performed on young women before the age of 45 years. 98%
of
endometrial samples were normal from 430 younger than 40 years. Better
selection
of cases might help to reduce the number of operations. In women of
reproductive
age the relation between normal and pathological findings was the same
for both
methods with the exception that conventional curettage seemed to detect
more
polyps. The frequency of insufficient samples after aspiration
curettage
increased markedly with age. Postmenopausal bleeding remains a strong
indication
for conventional curettage.

PMID: 6660829 [PubMed - indexed for MEDLINE]

4: Am J Obstet Gynecol. 2003 Feb;188(2):401-8.

Comment in:
   Am J Obstet Gynecol. 2004 Aug;191(2):677; author reply 678.

Can ultrasound replace dilation and curettage? A longitudinal
evaluation of
postmenopausal bleeding and transvaginal sonographic measurement of the
endometrium as predictors of endometrial cancer.

Gull B, Karlsson B, Milsom I, Granberg S.

Department of Obstetrics and Gynecology, University of Goteborg,
Sahlgrenska
University Hospital, Sweden. berit.gull@obgyn.gu.se

OBJECTIVE: The purpose of this study was to evaluate postmenopausal
bleeding and
transvaginal sonographic measurement of endometrial thickness as
predictors of
endometrial cancer and atypical hyperplasia in women whose cases were
followed
for > or =10 years after referral for postmenopausal bleeding. STUDY
DESIGN:
Women (n = 394) who had postmenopausal bleeding from November 1987 to
October
1990 underwent transvaginal sonographic measurement of endometrial
thickness and
curettage. It was possible to assess the medical records (regarding
recurrence
of a postmenopausal bleeding, development of endometrial cancer, and
death) in
339 of the 394 women (86%) > or =10 years after referral for
postmenopausal
bleeding. RESULTS: Thirty-nine of the 339 women (11.5%) had endometrial
cancer,
and 5 women (1.5%) had atypical hyperplasia. The relative risk of
endometrial
cancer in women who were referred for postmenopausal bleeding was 63.9
(95% CI,
46.0-88.8); the corresponding relative risk for endometrial cancer and
atypical
hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women
of the
same age from the general population of the same region of Sweden. No
woman with
an endometrial thickness of < or =4 mm was diagnosed as having
endometrial
cancer. The relative risk of the development of endometrial cancer in
women with
an endometrial thickness of >4 mm was 44.5 (95% CI, 6.5-320.1) compared
with
women with an endometrial thickness of < or =4 mm. The reliability of
endometrial thickness (cutoff value, < or =4 mm) as a diagnostic test
for
endometrial cancer was assessed: Sensitivity, 100%; specificity, 60%;
positive
predictive value, 25%; and negative predictive value, 100%. The
incidence of
endometrial cancer or atypical hyperplasia in women with an intact
uterus whose
cases had been followed for > or =10 years was 5.8% (15/257 women)
compared with
22.7% (15/66 women) in women who had < or =1 episode of recurrent
bleeding. No
endometrial cancer was diagnosed in women with a recurrent
postmenopausal
bleeding who had an endometrial thickness of < or =4 mm at the initial
scan.
CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk for
endometrial cancer. There was no increased risk of endometrial cancer
or atypia
in women who did not have recurrent bleeding, whereas women with
recurrent
bleeding were a high-risk group. No endometrial cancer was missed when
endometrial thickness measurement (cutoff value, < or =4 mm) was used,
even if
the women were followed up for < or =10 years. We conclude that
transvaginal
sonographic scanning is an excellent tool for the determination of
whether
further investigation with curettage or some form of endometrial biopsy
is
necessary

PMID: 12592247 [PubMed - indexed for MEDLINE]

5: Gynecol Oncol. 1995 Mar;56(3):376-81.

Predicting endometrial cancer among older women who present with
abnormal
vaginal bleeding.

Feldman S, Cook EF, Harlow BL, Berkowitz RS.

Department of Obstetrics, Gynecology, Brigham and Women's Hospital,
Boston,
Massachusetts, USA.

We studied 203 women ages 49 or over who presented with abnormal
vaginal
bleeding and who underwent either endometrial biopsy or dilation and
curettage
at the Brigham and Women's Hospital. Using information from the
clinical
history, we predicted their risk for endometrial cancer (36 patients)
or complex
endometrial hyperplasia (16 patients). Factors independently associated
with
endometrial cancer/complex hyperplasia included age 70 or older (OR =
9.1, P =
0.0001), diabetes (OR = 3.7, P = 0.02), and nulliparity (OR = 2.7, P =
0.02).
After adjusting for age, menopause was borderline significant (OR =
2.6, P =
0.07). Our data estimated a risk of endometrial cancer/complex
hyperplasia of
87% for a woman possessing all of these factors, and a risk of less
than 3% if
she had none of them. Our model provides an inexpensive, simple means
for
assessing the risk of endometrial cancer and complex hyperplasia in the
post- or
perimenopausal woman with abnormal bleeding.

PMID: 7705671 [PubMed - indexed for MEDLINE]

6: Acta Obstet Gynecol Scand. 2000 Apr;79(4):317-20.

The risk of premalignant and malignant pathology in endometrial polyps.

Bakour SH, Khan KS, Gupta JK.

Birmingham Minimal Access Surgical Training Centre, Academic Department
of
Obstetrics and Gynaecology, University of Birmingham, UK.

OBJECTIVE: To evaluate the risk of premalignant and malignant pathology
among
endometrial polyps. DESIGN: Prospective cohort study. SETTING: Minimal
Access
Surgical Training (MAST) center in a large teaching hospital. METHODS:
Among 248
patients seen in outpatient hysteroscopy clinic (1996-97), 62 had
endometrial
polyps. All patients had endometrial sampling for histological
assessment. To
determine the magnitude of malignant potential among polyps, we
compared the
pathological findings in polyps (cases) with non-polypoidal specimens
(controls). RESULTS: Out of 62 polyps, histologically 53 (85.5%) were
benign,
seven (11.3%) had hyperplasia, and two (3.2%) were associated with
malignancy.
Hyperplasia was more frequent in endometrial specimens with polyps than
in those
without (11.3% vs 4.3%, p=0.04), but the incidence of carcinoma in the
two
groups was the same (3.2% vs 3.2%, p= 1.0). CONCLUSION: In abnormal
uterine
bleeding, hyperplasia was, but cancer was not, more common in women
with
endometrial polyps compared to those without polyps.

PMID: 10746849 [PubMed - indexed for MEDLINE]

David

"Unfortunately, I don't have much experience... ."

Such simple words. David, truly, you are remarkable. Zee

HERS Foundation
http://www.hersfoundation.com/articles.htm
http://www.hersfoundation.com/facts.html

FACT: Women experience a loss of physical sexual sensation as a result
of hysterectomy.

FACT: A woman's vagina is shortened, scarred and dislocated by
hysterectomy.

FACT: Hysterectomy's damage is life-long. Among its most common
consequences, in addition to operative injuries are:

   * heart disease
   * osteoporosis
   * bone, joint and muscle pain and immobility
   * loss of sexual desire, arousal, sensation
   * painful intercourse, vaginal damage
   * displacement of bladder, bowel, and other pelvic organs
   * urinary tract infections, frequency, incontinence
   * chronic constipation and digestive disorders
   * profound fatigue
   * chronic exhaustion
   * altered body odor
   * loss of short-term memory
   * blunting of emotions, personality changes, despondency,
irritability,         anger, reclusiveness and suicidal thinking

FACT: No drugs or other treatments can replace ovarian or uterine
hormones or functions. The loss is permanent.

FACT: The medical term for the removal of the ovaries is castration.
Most women are castrated at hysterectomy.

FACT: The uterus and ovaries function throughout life in women who have
not been hysterectomized or castrated.

FACT: Twice as many women in their 20's and 30's are hysterectomized as
women in their 50's and 60's.

FACT: 98% of women HERS has referred to board-certified gynecologists
after being told they needed hysterectomies, discovered that, in fact,
they did not need hysterectomies.

FACT: Gynecologists, hospitals and drug companies make more than 8
billion dollars a year from the business of hysterectomy and
castration.

HERS is the only independent, international organization dedicated to
the issue of hysterectomy and advocates for fully informed medical
choices by women.

Distressing Howard, yes, but not catastrophic. What you've said is
IMMENSELY helpful.

The (brand new) physician gave me numbers similar to yours. He also
said if I refused what he recommends, they would ask me to sign that he
(they) had told me what my risk is, and that I declined to have what
they recommended, which is: an oopherectomy and hysterectomy with my
tubes removed. I didn't ask if it would be laparoscopic. I will, if I
make the decision for this surgery, which I view as castration.

He told me quite candidly, David, that this type of cancer, if it does
progress, was "very deadly" and they can't guarantee it isn't in my
tubes.

Thank you Steve. You do make me laugh. But best of all I have it here
now, in writing, that there is an area of medicine about which you know
little.

Zee