--
Richard Chudacoff, MD, FACOG
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net]On Behalf Of Joanne
Bulley, MD
Sent: Monday, March 11, 2002 9:29 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Follow up
Richard and Gail - you have outlined the two primary options that I will
be discussing with the couple when they return in the next week or two.
Progesterone therapy with monitoring - likely needing a tissue follow up
at some point. The US before this H/S D&C had an endometrial thickness
of only 7mm. Since she will never consent to an office biopsy again
(after the attempt in '96 put her in agony....) any further tissue
sampling will be in the OR.
I plan to discuss both TAH BSO and Progesterone therapy. I will discuss
what to expect if neither are followed.
Basically, with "menstrual" in 96 and "complex hyperplasia" in 2002, I
would expect this to proceed to atypical and cancer over the next 5
years - give or take a bit. Even though "complex hyperplasia without
atypia" is not considered a pre-cancerous lesion - her history suggests
underlying endogenous estrogen stimulation and I suspect the progression
to happen unless there is lifelong progesterone therapy.
Somehow I was unaware of the vascular dilators - never occurred to me. I
have used the nasolacrimal probes off & on over the decades as needed.
The single small stab with the #15 blade usually works to access the
canal - as long as the dimple over the os is detectable. This lady has
had two LEEPs - one for CIN and one for the last H/S. There is no
cervix to speak of protruding into the vaginal apex. So the stab was
definitely better in this case than cutting off a bit more cervix - and
the first LEEP is what led to the stenosis to begin with.
I always enjoy seeing what others would do - and the reasoning behind
it!
Joanne
At Mon, 11 Mar 2002, Gail Waldby wrote:
>
>Joanne, another choice if you have to do this again is to start with small
vascular
>dilators---they are longer and sturdier than nasolacrimal probes, but start
with similarly
>small sizes---the lacrimal probes were a great idea, though, I never
thought of using them
>on cases like this--I usually do a small LEEP to open up the canal when I
cannot get the
>smallest cervical dilator in.
>
>I would put her on progesterone and follow clinically and with sonography.
If she bleeds
>or if her endometrium is thickened on sonography, I would repeat
hysteroscopy, D&C.
>Gail Waldby, MD
>
>3/10/2002 10:12:51 PM, islesannie@yahoo.com (Joanne Bulley, MD) wrote:
>
>>I posted aboout the patient with PMB ans previous difficult H/S with
>>perforatin and extravasation of glycine ...
>>
>>Well the path at that time was "c/w menstrual shedding"
>>
>>I had no problem accessign the canal. The os was tiny - but using a #15
>>blade I made a puncture over the os and then dilated with naso-lacrimal
>>probes then the standard dilators we use.
>>
>>The endometrium seemed thickened and with some prominent vessels.
>>
>>Path - complex hyperplasia without atypia.
>>
>>She is short, heavy, recently diagnosed with AODM.
>>
>>Options:
>>
>>1. Progesterone therapy (but can't approach biopsy in office) - so
>>would need another D&C to follow up
>>
>>2. hyst - there is no decensus - so TAH BSO.
>>
>>3. other - you tell me what other thoughts you have.
>>
--
Joanne Bulley, MD
Keene, NH, USA
~*~ let there be peace on earth and let it begin with me ~*~
