Objective To investigate the effectiveness of misoprostol given vaginally for cervical priming before hysteroscopy in postmenopausal women. Design Double-blind randomised controlled study.Setting Regional hospital, Hong Kong.Participants One hundred women with postmenopausal bleeding scheduled for hysteroscopy from October 1998 to September 2001 were randomly assigned to receive either misoprostol or placebo vaginally before the operation. Main outcome measures The number of women requiring cervical dilatation, outcome of hysteroscopy and side effects of the medication were assessed. Results Forty-eight women receiving misoprostol and 48 women receiving placebo were compared. The mean degree of endocervical diameter estimated by Hegar's dilator was similar between the treatment group and the control group. A similar number of women in the treatment group and the control group required cervical dilatation. The operative times for both groups were similar. The incidence of side effects was comparable in both groups. The most common side effects for misoprostol were febrile episodes and diarrhoea. There was no cervical tear nor uterine perforation encountered in both groups. The mean duration of hospital stay in both groups were similar. Subanalysis of results were similar in women receiving vaginal medication at least five hours before the operation. Conclusion Vaginal misoprostol was not shown to reduce the need for cervical dilatation in postmenopausal women. It cannot convert diagnostic hysteroscopy from a hospital procedure into an office one in postmenopausal women with tight cervical os.

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, has been reported to occur in 0.3-9.3% of the adult population at autopsy. NBTE associated with malignancy is an underrecognised cause of thromboembolic disorders. The clinical spectrum encountered and investigation results can be non-specific, often mimicking other acute conditions such as infective endocarditis. We describe the case of a 34-year-old woman with non-localising and multifocal neurological symptoms, who was subsequently diagnosed with NBTE secondary to a resectable primary lung adenocarcinoma.

Most reports on histopathological findings of postmenopausal bleeding were published before hysteroscopy was widely used. Recent studies have shown that hysteroscopic examination is better than dilatation and curettage alone in detecting intrauterine pathology. The aim of this study is to assess histopathological findings of patients presented with postmenopausal bleeding after incorporation of hysteroscopic examination. Between 1 January 1996 and 31 December 1996, a total of 199 consecutive patients presenting with postmenopausal bleeding to a regional hospital were reviewed. Patients were investigated with cervical biopsy, endometrial aspiration or hysteroscopy and curettage. Excluding patients who had hysterectomy and cervical cancer, 97% of the patients had hysteroscopic examination. The majority of patients with postmenopausal bleeding had atrophic vaginitis and/or atrophic endometrium (58.8%). Other common diagnoses were endometrial polyp (9.4%), endometrial carcinoma (9.4%) and carcinoma of the cervix (6%). Other diagnoses included submucous fibroid, endometrial hyperplasia, pyometra, ovarian cancer and urethral caruncle. Pathologies found were similar to early reports, except that incidences of submucous fibroids and endometrial polyps were higher (13.4%). We concluded that all patients with postmenopausal bleeding should be investigated thoroughly as 22% have significant pathology. Hysteroscopy is the preferred investigation because of high incidences of endometrial polyps and submucous fibroids.

A 31-year-old primiparous women with haemoglobin H disease complained of epigastric pain one day after giving uneventful vaginal birth to a 2.0kg boy at 38 weeks. Epigastric pain temporarily settled with oral antacid, she became dizzy and sweaty associated with back pain. She was pale and hypotensive, abdomen distended. Ultrasound showed free fluid inside the abdomen. Diagnostic tapping yielded blood. Haemoglobin was 6.4g/dl. Emergency laparotomy was performed. Splenomegaly (20cm in span) with rupture and 2.5L hemoperitoneum was found. Splenectomy was done. The total blood loss was 3.5L. Seven units of pack cells and 4 units of fresh frozen plasma were transfused. Histology showed congestive splenomegaly (605gm). Further investigations showed normal G6PD activity, negative blood smears for malaria parasites, normal red cell morphology and negative monospot test. This is the first report of postpartum splenic rupture related to thalassemic splenomegaly.