Case Discussion: Post-Menopausal Bleeding in a 65-year-old Woman
Mrs. Pauline, a 65-year-old woman presenting with post-menopausal bleeding for the past 4 months, without associated symptoms, history of recent weight changes, or hormonal therapy. Her menstrual and obstetric histories, along with past medical and surgical history, are significant. Further evaluation and management are warranted to determine the cause of the bleeding.
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Case Discussion : Post-Menopausal Bleeding - DR. JAYATI DUREJA - DR. MYTHILI KUNDUR - DR. SPANDANA S. - DR. PAVANI MAKKENA CSI HOSPITAL, BANGALORE
PATIENT DETAILS & CHIEF COMPLAINTS Mrs. Pauline, 65 year old lady, a home-maker, educated till class 10th, resident of Benson Town (Bangalore), wife of Mr. Daniel, a manager, belonging to upper-middle socio-economic class by Kuppuswamy s modified scale, Presented to the Gyne OPD with the chief complaint of- Bleeding per vaginum on an off since 4 months
HISTORY OF PRESENTING COMPLAINT Patient attained menopause 17 years ago She noted the first episode of bleeding per vaginum 4 months ago, which was minimal in amount, requiring 1 pad/day and lasted 2-3 days, not associated with abdomen pain or passage of clots. No h/o malodourous or abnormal discharge No h/o abdominal discomfort or distension or backache. No history of bowel or bladder disturbances. She reports a total of 3 such episodes in the last 4 months, the most recent one being 2 days ago.
HISTORY OF PRESENTING COMPLAINT No h/o recent weight gain or loss No h/o hormonal therapy after attaining menopause No h/o anticoagulant use or aspirin therapy No h/o mass descending per vaginum No h/o post-coital bleeding or local trauma
MENSTRUAL HISTORY Age at Menarche : 11 years Age at Menopause : 48 years Past menstrual cycles : Regular, 3/28-30 days, average flow.
SEXUAL & CONTRACEPTION HISTORY Sexually active Underwent Tubectomy after 2ndDelivery. No h/o Hormonal Contraceptive use.
OBSTETRIC HISTORY Married Life = 39 years, Non Consanguineous Marriage P2L2 1 LSCS, 1 VBAC , LCB- 36 years ago
PAST MEDICAL & SURGICAL HISTORY K/C/O TYPE II DM x 3 years, on Tab Glimepiride 2 mg and T. Metformin 500mg combined tablet b.i.d., and blood sugars have been told to be under good control. K/C/O HYPERTENSION x 2 weeks, on Tab Atenolol 25mg o.d. Underwent R. Ovarian cystectomy + B/L Tubal Ligation 35 years ago. The cyst was told to be benign on follow up and she did not receive further treatment for the same.
FAMILY HISTORY Father diabetic and hypertensive Younger sister had Endometrial Cancer Older sister had Breast Cancer with ? Liver Mets
PERSONAL HISTORY Consumes mixed diet Good appetite , No change in weight Bowel and bladder habits are regular Sleep undisturbed Not an active/ passive smoker, does not consume alcohol, no addictions.
History - Summary 65 year old with Post-menopausal Bleeding P2L2 , tubectomised with no h/o oral contraceptives used Diabetic And Hypertensive Family History Of 1stDegree Relatives With Endometrial Cancer And Breast Cancer
GENERAL PHYSICAL EXAMINATION Patient comfortable at the time of examination, Afebrile BMI= 38.95 (weight- 90 kg, height-152cm) : Obese Pulse = 76 bpm BP= 150/86mm Hg (R. arm, sitting) No Pallor/ Icterus/ Lymphadenopathy/ Edema. B/L Varicose veins+ up to thighs Breasts, Thyroid, Spine Clinically normal
SYSTEMIC EXAMINATION Cardio-Respiratory examination - Clinically normal Per Abdomen- Inspection : obese abdomen, umbilicus in midline and deep, vertical lower midline scar of c.section and transverse suprapubic scar of Tubal Ligation + Cystectomy seen, all healed by primary intention with no incisional hernia. All quadrants move equally with respiration. No other scars or sinuses seen, hernial orifices free. Palpation : Soft, non-tender , no organomegaly or mass felt Percussion: No free fluid Auscultation : Bowel sounds +
SYSTEMIC EXAMINATION Local Examination Vulva appears normal and healthy Per Speculum Minimal bleed seen from cervical os, otherwise cervix and vagina appear normal and healthy Bimanual Examination Uterus bulky, regular, anteverted, mobile, all fornices free and non-tender. Per Rectal Rectal mucosa smooth and free Recto-vaginal No nodularity felt in cul-de-sac or parametrium, uterus mobile.
Summary 65 year old P2L2 Tubectomised Obese, Diabetic And Hypertensive Lady With Post-menopausal Bleeding Since 4 Months, With Family History Of 1stDegree Relatives With Endometrial Cancer And Breast Cancer, On Examination Had A Bulky And Mobile Uterus Associated With Bleeding Through Cervical Os, For Further Evaluation.
Provisional Diagnosis 65 year old P2L2 Obese, Diabetic And Hypertensive Lady With Post-menopausal Bleeding with Post-Menopausal Bleeding for evaluation
Differential Diagnosis 1. ENDOMETRIAL HYPERPLASIA / POLYP 2. ENDOMETRIAL CANCER 3. ATROPHIC ENDOMETRIUM 4. ENDO-CERVICAL CANCER
Investigations USG (Pelvis) TAS and TVS: Uterus AV, 11.9x5.7x6.5cm, ET-25mm with few areas of altered echotexture with increased vascularity seen. B/L ovaries atrophic. Endometrial Pipelle biopsy : Well differentiated adenocarcinoma of endometrium. MRI : Uterus mildly bulky, ET-25mm, myometrium, parametrium and cervix normal with no extensions seen. B/L ovaries atrophic, B/L internal iliac lymph nodes enlarged, no free fluid.
Management Extrafascial Total Abdominal Hysterectomy + Left salpingoophorectomy+ Right Salpingectomy+ B/L Pelvic Lymphadenectomy Sub-umbilical midline vertical incision taken Intra-op findings : Uterus was enlarged to 8-10 weeks gravid uterus size. B/L fallopian tubes normal with post-tubectomy status seen Left Ovary atrophic, Right Ovary not visualized (H/o R. Ovarian Cystectomy) Cut section of uterus showed a fleshy mass filling the endometrial cavity, no gross involvement of cervix or myometrium seen B/L enlarged iliac lymph nodes seen
Follow Up : HPE Report : well differentiated endometrial adenocarcinoma, confined to body of uterus (FIGO Grade 1, TNM Stage- T1a, No, Mx) All Lymph Nodes show changes of reactive lymphadenitis Follow Up : No Radiotherapy required Every 3 months x 1 year for clinical examination.
