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Post Menopausal Bleeding-1

A 58-year-old woman presents with a 4-day history of blood-stained vaginal discharge that has now stopped. She is post-menopausal. On examination, she has suprapubic tenderness. An endometrial biopsy is performed. The differential diagnoses are endometrial hyperplasia, cancer, or atrophy. Management will depend on biopsy results but may include hysterectomy, progesterone treatment, or estrogen therapy.

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010527anw
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17 views

Post Menopausal Bleeding-1

A 58-year-old woman presents with a 4-day history of blood-stained vaginal discharge that has now stopped. She is post-menopausal. On examination, she has suprapubic tenderness. An endometrial biopsy is performed. The differential diagnoses are endometrial hyperplasia, cancer, or atrophy. Management will depend on biopsy results but may include hysterectomy, progesterone treatment, or estrogen therapy.

Uploaded by

010527anw
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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58 year old P3G3 presents at gynae clinic with complaints of bloodstained vaginal d/c for 4 days the

previous week. Has now stopped. Mild abdominal discomfort.

History:
Main complaint:
- Has she ever had this discharge before, was it foul smelling, characteristics, associated sx: LAP,
systemic symptoms SOB, Fever, Urinary, bowel symptomsà first vaginal D/C since her
menopause that occurred at 49 years old, no systemic compliants
- LAP: abdominal pains felt like mild period pains, was present on all 4 days the bleeding lasted,
no history of trauma but did have intercourse the week prior to noticing the bleeding
- Is she post-menopausal? Amenorrhea for 6 months
- Precipitating factors: Did she have any sexual intercourse à post coital bleeding
Gynae:
- Menstrual cycle before: bleeding days, cycle regular, normal volume, dysmenorrhea regular
5/30
- Menopausal complaints? Asymptomatic menopause
- Menarche =15
- LMP: normal?
- Papsmear? Results: normal (15 years ago)
- Sexual history
- Contraception/HRT no treatment taken
- Gynae surgeries: hysterectomy
Obstetric: 1x NVD
- Parity, gravidity
- Mode of delivery and GA
- Complications
- Previous C/S
Medical:
- HIV, DM, Epilepsy, Asthma, thyroid, hypertension, heart disease: hpt on ACE-I
- Any medication currently
Surgical Allergies Family hx: none
Social:
- Stable relationship, home, support, occupation/pensioner, sexually active, smoke, drink: des not
work, no smoke/drinking, supported by her husband, circumstances adequate

Examination:
General impression: well, moderately overweight
Vitals t 37 p 89 bp 130/90 R 19
JACCOLD: no jaundice pallor anaemia, cyanosis BUT small innoculous LN palpable in groins
All the systems: clear
Abdomen: suprapubic tenderness, no guarding, rebound ascites or masses
- Abdominal masses, tenderness, rebound, guarding, free fluid, organomegally
- BS
Gynae:
External examination: normal, no discharge present
Bimanual: uterus and adnexae both normal size and shape
- Cervix: CET, masses¸ cervix irregular, discharge/blood
- Uterus
- Adnexae
PR
Speculum: cervix appears normal
- Cervical lesions, redness, discharge from the cervix or vagina
- Vaginal wall for lesions
Investigations:
- Papsmear
- Bloods: FBC, UKE, LFT, FSH and LH: Hct = 36%
- Urine distix : clear
- TV ultrasound: uterus measures 8cm and endometrial lining is 6mm
Management:
- Endometrial biopsy done describe method:
o Office procedure
o Tools: pipelle, Z-sampler
o Visualise the cervix with cusco speculum
o Remove excess d/c with chlorhexidine and water
o Grasp ant lip of cervix with a valsellum
o Cervical block only if cervical stenosis
o Introduce sampler into os until resistance of the fundus is felt
o Create a vacuum
o Withdrawal slowlyà rotating in a corkscrew manner at least 3 times 360 degrees with
in and out movement
o Remove endometrial tissuesà fix 10% formalin solution
o Repeat 1-2 times
Differential diagnosis
Post-menopausal hemorrhage due to:
1. endometrial hyperplasia
2. Cancer
3. Atrophy
4. Unlikely to be: polyps, oestrogen effect, myoma
Management if endometrial biopsy shows complex hyperplasia:
- Best treatment option = hysterectomy + BSO
- If refuse = high dose progesterone treatment for 6 months the followd by reassessment.
May include hysteroscopy
Management if endometrial cancer:
- Admit
- Stage:
o Histology
o Cervical smear
o FBC, UKE, LFT, HIV, RPR CA125
o CXR
o Abdominal U/S or CT scan
- Surgery: total abdominal hysterectomy and lymph node dissection
o Why is the LN’s removed?
§ High risk of involvement even if stage 1 cancer
§ Increase risk for node mets:
• >2cm, >2stage > 2 grade, elderly, myometrial involvement
- Adjuvant: radiotherapy if:
o Grade 3 cancer (poor diff)
o Deeply invasive into myometrium
o More than stage 1
o Inadequate margins after resection
Management if atrophy
- Patient should receive opposed oestrogen therapy, systemically = climen/ kliofgest
o Side effects: breast cancer, DVT, CVD, alzheimers
o Advantages: protects against osteoporosis, climacteric sx improves
Follow-up:
- regular assessment with emphasis on screening or early detection of breast cancer, coronary
heart disease, hyperlipidemia

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