Case 22: Postmenopausal bleeding

 

Case 22: Postmenopausal bleeding

CASE 22: POSTMENOPAUSAL BLEEDING

History

A 58-year-old woman reports postmenopausal bleeding for 6 months. Initially she did not

pay much attention to it but she has had several episodes and it now occurs most days. It is

generally light but for a few days recently it was almost like a period. There is no associated

pain. The woman has never married or been sexually active. She has no previous gynaecological history and has never had a smear test. She was diagnosed with type 2 diabetes 4

years ago for which she takes oral hypoglycaemics. However she is not very compliant with

diet modification, and her blood glucose is not well controlled such that starting insulin is

being considered.

Examination

The woman is obese with a body mass index of 32 kg/m2. Her blood pressure is 150/80

mmHg. The abdomen is non-tender, but due to her adiposity it is not possible to feel abdominal masses.

External genital examination is unremarkable. Speculum and bimanual examination are not

performed as she has never been sexually active.

Transvaginal ultrasound was not possible and a transabdominal ultrasound examination

was therefore performed with a full bladder.

INVESTIGATIONS

Transabdominal ultrasound report: The uterus is normal size and anteverted. The endometrium could not be clearly visualized. Both ovaries appear normal. Ultrasound view was

restricted by patient adiposity.

Examination under anaesthetic and hysteroscopy: The vagina and cervix appear normal.

Hysteroscopy showed an irregular vascular mass arising from the uterine wall with contact

bleeding. Curettage was performed and products sent for histological examination.

The findings at hysteroscopy are shown in Fig. 22.1.

Questions

• What is the likely

diagnosis?

• If this is confirmed how

would you manage this

patient?

Figure 22.1 Hysteroscopy findings (see colour insert).100 Cases in Obstetrics and Gynaecology

52

ANSWER 22

Postmenopausal bleeding should be considered to be due to endometrial carcinoma until

proven otherwise. In many cases the diagnosis turns out to be benign. However in this case

early suspicion is raised by the risk factors for endometrial carcinoma:

• type 2 diabetes

• obesity

• nulliparity.

There is also a long history of significant bleeding suggesting a more significant pathology. In

women who can tolerate the examination, the diagnosis may be made by outpatient endometrial sampling. In this case however the inability to examine properly meant it was appropriate to investigate the uterine cavity and the rest of the lower genital tract under anaesthetic.

The diagnosis of endometrial cancer was confirmed on histology report from the curettage

specimen.

Management

Most (up to 90 per cent) of women with endometrial cancer have localized disease and are

usually cured by hysterectomy and bilateral salpingo-oophorectomy. Magnetic resonance

imaging (MRI) scan prior to surgery should be carried out to check for possible lymph node

involvement, in which case lymph node biopsy or excision should be performed at the time

of surgery. Formal staging is histological. Adjuvant radiotherapy is indicated if there is deep

invasion of the myometrial muscle (50 per cent of the depth) or in grade 3 disease.

! FIGO staging of endometrial carcinoma

Stage

Prognosis

(5-year

survival rate)

I IA Tumour confined to the uterus, no or <50% myometrial

invasion

85%

IB Tumour confined to the uterus, >50% myometrial invasion

II Cervical stromal invasion, but not beyond uterus 75%

III IIIA Tumour invades serosa or adnexa 45%

IIIB Vaginal and/or parametrial involvement

IIIC Pelvic/para-aortic node involvement

IV IVA Invasion into bladder and/or bowel mucosa 25%

IVB Distant metastases including abdominal metastases and/or

inguinal lymph nodes

KEY POINTS

• Postmenopausal bleeding is due to endometrial cancer until proven otherwise.

• Women with prolonged or heavy bleeding are more likely to have pathology.

• Endometrial cancer is staged histologically.

• The majority of women present with stage I disease and have a good prognosis

(85 per cent 5-year survival).