Case Study Reports: Postmenopausal Bleeding

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 asso- ciated 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.

Questions

·             What is the likely diagnosis?

·             If this is confirmed how would you manage this patient?

ANSWER

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 path- ology. In women who can tolerate the examination, the diagnosis may be made by outpa- tient 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

Management of endometrial carcinoma is simple total abdominal hysterectomy and bilat- eral salpingoophorectomy, as 90 per cent of women present with early-stage disease. Magnetic resonance imaging (MRI) scan prior to the procedure may be carried out to check for possible lymph node involvement, in which case lymph node biopsy should be performed at the time of surgery. Cases of stage 2 or greater disease are less common and need adjuvant radiotherapy.

Histology is needed to stage endometrial cancer:

·              stage 1: confined to the body of the uterus

·              1a limited to the endometrium

·              1b invasion only of the inner half of the myometrium

·              1c invasion to the outer half the of the myometrium

·              stage 2: involving the uterus and cervix only

·              stage 3: extending beyond the uterus but not beyond the true pelvis

·              stage 4: extending beyond the true pelvis or into the bladder or rectum.

The woman should be advised that the prognosis is generally good with over 70 per cent survival at 5 years for stage 1 disease, though it is only 10 per cent for stage 4 disease.