Linda is a 59 year old women. She presents to you with PV bleeding on and off for the last 2-3 weeks. She had her last period age 54 years and has no other bleeding except this. She has a history of PCOS when she was younger and diabetes since the age of 40 . She has had no children. She is on metformin 2g XR nocte and has no allergies. She does not smoke and only socially drinks alcohol. Her BP is normal. Her BMI is elevated at 34.
What are the most important diagnosis to consider? List 2
- Endometrial Cancer
- Cervical Cancer
What are the risk factors present and not present in the stem for endometrial cancer? List 8
- Obesity
- DM
- Nulliparity
- Early menarche
- Late menopause
- Estrogen therapy
- Tamoxifen
- PCOS
- Pelvic irradiation
- FHx of cancer – breast, endometrium, ovary, colon
What are two important investigations to perform? List 2
- Pelvic TV USS
- Pap smear
- +/- FBC if heavy bleeding
What two features on pelvic TV USS are you specifically looking for that would be concerning? List 2
- Endometrial thickness >5mm
- Focal endometrial pathology e.g. mass
If either of these features are present, what is the next steps in management? List 1
- Immediate referral to gynaecology for hysteroscopy and DnC
NB – If neither of these features are present on USS, but significant endometrial cancer risk factors are present – referral still should be considered
If the patient had recently started HRT – how would this change you management?
- For women on combined oestrogen/progesterone HRT, investigations are only warranted if the bleeding persists for > 6 months
References
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http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/obstetric-gynaecological/post-menopausal-bleeding#pathway
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NCGC vaginal bleeding in post2menopausal women: A diagnostic guide for General Practitioners and Oncologists (Feb! 2011): http://www.canceraustralia.gov.au/sites/default/files/publications/NCGCGVaginalGbleedingGflowchartsG MarchG2011[1].pdf
