Post Menopausal Uterine Bleeding

Age: ‍ years old

Gender: female



HISTORY:

Presents with a ‍-‍day history of post-menopausal bleeding

Described as ‍spottinglightmoderateheavy, ‍with smallwith largewithout clots

Bleeding is ‍constantintermittent



Associated symptoms: *Try using right-click for negatives*

‍pelvic pain

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍vaginal discharge, ‍clear, ‍thin, ‍withwithout fishy odor

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fatigue



Gynecological history:

Menopause: ‍ years old

G‍01234 P‍01234 A‍01234

Last Pap smear: ‍ ‍monthsyears ago



Contributing factors:

‍obesity

‍late menopause

‍nulliparity

‍smoking

no history of: ‍uterine fibroids, ‍endometrial hyperplasia, ‍endometrial cancer

no use of: ‍hormone replacement therapy, ‍unopposed estrogen therapy, ‍tamoxifen use, ‍anticoagulants





EXAM:

Pelvic:

- External genitalia: ‍normal, ‍rashlesions, ‍inguinal lymphadenopathy

- Vagina: ‍normal, ‍lesions, discharge ‍normal, ‍foul-smelling

- Cervix: ‍normal, ‍, ‍IUD strings visualized

- Bimanual exam: ‍normal, uterus ‍tendernessmass, adnexa ‍tendernessmass ‍on righton left, ‍cervical motion tenderness

- Tests performed: ‍Pap smearHPV test, ‍vaginal culturechlamydia/gonorrhea screeningHSV sample, pH ‍< 4.5 (normal)> 4.5, KOH sniff test ‍negative

- ‍Pelvic exam performed with chaperone 





ASSESSMENT:

‍Endometrial hyperplasia ‍likelysuspectedpossible

DDx: endometrial hyperplasia, endometrial cancer, endometrial polyps, cervical polyps, cervical cancer, leiomyoma (fibroids), hormone therapy side effects, tamoxifen therapy side effects, endometrial atrophy, atrophic vaginitis, coagulopathy, pelvic infection, uterine sarcoma, thyroid dysfunction, chronic endometritis, foreign body, trauma, iatrogenic causes





PLAN:

Investigations:

- Blood work: ‍CBC, ‍coagulation profile, ‍TSH, ‍FSH, ‍β-hCG

- Pelvic ultrasound

- Endometrial biopsy if endometrial thickness > 4 mm

Treatments:

- Stop hormone replacement therapy

Further care:

- Referral to gynecologist

- Follow-up in ‍ ‍weeksmonths

- Return if bleeding worsens, if new symptoms develop such as pelvic pain or weight loss, or if symptoms do not improve with treatment