Abnormal Vaginal Bleeding in a 56 year old

Max Brinsmead PhD FRANZCOG

May 2015

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

WHAT ARE THE POSSIBLE CAUSES?

Mrs. JP Differential Diagnosis

Endometrial Pathology Carcinoma Benign eg Polyp

Cervical PathologyOther genital tract pathology Ovarian Ca Trauma

Dysfunctional Uterine BleedingBlood dyscrasia

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

WHAT ADDITIONAL INFORMATION DO YOU REQUIRE?

Mrs. JP Additional History Required

Usual menstrual pattern

Recent menstrual cycles and LNMP

Estimate of blood loss

Description of the pain

Use of hormones - COC or HRT

Pap & Gynae History

Risk factors for endometrial Ca

Sexual, contraception & social history

Mrs. JP Additional History

Usual cycle

Recent cycles & LNMP

Estimate of blood loss

Description of the pain

Use of hormones - COC or HRT

Pap & Gynae History

Risk factors for endometrial Ca

Sexual history etc.

Monthly until 6m ago

Some early and some late. Skipped one month. This period 3w late

Has used 3 packets pads, some 3’’ clots. “Flooding”

“Like labour”

Nil

Regular Paps – NAD. One CS and postpartum curette. Took pill for 10 yrs then separated

Infertility. Hypertension. Obese

Celibate since separation

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

DO YOU EXAMINE THIS PATIENT?

WHAT DO YOU LOOK FOR?

Mrs. JP Physical Exam Required

Signs of anaemiaSigns of endocrinopathy Thyroid Androgen excess

Examine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open?

Uterine size and regularityPelvic tenderness or adnexal mass?

Mrs. JP Physical Exam

Signs of anaemiaSigns of endocrinopathy Thyroid Androgen excess

Examine the cervix ?Pap or ThinPrep Look for cervical mucous Is the cervix open?

Uterine size and regularityPelvic tenderness or adnexal mass?

Pale. PR 96/minMale type hair distribution

Intact but patulous with abundant clear mucous

NAD

NAD

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

DO YOU SEND THIS PATIENT FOR SCAN?

Mrs. JP Scan Report

“Thank you for referring this patient with menorrhagia. Abdominal and transvaginal scans were performed. The uterus is enlarged by multiple fibroids the largest of which measures 2.5 cm in diameter. However, there is no distortion of the endometrial cavity which measures 17 mm. This is at the upper limit of normal and reevaluation at another stage of the menstrual cycle may be desirable. The right ovary is mildly enlarged with a volume of 40 cc and the left ovary contains a cyst measuring 2.8 x 2.7 cm. This was evaluated with colour Doppler and no abnormal vascularity noted.”

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

DO YOU SEND THIS PATIENT FOR BLOOD TESTS?

WHAT TESTS WOULD YOU ORDER?

Mrs. JP Pathology Results

HB 90 Microcytic and hypochromic film

S. Ferritin – 5

Pap smear + ThinPrep NAD “but only scanty squamous cells are present

TSH - normal

Mrs. JP Age 56 Para 1

Complains of a period that has been “going on for 2 weeks” with pain

DO YOU PRESCRIBE FOR THIS PATIENT?

WHAT WOULD YOU Rx?

Mrs. JP Treatment

Complains of a period that has been “going on for 2 weeks” with pain

Rx Tabs Primolut 5 mg TDS for 10 days

Ferro-gradumet – one daily

Maybe Nurofen 1-2 Q4-6H

Mrs. JP Age 56 Para 1

DOES THIS PATIENT REQUIRE?

Abdominal CT scan?Immediate D&C?Hysteroscopy?Saline sonography?Endometrial biopsy?Hysterectomy?

Mrs. JP Next Steps

Abdominal CT scan?Immediate D&C?Hysteroscopy?Saline sonography?

Endometrial biopsy?

Hysterectomy?

NoThere are better optionsThis is one that can be performed as an outpatientMaybe – but best for delineating polypsPipelle endometrial sampling is the best option

Only required if cancer of the endometrium is diagnosed