Description
History
A 48-year-old woman presents with intermenstrual bleeding for 2 months. Episodes of
bleeding occur at any time in the cycle. This is usually fresh red blood and much lighter than
a normal period. It can last for 1–6 days. There is no associated pain. She has no hot
flushes or night sweats. She is sexually active and has not noticed vaginal dryness.
She has three children and has used the progesterone-only pill for contraception for 5 years.
Her last smear test was 2 years ago and all smears have been normal. She takes no medication and has no other relevant medical history.
Examination
The abdomen is unremarkable. Speculum examination shows a slightly atrophic-looking
vagina and cervix but there are no apparent cervical lesions and there is no current bleeding.
On bimanual examination the uterus is non-tender and of normal size, axial and mobile.
There are no adnexal masses.
Normal range
Haemoglobin 12.7 g/dL 11.7–15.7g/dL
White cell count 4.5 109/L 3.5–11 109/L
Platelets 401 109/L 150–440 109/L
INVESTIGATIONS
Figure 1.1
QuestionsWhat is the diagnosis and differential diagnosis?How would you further investigate and manage this woman
The diagnosis is of an endometrial polyp, as shown by the hydrosonography image (Fig. 1.1). These can occur in women of any age although they are more common in older women and may be asymptomatic or cause irregular bleeding or discharge. The etiology is uncertain and the vast majority are benign.
In this specific case, all the differential diagnoses are effectively excluded by the history and examination.
• Cervical malignancyCervical ectropionEndocervical polypAtrophic vaginitisPregnancyIrregular bleeding related to the contraceptive pill
Differential diagnosis for intermenstrual bleeding !
Management
Any woman should be investigated if bleeding occurs between periods. In women over the
age of 40 years, serious pathology, in particular endometrial carcinoma, should be excluded.
The polyp needs to be removed for two reasons:
1 to eliminate the cause of the bleeding
2 to obtain a histological report to ensure that it is not malignant.
Management involves outpatient or day case hysteroscopy, and resection of the polyp
under direct vision using a diathermy loop or other resection technique (Fig. 1.2). This
allows certainty that the polyp had been completely excised and also allows full inspection of the rest of the cavity to check for any other lesions or suspicious areas. In some
settings, where hysteroscopic facilities are not available, a latation and curettage may
be carried out with blind avulsion of the polyp with polyp forceps. This was the standard
management in the past but is not the gold standard now, for the reasons explained.Any woman over the age of 40 years should be investigated if bleeding occurs between
the periods, to exclude serious pathology, in particular endometrial carcinoma.Hysteroscopy and dilatation and curettage is rarely indicated for women under the age
of 40 years.
Assignment
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
