Postmenopausal Bleeding

Thank you for your referral of Margaret Tremblay, a pleasant 64 year old woman referred for postmenopausal bleeding and a thickened endometrium on ultrasound.

Reason for Consultation

• Presented on 14/05/2024 following two episodes of light vaginal spotting over the past month, each lasting 3 days. Associated with mild, intermittent lower abdominal cramping; denies dysuria or dyschezia.

Review of Systems

• Positive for occasional mild pelvic bloating. Negative for hot flashes, night sweats, unintentional weight loss, reduced appetite, fatigue, hematuria, or change in bowel habits.

Past Medical History

• HTN, T2DM, dyslipidemia. No prior medical hospital admissions.

Medications

• metformin (Glucophage®) 500 mg PO BID
• ramipril (Altace®) 5 mg PO daily
• rosuvastatin (Crestor®) 10 mg PO daily

Allergies

• Penicillin (maculopapular rash); no known food or environmental allergies.

Surgical History

• Laparoscopic cholecystectomy (2015), uncomplicated; no adverse reactions to anaesthesia.

Gynecological History

• Menarche at age 12; menopause at age 52. Prior menses were regular. Last Pap test in 2021 was NILM. Denies history of STIs, prior IMB, or PCB. Never used HRT.

Obstetrical History

• G2T2P0A0L2. Two uncomplicated spontaneous vaginal deliveries at term in 1986 and 1989.

Social History

• Non-smoker, 1–2 alcoholic drinks per week, retired elementary school teacher.

Family History

• Maternal aunt with breast cancer at age 68; no family history of endometrial, ovarian, or colorectal cancer (Lynch syndrome).

Physical Examination

• BP 134/82 mmHg, HR 74 bpm, Temp 36.7 °C, BMI 31.2 kg/m². Abdomen soft, non-tender, no masses. Vulva and vagina show mild atrophic changes; no active bleeding or cervical lesions on speculum exam.
• Bimanual examination performed: uterus small, anteverted, mobile, non-tender; adnexa bilateral unremarkable with no palpable masses.
• Pap test was collected today.
• Endometrial biopsy performed: cervix cleansed with povidone-iodine, anterior lip grasped with a single-tooth tenaculum, uterus sounded to 7 cm, 2 passes completed with Pipelle, moderate amount of tissue obtained and sent to pathology.

Investigations

• Pelvic ultrasound (02/05/2024): uterus measures 7.2 x 4.1 x 4.8 cm, homogeneous myometrium; endometrial thickness 8.5 mm; ovaries normal bilaterally, no free fluid.

Assessment

• 64 yo G2P2 presenting with PMB and thickened endometrium (8.5 mm) on TVUS.
• Increased risk of endometrial hyperplasia/malignancy given T2DM and BMI > 30 kg/m².

Plan

• Await Pipelle endometrial biopsy and Pap test pathology results. Follow up in clinic in 4 weeks to review pathology; will arrange diagnostic hysteroscopy and D&C if biopsy is insufficient or shows hyperplasia.
• Counselled regarding the differential diagnosis of PMB (atrophy, polyps, hyperplasia, malignancy) and advised to seek urgent care if she develops heavy vaginal bleeding, fever, or severe pelvic pain post-procedure.

Once again, thank you for involving me in her care.