Dr Jayati DUREJA DR MYTHILI KUNDUR DR SPANDANA s DR PAVANI Makkena CSI HOSPITAL BANGALORE PATIENT DETAILS amp CHIEF COMPLAINTS Mrs Pauline 65 year old lady a homemaker educated till class 10th resident of Benson Town Bangalore wife of Mr Daniel a manager belonging ID: 1041123
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1. Case Discussion :Post-Menopausal BleedingDr. Jayati DUREJADR. MYTHILI KUNDURDR. SPANDANA s.DR. PAVANI MakkenaCSI HOSPITAL, BANGALORE
2. PATIENT DETAILS & CHIEF COMPLAINTSMrs. Pauline, 65 year old lady, a home-maker, educated till class 10th, resident of Benson Town (Bangalore), wife of Mr. Daniel, a manager, belonging to upper-middle socio-economic class by Kuppuswamy’s modified scale,Presented to the Gyne OPD with the chief complaint of- Bleeding per vaginum on an off since 4 months
3. HISTORY OF PRESENTING COMPLAINTPatient attained menopause 17 years agoShe noted the first episode of bleeding per vaginum 4 months ago, which was minimal in amount, requiring 1 pad/day and lasted 2-3 days, not associated with abdomen pain or passage of clots.No h/o malodourous or abnormal discharge No h/o abdominal discomfort or distension or backache. No history of bowel or bladder disturbances.She reports a total of 3 such episodes in the last 4 months, the most recent one being 2 days ago.
4. No h/o recent weight gain or lossNo h/o hormonal therapy after attaining menopauseNo h/o anticoagulant use or aspirin therapy No h/o mass descending per vaginumNo h/o post-coital bleeding or local traumaHISTORY OF PRESENTING COMPLAINT
5. MENSTRUAL HISTORYAge at Menarche : 11 yearsAge at Menopause : 48 yearsPast menstrual cycles : Regular, 3/28-30 days, average flow.
6. SEXUAL & CONTRACEPTION HISTORYSexually activeUnderwent Tubectomy after 2nd Delivery.No h/o Hormonal Contraceptive use.
7. OBSTETRIC HISTORYMarried Life = 39 years, Non Consanguineous MarriageP2L21 LSCS, 1 VBAC , LCB- 36 years ago
8. PAST MEDICAL & SURGICAL HISTORYK/C/O TYPE II DM x 3 years, on Tab Glimepiride 2 mg and T. Metformin 500mg combined tablet b.i.d., and blood sugars have been told to be under good control.K/C/O HYPERTENSION x 2 weeks, on Tab Atenolol 25mg o.d.Underwent R. Ovarian cystectomy + B/L Tubal Ligation 35 years ago. The cyst was told to be benign on follow up and she did not receive further treatment for the same.
9. FAMILY HISTORYFather diabetic and hypertensiveYounger sister had Endometrial CancerOlder sister had Breast Cancer with ? Liver Mets
10. PERSONAL HISTORYConsumes mixed diet Good appetite , No change in weightBowel and bladder habits are regularSleep undisturbedNot an active/ passive smoker, does not consume alcohol, no addictions.
11. History - Summary65 year old with Post-menopausal Bleeding P2L2 , tubectomised with no h/o oral contraceptives usedDiabetic And Hypertensive Family History Of 1st Degree Relatives With Endometrial Cancer And Breast Cancer
12. EXAMINATION
13. GENERAL PHYSICAL EXAMINATIONPatient comfortable at the time of examination, AfebrileBMI= 38.95 (weight- 90 kg, height-152cm) : ObesePulse = 76 bpm BP= 150/86mm Hg (R. arm, sitting)No Pallor/ Icterus/ Lymphadenopathy/ Edema.B/L Varicose veins+ up to thighsBreasts, Thyroid, Spine – Clinically normal
14. SYSTEMIC EXAMINATIONCardio-Respiratory examination - Clinically normalPer Abdomen-Inspection : obese abdomen, umbilicus in midline and deep, vertical lower midline scar of c.section and transverse suprapubic scar of Tubal Ligation + Cystectomy seen, all healed by primary intention with no incisional hernia.All quadrants move equally with respiration. No other scars or sinuses seen, hernial orifices free.Palpation : Soft, non-tender , no organomegaly or mass feltPercussion: No free fluidAuscultation : Bowel sounds +
15. SYSTEMIC EXAMINATIONLocal Examination – Vulva appears normal and healthyPer Speculum – Minimal bleed seen from cervical os, otherwise cervix and vagina appear normal and healthyBimanual Examination – Uterus bulky, regular, anteverted, mobile, all fornices free and non-tender.Per Rectal – Rectal mucosa smooth and free Recto-vaginal –No nodularity felt in cul-de-sac or parametrium, uterus mobile.
16. Summary 65 year old P2L2 Tubectomised Obese, Diabetic And Hypertensive Lady With Post-menopausal Bleeding Since 4 Months, With Family History Of 1st Degree Relatives With Endometrial Cancer And Breast Cancer, On Examination Had A Bulky And Mobile Uterus Associated With Bleeding Through Cervical Os, For Further Evaluation.
17. Provisional Diagnosis65 year old P2L2 Obese, Diabetic And Hypertensive Lady With Post-menopausal Bleeding with Post-Menopausal Bleeding for evaluation
18. Differential DiagnosisEndometrial hyperplasia / polypEndometrial cancerAtrophic endometriumENDO-Cervical cancer
19. Investigations USG (Pelvis) TAS and TVS: Uterus AV, 11.9x5.7x6.5cm, ET-25mm with few areas of altered echotexture with increased vascularity seen. B/L ovaries atrophic. Endometrial Pipelle biopsy : Well differentiated adenocarcinoma of endometrium.MRI : Uterus mildly bulky, ET-25mm, myometrium, parametrium and cervix normal with no extensions seen. B/L ovaries atrophic, B/L internal iliac lymph nodes enlarged, no free fluid.
20. Management Extrafascial Total Abdominal Hysterectomy + Left salpingoophorectomy+ Right Salpingectomy+ B/L Pelvic LymphadenectomySub-umbilical midline vertical incision takenIntra-op findings : Uterus was enlarged to 8-10 weeks gravid uterus size. B/L fallopian tubes normal with post-tubectomy status seenLeft Ovary atrophic, Right Ovary not visualized (H/o R. Ovarian Cystectomy)Cut section of uterus showed a fleshy mass filling the endometrial cavity, no gross involvement of cervix or myometrium seen B/L enlarged iliac lymph nodes seen
21. Follow Up : HPE Report : well differentiated endometrial adenocarcinoma, confined to body of uterus (FIGO Grade 1, TNM Stage- T1a, No, Mx) All Lymph Nodes show changes of reactive lymphadenitisFollow Up : No Radiotherapy requiredEvery 3 months x 1 year for clinical examination.
22. Thank You