Obgyn · Year 3 · from Obgyn
Case 2: Postmenopausal Bleeding with Endometrial Cancer
Patient Demographics
- Age: 64 years
- Sex: Female
- Occupation: Retired accountant
Chief Complaint
"I've been having vaginal bleeding for the past 3 months, and I went through menopause 12 years ago."
History of Present Illness
The patient reports intermittent vaginal bleeding over the past 3 months. Initially, it was light spotting occurring once weekly, but it has progressively increased to daily bleeding with occasional heavier episodes requiring a pad. She denies pelvic pain, urinary symptoms, or bowel changes. She has not had any vaginal bleeding since menopause at age 52 until these recent episodes.
Gynecologic History
- Menarche: Age 10 (early)
- Menopause: Age 52
- No hormone replacement therapy
- Prior pregnancies: G1P0010 (one spontaneous abortion at age 28, no live births - nulliparous)
- Last Pap smear: 3 years ago, normal
- No history of abnormal Pap smears
Past Medical History
- Type 2 diabetes mellitus x 15 years (on metformin)
- Hypertension (on lisinopril)
- Obesity (BMI 38)
- Hyperlipidemia (on atorvastatin)
Family History
- Mother: Colon cancer at age 65
- Sister: Endometrial cancer at age 58
- No known genetic testing in family
Risk Factor Assessment for Endometrial Cancer
- Obesity (BMI 38): Present - major risk factor
- Diabetes mellitus: Present
- Hypertension: Present
- Nulliparity: Present
- Early menarche (age 10): Present
- Late menopause: No (age 52)
- Family history of endometrial cancer: Present (sister)
- No protective factors (no OCP use, no breastfeeding)
Physical Examination
- Vital Signs: BP 142/88, HR 78, BMI 38 kg/m2
- General: Obese woman in no acute distress
- Abdomen: Obese, soft, non-tender, no masses palpable
- Pelvic:
- External genitalia: Normal, atrophic changes
- Speculum: Scant blood in vaginal vault, cervix appears normal
- Bimanual: Uterus normal size, non-tender, no adnexal masses
Red Flags
Postmenopausal bleeding is endometrial cancer until proven otherwise
- Requires urgent workup
- 10% of postmenopausal bleeding is due to endometrial cancer
Diagnostic Workup
Transvaginal Ultrasound:
- Endometrial thickness: 14 mm (abnormal in postmenopausal woman; normal <4-5 mm)
- Heterogeneous endometrial echo
- Myometrium: Normal
- Ovaries: Atrophic, normal
- No adnexal masses
- No free fluid
Office Endometrial Biopsy:
- Performed with Pipelle device
- Adequate tissue obtained
- Pathology: Grade 1 endometrioid adenocarcinoma
Additional Staging Workup
MRI Pelvis:
- Endometrial mass with less than 50% myometrial invasion
- No cervical involvement
- No lymphadenopathy
- No adnexal abnormalities
Chest X-ray: Normal
Laboratory Studies:
| Test | Result |
|---|---|
| CBC | Normal |
| CMP | Normal |
| CA-125 | 28 U/mL (normal) |
| HbA1c | 7.8% |
Diagnosis
Endometrial Cancer - Grade 1 Endometrioid Adenocarcinoma
- Type I endometrial cancer (estrogen-dependent)
- Clinical stage I (confined to uterus on imaging)
Surgical Staging and Treatment
Procedure: Total Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy and Sentinel Lymph Node Mapping
Operative Findings:
- Uterus normal size
- Tumor confined to endometrial cavity grossly
- Ovaries and tubes normal
- No peritoneal implants
- Sentinel lymph nodes identified bilaterally
Final Pathology:
- Grade 1 endometrioid adenocarcinoma
- Depth of invasion: 4 mm into 18 mm myometrium (22% - less than 50%)
- No lymphovascular space invasion
- Cervix: Negative
- Both ovaries and tubes: Negative
- Sentinel lymph nodes (4): Negative for malignancy
FIGO Stage
Stage IA - Tumor confined to uterus, less than 50% myometrial invasion
Tumor Molecular Classification
- MSI testing: Microsatellite stable (MSS)
- p53: Wild-type
- POLE mutation: Not detected
- Classification: No specific molecular features (NSMP) - intermediate prognosis
Adjuvant Treatment
- Stage IA, Grade 1 with no lymphovascular invasion: No adjuvant therapy required
- Low risk of recurrence (<5%)
- Surveillance only
Prognosis
- Five-year survival for Stage IA, Grade 1: >95%
- Excellent prognosis
Genetic Counseling
Given family history (sister with endometrial cancer, mother with colon cancer):
- Lynch syndrome evaluation recommended
- MSI testing was negative on tumor, but germline testing discussed
- Patient referred for genetic counseling
Surveillance Plan
- History and physical every 3-6 months for 2 years, then every 6-12 months
- Vaginal cytology (Pap) not routinely recommended
- Imaging only if symptomatic
- Patient education on symptoms of recurrence
Teaching Points
- Postmenopausal bleeding requires urgent evaluation - 10% is endometrial cancer
- Endometrial thickness >4 mm in postmenopausal women requires biopsy
- Type I endometrial cancer (80%) is estrogen-dependent, associated with obesity
- Surgical staging (hysterectomy, BSO, lymph node assessment) is standard treatment
- Stage IA, Grade 1 has excellent prognosis with surgery alone
- Lynch syndrome should be considered in patients with endometrial cancer
Clinical Image
Image Description: Transvaginal ultrasound demonstrating thickened, heterogeneous endometrium measuring 14 mm in a postmenopausal woman, suspicious for endometrial pathology. The thickened endometrial stripe contains areas of increased echogenicity.
Attribution: Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.