Case study - Dysfunctional uterine bleeding

Dr Lizzie Croton discusses a case of menorrhagia with a sinister cause.

Ms Price, a 43-year-old nulliparous woman, presented with recent onset irregular menstrual bleeding. The bleeding was heavy and erratic with a variable cycle length of 24-48 days, with a duration between 4 and 12 days. Prior to this, her cycle had been regular.

Her periods were largely pain free. She was sexually active and there was no associated dyspareunia or postcoital bleeding. Her last smear had been normal. She was not using any contraception and had only ever used condoms. Ms Price herself felt well with no associated mood changes or hot sweats. She was a non-smoker.

Ms Price was obese with a BMI of 31. A pregnancy test was negative. On pelvic examination she had an anteverted mobile uterus the size of a small orange, in keeping with an eight-week pregnant uterus. There were no ovarian masses and her cervix looked normal. An STI screen was normal.

She was referred for a pelvic ultrasound scan because of the uterine enlargement, with fibroids as the suspected cause. A provisional diagnosis of dysfunctional uterine bleeding was made.

Three weeks later, Ms Price returned with a large membranous clot that she had passed. It looked quite atypical of a menstrual clot and so was sent for histopathology.

The results showed a moderately differentiated endometrial carcinoma with possible myometrial invasion (Stage I). Ms Price was admitted and underwent a total abdominal hysterectomy with bilateral salpingooophorectomy.

Endometrial carcinoma is primarily a disease of postmenopausal women. It has a peak incidence at the age of 61. Risk factors include obesity and nulliparity. It is also more common in women with diabetes and polycystic ovarian syndrome.

The classical presentation is of bleeding in the postmenopausal woman. Usually the patient will complain of slight and intermittent bleeding, which later becomes continuous and heavier. There may be offensive discharge with advanced disease. Uterine enlargement is unusual unless the woman has co-existent fibromyomata. Pelvic pain or discomfort is a late sign suggestive of advanced disease.

Around 75 per cent are pure adenocarcinomas. Squamous elements are occasionally present and carries a poorer prognosis.

Spread is usually by invasion into adjacent structures. Tumours are staged according to the degree of cellular differentiation and degree of spread outside the uterus. Tumours confined to the uterus are stage I.

Treatment and prognosis
Disease confined to the uterus can be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy. Poorly differentiated tumours confined to the uterus and stage II disease are treated with hysterectomy plus post-operative radiotherapy. Stages III and IV may be managed non-surgically with chemotherapy or occasionally progesterone therapy. Prognosis depends on tumour stage and cellular differentiation, lymph node involvement and degree of myometrial invasion.

- Dr Croton is a salaried GP in Birmingham

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