Case 1: “Spotting” 1st handout:

 Age (mean age at diagnosis in the United States is 63 years);

 White race (usually for type I cancer; African American women
tend to have the more aggressive type II cancer);
 Prolonged exposure to unopposed estrogen: Endogenous
(obesity, chronic anovulation/polycystic ovarian syndrome
[PCOS], estrogen-producing tumors) or exogenous (hormone
replacement therapy, tamoxifen) sources are usually linked to
type I uterine cancer;
 Early menarche, late menopause, nulliparity; and
 Smoking (linked to type II cancer).

Obesity, especially if associated with hypertension and diabetes

mellitus; nulliparity; PCOS; irregular menstrual cycles; and genetic
predispositions (Lynch and Cowden syndromes) are also risk factors
for developing uterine cancer at an earlier age.Protective factors for
endometrial cancer include previous use of combined oral
contraceptive pills, depot shots, and the levonorgestrel intrauterine
device.
Never had a partner?

And here we are—natural menopause, the spontaneous, permanent ending of menstruation that is not
caused by any medical treatment. Menopause is a normal, natural event. It’s defined as the final
menstrual period and is confirmed when a woman has not had her period for 12 consecutive months.

2nd handout: History of Present Illness

3 months PTC, patient noted vaginal spotting occurring 2-3x/week, characterized as dark brown
spots in her panties. She thought this was normal because since she had her menopause at 50 y/o, she
sometimes had vaginal spotting 1-2x per year. She had no other symptoms noted. No consult done.

Volume: “Have you noticed any change in the amount of vaginal discharge?”

Colour (e.g. green, yellow or blood-stained): “Have you noticed any change in
the colour of your discharge?”
Consistency (e.g. thickened or watery): “Have you noticed that your discharge
has become more watery or thickened recently?”
Smell: “Have you noticed any change in the smell of the vaginal discharge?”
Associated symtoms
Medications
Systemic symptoms
fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease) and weight loss (e.g.
malignancy).

Vaginal atrophy occurs in post-menopausal women and can lead to itching and
bleeding of the vagina.

Post-menopausal bleeding: bleeding that occurs after the menopause. Causes

include vaginal atrophy, hormone replacement therapy and malignancy (e.g.
uterine cancer, cervical cancer and vaginal cancer).

Other symptoms
Urinary symptoms such as frequency, urgency and dysuria can be relevant to
gynaecological problems (e.g. dyspareunia, vaginal prolapse, pelvic pain).

Bowel symptoms such as a change in bowel habit or pain during defecation can be

associated with endometriosis.

Fever may be associated with pelvic inflammatory disease.

Fatigue is a non-specific symptom, but its presence may indicate anaemia or

malignancy.

Unintentional weight loss is a concerning feature that may indicate underlying

malignancy.

Abdominal distension is often a benign symptom, however, it can be associated with

serious underlying pathology such as ovarian cancer with ascites.

2 weeks PTC, she noted her vaginal spotting occurs almost everyday and she would always wear
pantyliners which she change 2x/day though it was not fully soaked. No abdominal pain, no dysuria.
No medications taken.

Few hours PTC, due to persistence of vaginal bleeding, patient sought consult at the OPD.
Postmenopausal vaginal bleeding can be caused by:

 Cancer of the uterus, including endometrial cancer and uterine sarcoma

 Cancer of the cervix or vagina
 Thinning of the tissues lining the uterus (endometrial atrophy) or vagina
(vaginal atrophy)
 Uterine fibroids
 Uterine polyps
 Infection of the uterine lining (endometritis)
 Medications such as hormone therapy and tamoxifen
 Pelvic trauma
 Bleeding from the urinary tract or rectum
 Excessive overgrowth of the cells that make up the lining of the uterus
(endometrial hyperplasia)
Causes of postmenopausal bleeding
There can be several causes of postmenopausal bleeding.

The most common causes are:

 inflammation and thinning of the vaginal lining (atrophic vaginitis) or womb lining

(endometrial atrophy) – caused by lower oestrogen levels
 cervical or womb polyps – growths that are usually non-cancerous
 a thickened womb lining (endometrial hyperplasia) – this can be caused
by hormone replacement therapy (HRT), high levels of oestrogen or being
overweight, and can lead to womb cancer
Less commonly, postmenopausal bleeding is caused by cancer, such as ovarian and
womb cancer.

Treatment for postmenopausal bleeding

Treatment depends on what's causing your bleeding.
Treatment for postmenopausal bleeding

Cause Treatment

Cervical polyps the polyps may need to be removed by a specialist

Endometrial you may not need treatment, but may be offered oestrogen cream or pessaries
atrophy

Endometrial depending on the type of hyperplasia, you may be offered no treatment, hormone
hyperplasia medicine (tablets or an intrauterine system, IUS) or a total hysterectomy (surgery to
remove your uterus, cervix and ovaries)

Side effect of changing or stopping HRT treatment

HRT

Womb cancer total hysterectomy will often be recommended

Ovarian cancer surgery to remove your ovaries and your womb (total hysterectomy)

Past Medical History

The past medical history is an important aspect of gynaecological history
taking. In particular, inquire about:

 Pregnancies (learn about a full obstetric history here):

o Number of births/miscarriages/abortions/ectopics.
o Means of delivery, age of child and birth weight.
o Explore any obstetric/delivery complications.
  Cervical smear – ascertain the date of the last smear, its result, and
any treatment arising.
 Surgical history – particularly any pelvic or abdominal surgery.
 Previous gynaecological problems
 Previous sexually transmitted infections

Drug History
Many prescribed (and over the counter) medications can have an effect on
gynaecological health. Inquire about the use of the following:

 Contraception:
o Type and brand name
o Correct use
o Previous contraception history
 Hormone replacement therapy:
o Duration of use
o Cyclical or continuous
o Combined or oestrogen-only
o Method of delivery.
 Recent antibiotic use – some antibiotics are associated with vaginal
candidiasis.
 Any other medications – including over the counter medications
 Known allergies

Systemic: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease, urinary
tract infection), weight loss (e.g. endometrial cancer)
Respiratory: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)
Gastrointestinal: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea),
painful defecation (e.g. endometriosis), abdominal bloating (e.g. ovarian
cancer)
Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract
infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)
Dermatological: white patches on the vulva/vagina associated with pruritis (e.g.
lichen sclerosis)