Chief Complaint

Per vagina bleeding for 4 years

History of Presenting Illness

Madam A, a 53-year-old Malay lady, Para 2, was admitted electively for ……

She was apparently well until 4 years ago in 2019, when she started to experience per vaginal
bleeding. Initially, the bleeding was of minimal amount, presented as spotting of blood on the
patient’s undergarment without involvement of blood clots, and mostly occurred during the
intermenstrual period once in 2 to 3 months. Madam A was able to continue with her daily
activities normally without impact from this problem.

However, over the course of 4 years, Madam A’s condition had worsened, with the frequency
of intermenstrual bleed and the volume of bleeding increased, achieving the maximum severity
around 8 months ago during August of 2022. The bleeding occurred up to 5 times per month
during the intermenstrual period and postcoitally, each time with copious of blood drippling
down her thigh, with 5 – 6 fully soaked night pads changed per day. The blood clots were found
expelled occasionally with the bleeding as well. Along with the current event, Madam A had
developed anaemic symptoms such as fatigue, palpitation and dizziness. Otherwise, Madam
A’s menstrual cycles were generally normal and regular with normal amount of blood flow.

In the past 5 months, Madam A had on and off suprapubic and vaginal discomfort with sense
of fullness in said area. It was associated with occasional yellowish, sticky, foul-smelling
discharge and dysuria. Otherwise, there was no other symptoms suggestive of urinary tract
infection such as urinary urgency and frequency, bladder fullness, haematuria or flank pain.

2 months prior to the current admission, Madam A was unable to pass motion for 4 days. She
had visited a local clinic and was referred to Hospital Selayang for investigation. She was
treated as constipation colic, and was discharged with laxative on PRN basis. Since then, she
had abdominal distension and had drastic changes on her bowel habit of once per day as she
currently having frequent loose and watery stool. Colonoscopy was not done during her visit
at Hospital Selayang. Madam A was unable to tell the investigation result from her visit to
Hospital Selayang as well.

Madam A had a loss of appetite for the past 2 months, along with significant loss of weight of
6 kg in 2 months. There was no other constitutional symptom like fever, anorexia or night
sweat. Madam A also did not have metastatic symptom including jaundice, low back pain or
bone pain, altered consciousness or shortness of breath.

Madam A do not have risk factor of HPV infection including having early onset of sexual
activity, multiple sexual partners, having a high-risk partner, history of sexually transmitted
disease, neither she has risk factor of malignancy such as cigarette smoking, family history of
malignancy, or oral contraceptive use. However, Madam A did not had pap smear or other
screening programs done in the past.

Madam A also had occasional abnormal vaginal discharge in the past 5 months. The discharge
was mostly yellowish and sticky with foul smelling. IT

Abdominal painhttps://emedicine.medscape.com/article/253513-clinical

Urle out differential, metastatic and constitutional

Pv bleed since 4 years ago 2019

Irregular heav menstrual since august 2022

Madam C, a 51-year-old Chinese lady, Para 3, was electively admitted for examination
under anaesthesia after complaining of worsened heavy menstrual bleeding.

She was apparently well until approximately 1 year ago, that she would find herself
bleeding more during her menstrual period. Her usual menstrual cycle took place once in 30
days, 4 days of bleeding per cycle. She would use 3-4 sanitary pads per day, mostly were only
partially soaked. After the onset of disease, the amount of menstrual bleeding increased by
every month, and she had to changed her fully soaked pads up to 6 times per day. Otherwise,
Madam C was able to continue with her daily activities normally without impact from this
existing problem or other symptoms/complications.

However, Madam C’s condition worsened 3 months ago. She started to pass copious
amount of blood throughout the day during her menstrual period and continued up to 3 weeks.
During this period, she had to use adult diapers instead, and had then changed 5-6 times a day.
The bleeding would even overflow the diapers and stained her lower garment. Blood clots were
found in the diapers as well. Besides, Madam C also presented with anaemic symptoms
including dizziness, palpitation, fatigue and reduced effort tolerance. The bleeding was
associated with severe dysmenorrhoea as well. Madam C described the pain as a cramping pain
with pain score of 10/10, mostly felt around suprapubic region.

Madam C was sent to Hospital Ampang to seek treatment, and was discharged with
tranexamic acid and Ponstan with arrangement made for examination under anaesthesia with
hysterectomy.

Madam C had a history of uterine fibroid and had myomectomy done in a private
hospital more than 10 years ago. However, no HPE documentation was available. Otherwise,
Madam C had denied of other gynaecological symptoms such as intermenstrual or postcoital
bleeding, abnormal vaginal discharge, vulval skin changes and itching, or dyspareunia. No pap
smear was done before. Madam C also denied of precipitating factors including trauma,
intercourse or other procedures done such as c-section, pregnancy termination or intrauterine
device placement. She was not on practices which would alter her hormones such as taking
oral contraceptive pills or on hormone therapy, or other systemic agents such as antidepressants
or anticoagulants. Madam C have normal appetite, did not experienced unexplained weight
loss, and did not have other metastatic symptoms such as unexplained chronic low back pain,
ascites, or jaundice. She was able to pass urine and had normal bowel movement.

Systemic Review

General Health No recent weight changes. Good appetite. No fever.

Cardiovascular system No chest pain, no orthopnoea, no paroxysmal nocturnal dyspnoea,

no palpitation, no claudication, no ankle swelling

Respiratory system No cough, no sputum production, no shortness of breath, no

wheezing, no sore throat, no haemoptysis, no runny nose

Gastrointestinal system Abdominal pain. No dysphagia, no nausea and vomiting, no

hematemesis, no indigestion, no altered bowel habit

Genitourinary system Normal urine output and colour, no dysuria, no nocturia, no

haematuria, no urinary incontinence, no urgency, no vaginal
discharge, no genital ulcer

Nervous system No headache, no dizziness, no weakness, no loss of

consciousness, no confusion, no fits, no altered sensation, no
visual / hearing / speech problems, no memory / concentration
problem
 Musculoskeletal system No difficulty in movement, no joint / muscle pain, no joint
stiffness, no joint swelling, no falls / recent trauma

Endocrine system No heat / cold intolerance, no changes in sweating, no polyphagia,

no polydipsia

Other No bruising, no skin rashes

Past Obstetric History

Madam C had experienced 3 pregnancies and 3 labours through spontaneous vaginal delivery.
She did not experience abortion or miscarriage in the past. Her obstetric history was as
followed.

2000, boy, spontaneous vaginal delivery, no complication

2002, boy, spontaneous vaginal delivery, no complication

2006, girl, spontaneous vaginal delivery, no complication

Past Gynaecology History

Madam C attained menarche at 13 years old. Her menses had been regular with a 30-day cycle
with a normal flow of about 4 days. She used about 4 sanitary pads per day for the first 2 days
and 3 sanitary pads per day for the following days. However, her menses had become irregular
in the past 1 year. Other history was as mentioned in history of presenting illness. She had no
history of sexually transmitted disease, urinary tract or vaginal infections. Pap smear was done
4 years ago and the result was normal. She was unsure of her last menstrual period.

Past Medical History

Madam C was diagnosed with iron deficiency anaemia with possible thalassaemia trait few
years ago. She was not on any medication and was not transfusion dependant. She did not have
past history of chronic diseases, malignancies, or coagulopathies.

Past Surgical History

Madam C had myomectomy done more than 10 years ago in a private hospital. The indication
of said procedure was not mentioned, most likely to be a uterine fibroid.

Drug History

Madam C was on tranexamic acid and Ponstan tablet after her most recent discharge from
Hospital Ampang. She was not on other OTC or other alternative medication, oral
contraceptives or hormone replacement drugs.

Madam C had no known food or drug allergy.

Family History

Madam C is the 4th child among her 5 siblings. Her father had passed away at the age of 80 due
to unknown cause. Her mother is currently 85 years-old without suffering from any medical
illness. Madam C was clueless about the source of thalassaemia trait among her family
members. Otherwise, there was no family history on malignancy, chronic illness, or other
hereditary health condition.

Social History

Madam H worked as a yoga coach. She stayed with her husband in a flat in Pandan Indah. She
did not practice cigarette smoking nor drinks alcohol.
PHYSICAL EXAMINATION

Anthropometric Measurements

Height: 160 cm

Weight: 68 kg

BMI: 26.6 kg/m2

Vital Sign

Blood pressure: 112/68 mmHg

Pulse rate: 80 beats per minute

Respiratory rate: 20 breaths per minutes

Temperature: 37.0 °C

SPO2: 98% under room air

General Examination

Madam C was alert, conscious and well orientated. She was lying comfortably on the
bed with the head of bed elevated at 45°. She was slightly overweight. She was not in pain or
respiratory distress, did not require oxygen support or respiratory aids. There was no signs of
sepsis, dehydration or nutritional deficiency.

The hands were warm but pale. There was no peripheral cyanosis, leukonychia, nail
clubbing, pallor, or palmar erythema. Capillary refill time was less than 2 seconds. Her radial
pulse was beating at 80 beats per minute with regular rhythm and the adequate pulse volume.

On examination of the eyes and face, there was no scleral icterus but with slight
conjunctival pallor. The patient was well hydrated as evidenced by moist oral mucosa and
normal skin turgor. The oral hygiene was good with healthy teeth and gum. No aphthous ulcer,
angular stomatitis, glossitis or central cyanosis were noted. Cervical lymph nodes were not
enlarged.

There was no pedal oedema. Dorsalis pedis pulse can be palpated.

Abdominal Examination

On inspection, the abdomen was flat and moved with respiration. The umbilicus was
centrally located and inverted. There was a 10 cm horizontal surgical scar seen at the
suprapubic region. It was well-healed without keloid formation, non-tender on palpation,
without cough impulse suggesting of hernia. There was no other surgical scar or marking,
stoma, dilated veins, abnormal peristaltic wave or flank fullness seen.

The abdomen was generally soft without tenderness or guarding upon palpation. On
deep palpation, no mass was palpated on the abdomen. Normal liver dullness can be heard from
5th intercostal space along the right midclavicular line down to the subcostal margin. Traube’s
space was resonant upon percussion. Shifting dullness was negative.

On auscultation, there was no bruit heard.

Bimanual Examination, Vaginal and speculum examination.

A huge polyp can be seen arising from the os about 6cm in length with thick stalk inside the
os. Active bleeding was seen from os. Unable to pass through with pipelle into the os. Cervix
was normal otherwise. Blood was seen in vaginal canal. Otherwise, both vulva and vagina were
normal without abnormal discharge, growth, hematoma, or warts.

The uterus was anteverted and was of 8th week of size, mobile. The rim of the cervix
was smooth. Cervical excitation was negative. No adnexal mass palpable.
**Other systemic examinations were unremarkable. **

Case Summary

Madam C is a 51-year-old Para 3 Chinese lady with underlying iron deficiency anaemia and
with suspected thalassaemia trait. She was electively admitted for examination under
anaesthesia with hysteroscopy due to complains of menorrhagia manifested in the past 1 year
with worsening of symptoms in the past 3 months, including severe menorrhagia,
dysmenorrhoea, and symptomatic anaemia. She denied of constitutional and metastatic
symptoms from malignancy, oral contraceptives or tamoxifen usage, postcoital or
intermenstrual bleeding, pressure symptoms with abdominal distension, or coagulopathy. On
examination, polyp was found on vaginal and speculum examination, with active bleeding.

Provisional and Differential Diagnosis

Provisional Diagnosis

Abnormal uterine bleeding secondary to endometrial polyp

Supporting Evidence Evidence Against

● Heavy uterine bleeding ● No tamoxifen usage

● Overweight: endometrial polyp was ● No Lynch or Cowden syndrome

associated with obesity
● No intermenstrual or postcoital
● Multiparous bleeding

● Lower abdominal pain ● No vaginal discharge

● Speculum examination showed

bleeding and mass with stalk
 extended deep from os (endocervical
canal)

Differential Diagnosis

Leiomyoma (uterine fibroid)

Supporting Evidence Evidence Against

● Heavy uterine bleed ● No family history

● Overweight ● No abdominal distension due to mass

● No early menarche

● Multiparous

● No pressure symptoms to urinary

tract or bowel

Endometrial hyperplasia/carcinoma

Supporting Evidence Evidence Against

● Heavy uterine bleeding ● No tamoxifen usage

● High BMI ● No constitutional symptoms

● No chronic anovulation
 ● No early menarche

● No hereditary factors
(Lynch/Cowden Syndrome)

● No family history of endometrial

CA/having BRCA gene)

Adenomyosis

Supporting Evidence Evidence Against

● Heavy uterine bleed ● No subfertility

● Dysmenorrhoea ● No dyspareunia
Investigation

Full blood count with white cell differential count

Indications:

● To assess haemoglobin and haematocrit level as patient has heavy menstrual bleeding

● Patient had symptomatic anaemia

● Patient has underlying IDA and thalassaemia

Result:

Parameters Results Normal Range

RBC 3.61 3.87 - 5.21 × 10^6/uL

Haemoglobin 9.5 11.6 - 15.1 g/dL

Haematocrit 30.5 35.1 - 44.9%

MCV 84.5 80.6 - 95.5 fL

MCH 26.3 26.9 - 32.3 pg

MCHC 31.1 31.9 - 35.3 g/dL

Platelet 400 171 - 399 K/uL

RDW-CV 12.8 12.0 - 14.8%

WBC 9.6 4.1 - 11.4 K/uL

Absolute Neutrophil 6.0 3.9 - 7.1 K/uL

Absolute Lymphocyte 2.6 1.8 - 4.8 K/uL

Absolute Monocyte 0.5 0.4 - 1.1 K/uL

 Absolute Eosinophil 0.4 0.0 - 0.8 K/uL

Absolute Basophil 0.0 0.0 - 0.1 K/uL

Interpretation: Decreased red blood cell, haemoglobin and haematocrit implying an anaemia,
which corresponds to patient’s symptoms. Low MCH and MCHC most likely due to underlying
IDA. The was no active infection.

Renal Profile

Indications:

● Preoperative examination

● To assess kidney function and electrolyte balance

Result:

Parameters Results Normal Range

Urea 3.1 2.76 - 8.07 mmol/L

Sodium 140 136 - 145 mmol/L

Potassium 3.9 3.4 - 4.5 mmol/L

Chloride 106 98 - 107 mmol/L

Creatinine 54 62 - 106 mmol/L

Calcium 2.21 2.08 - 2.65 mmol/L

Magnesium 0.7 0.66 - 1.07 mmol/L

Phosphate 1.3 0.78 - 1.65 mmol/L

Inorganic

Interpretation: Normal renal profile.

Chest X-ray

Indications:

● Preoperative investigation

● To make sure the patient is fit for surgery and does not have heart / lung problems

● To look for metastasis

Result:
Interpretation:

This is an AP view of chest x-ray. The radiograph was adequately exposed with good
penetration. Lung markings, aortic knuckle and heart border can be seen clearly. All pairs of
ribs were normal. There is no cardiomegaly, loss of costophrenic angle, tracheal deviation, or
consolidation/pleural effusion.

Electrocardiography

Indications:

● Preoperative investigation
 ● To check for current cardiac condition and make sure the patient is fit for surgery

Result:

Interpretation: The heart rate was 100 beats per minute with normal sinus rhythm. There was
no axis deviation, ST elevation or depression. The P wave, QRS complex and T wave showed
normal characteristics. There was no sign of ischemia or atrial fibrillation. The ECG findings
were normal.

Transvaginal Ultrasound

Indications:

● To detect any abnormalities on the uterus

● To detect mass and to localise them if present

● To visualise the ovaries

● To assess the endometrial thickness

Result:

Uterus was normal with size of 4.6 x 8.1cm. Endometrial thickness was 7.9mm. Right ovarian
cyst was seen, 4.7 x 5.5cm, ground glass, no solid area within. No papillary projection, likely
an endometrioma. No free fluid, bilateral kidney normal.

Other investigation could be done:

Coagulation profile, pap smear, group screening and hold

Management & Follow Up

Day 1

Subjective ● New case admitted to gynaecology ward, accompanied by relative

Objective • Patient was alert and calm

• No anaemic symptoms
• Vaginal examination done: polyp much reduced in size but was unable
to feel base of stalk

Assessment ● Blood pressure: 121/77 mmHg

● Pulse rate: 80 beats per minute

● Respiratory rate: 20 breaths per minutes

● Temperature: 37.0 °C

● SPO2: 98% under room air

Plan ● EUA, hysterectomy, polypectomy, endometrial sampling and

colposcopy on the next day as planned

● Trace all blood investigation and anaesthetic review

● Keep Nil by mouth at 12 midnight

● For IVD 4 pints over 14 hours once NBM

● Explained VE finding to patient, offered to perform total hysterectomy

in event of uncontrolled bleeding after polypectomy, however, patient
was not keen for the offer.
Day 2

Subjective ● Well

● No abdominal pain

Objective • No more per vaginal bleed

Assessment ● Blood pressure: 136/70 mmHg

● Pulse rate: 76 beats per minute

● Respiratory rate: 20 breaths per minutes

● Temperature: 36.8 °C

● SPO2: 98% under room air

OT (Subsequent ● VE: uterus at 8 weeks, cervix noted endocervical mass measuring

investigation***) 2x3cm with broad base measuring 2cm

● Hysteroscopy findings: endometrium lining smooth, bilateral ostia

seen, no polyp/mass seen

● Colposcopy: Acetic acid applied, noted acetowhite uptake seen at 6

o’clock area, punch biopsy done, haemostasis secured with copper
sulphate

● Minimal blood loss

Plan ● Allow orally as per tolerated

● Vital sign monitoring

● T PCM 1g QID

● Send polyp for HPE, cervical punch biopsy for HPE

● Keep CBD for 6 hours

 ● KIV discharge if patient well

● TCA gynae clinic in 6 weeks

Day 3

Subjective ● Patient was alert, conscious, orientated, ambulating well

● Able to tolerate orally

Objective • Vital signs checked and recorded, afebrile

Assessment ● Blood pressure: 129/79 mmHg

● Pulse rate: 79 beats per minute

● Respiratory rate: 20 breaths per minutes

● Temperature: 36.5 °C

● SPO2: 99% under room air

Plan ● Allow discharge

● Discharge with T PCM 1g QID

● TCA gynae clinic in 6 weeks

● TCA stat if develop abdominal pain, pv bleeding or fever

Subsequent Investigation

Full Blood Count & White Cell Count Differential

Indications:

● To assess the haemoglobin level as previous FBC showed anaemia

Result:

Parameters Results Normal Range

RBC 4.51 3.87 - 5.21 × 10^6/uL

Haemoglobin 11.3 11.6 - 15.1 g/dL

Haematocrit 34.7 35.1 - 44.9%

MCV 76.9 80.6 - 95.5 fL

MCH 25.1 26.9 - 32.3 pg

MCHC 32.6 31.9 - 35.3 g/dL

Platelet 273 171 - 399 K/uL

WBC 5.3 4.1 - 11.4 K/uL

Absolute Neutrophil 4.2 3.9 - 7.1 K/uL

Absolute Lymphocyte 1.9 1.8 - 4.8 K/uL

Absolute Monocyte 0.4 0.4 - 1.1 K/uL

Absolute Eosinophil 0.2 0.0 - 0.8 K/uL

Absolute Basophil 0.0 0.0 - 0.1 K/uL

Interpretation: Normal result

Final Diagnosis

Abnormal uterine bleed secondary to endocervical polyp

Supporting Evidence Evidence Against

● Heavy and prolonged menstrual bleed ● Dysmenorrhoea

● Vaginal, bimanual and speculum ● Lack of risk factors such as tamoxifen

examination revealed bleeding with use, obesity, hormone replacement
polyp seen extending out of therapy, having Lynch or Cowden
endocervical canal syndrome