CLINICOPATHOLOGIC CASE PRESENTATION

Princess Aliza Gonzales

GENERAL DATA
A

case of C.P.R., 82 y.o., P6005, menopause at 50 y.o., admitted for the first time on August 7, 2006 at 1637.

CHIEF COMPLAINT

vaginal bleeding

HISTORY OF PRESENT ILLNESS

2 weeks prior to admission, noted vaginal bleeding
Sudden onset  Intermittent  Scanty – consuming 1 thinly-soaked sanitary pad per episode  No clots  Red  Non-foul

Not exacerbated by physical activity nor intake of drugs  Not relieved by rest

Associated with vaginal discharge,
Minimal  Watery  Non-foul  Whitish

 

Not associated with abdominal or hypogastric pain nor dyspareunia No medications taken No consult done

2 hours prior to admission, recurrence of vaginal bleeding

consulted a private physician

thus, advised admission

MENSTRUAL HISTORY
 

17 X 28-30 X 3-7 consumed 2-3 moderately-soaked pads per day. associated with premenstrual dysmenorrhea characterized as
localized, moderate, intermittent, crampy hypogastric pain  occurring 1-2 days before the onset of menstruation  disappeared on the day when bleeding began

by bed rest  No medications taken Not associated with NAV, headache, breast pain, irritability, constipation, diarrhea Menopause at 50 y.o. with episodes of hot flushes, headache, fatigability and irritability which lasted for about half a year.

 Relieved

O r d e r 1

Year A of O deliv G ery

OBSTETRIC HISTORY
Type S Condition of e at birth delive x ry B W

Place of H Cx delivery and led by Home Home TBA No TBA No

1949 FT NSVD F Good

2 1950 FT NSVD F Good 3 1952 FT CS 2° M Good CPD 4 1954 FT NSVD M Died 30min. after birth due to 5 1957 FT NSVD M tight cord Good coil 6 1959 FT NSVD F Good

7 Hospital MD No to 8 Home TBA No Lb

Home Home

TBA No TBA No

CONTRACEPTIVE HISTORY
 No

history of contraceptive use

SEXUAL HISTORY
   

First coitus at 23 y.o. Husband as the only sexual partner 3-4 times a week Last sexual contact was around 5557 y.o. Not associated with dyspareunia nor postcoital bleeding.

PAST ILLNESSES & OPERATIONS

  

M – HTN, had cervical polyp, had arthritis, no DM, no asthma, no heart and kidney diseases, no CA M – took Diovan OD for HTN, Colchicine for arthritis A – no food and drug allergies S – 1952, had CS 2° to CPD 2002, Polypectomy done at Los Angeles, U.S.A. H – previous surgery

FAMILY HISTORY
  

Breast CA on the maternal side HTN on paternal side No heredofamilial diseases like DM, TB, asthma, kidney and heart diseases

SOCIAL HISTORY

Marital – married; living with husband and family of her youngest daughter Stress level – no significant recent life events; unemployed Life history information – had history of travel to Bohol, Manila, and Los Angeles

 

Habits – does not smoke nor drink alcoholic beverages, occasional coffee drinker, no history of illicit drug use Education – secondary education Husband – 84 y.o., businessman, non-promiscuous

NUTRITIONAL HISTORY

Meals for the past 24 hours

Aug.6,2006 – Dinner:

2 cups rice, 1 medium-sized fish, 1 glass of water 2 pcs stuffed bread, 1 glass of milk 2 cups rice, 1 medium-sized fish, 1 serving vegetables, 1 glass of juice

Aug.7,2006 – Breakfast:

Aug.7,2006 – Lunch:

  

No change of appetite With dentures No allergy to foods, not choosy with foods Budget for food varies with availability with money

Ideal Body Weight (IBW)
IBW = ht (cm) – 100 – 5% = 5’(12’)(2.54cm) – 100 – 5% = 152.4 – 100 – 5% = 52.4 – (2.62) = 49.78 kg ~ 50 kg Actual wt = 74 kg

Total Energy Requirement (TER)

TER = IBW (30) + 300 = 50 (30) + 300 = 1500 + 300 = 1800 cal/day

Basal Metabolic Rate (BMR)

BMR = weight (kg) height (m)2 = 74 kg (1.52)2 = 74 kg 2.31 m2 = 32.0 kg/m2 ~ obese

SYSTEMS REVIEW

 

General. on walker, no easy fatigability, had occasional headache, no fever, no dizziness, (+) blurring of vision Respiratory. No cough, no dyspnea Cardiovascular. No chest pain, no tightness, no palpitations

Gastrointestinal. No dysphagia, no weight loss Urinary. No urgency, no frequency, no dysuria Reproductive. (+) vaginal bleeding, (+) abnormal discharge, no pruritus nor pain

PHYSICAL EXAMINATION

General. Patient was conscious, coherent, cooperative, afebrile, not in respiratory distress with the following vital signs: BP = 130/80 mmHg HR = 74 bpm Ht = 5’ RR = 18 cpm Wt = 74kg Temp.= 36.6ºC

 

Skin. Warm, senile turgor HEENT.
Head: symmetric, no scars, no fractures, thin grayish hairs  Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, clear cornea  Ears: no discharge, no foreign body, no tenderness,

body  Mouth and Throat: lips pink, moist oral mucosa and tongue Neck. No venous engorgement, no tenderness, no rigidity, no lymphadenopathy

 Nose:

no discharge, no foreign

Breast. I - symmetrical, no skin retraction or dimpling, no swelling or discoloration, no discharge, brown areola with everted nipple P – no tenderness, no mass,

Chest and Lungs. I – No gross deformities, equal chest expansion P – equal tactile fremitus, no tenderness P – resonant A – clear breath sounds, no rales, no wheeze

Heart. I – no bulging of precordium P – PMI at 5th L ICS midclavicular line, no heave, no thrill P – dullness within normal limits A – distinct heart sounds, normal rate and rhythm, no murmur, no pericardial friction rub

Abdomen. I – flat, silvery striae, midline CS scar P – soft, no tenderness, no mass, no organomegaly P – tympanitic A – normoactive bowel sounds

Genitalia.

Speculum exam
cervix: pinkish, smooth, no ulcerations  scanty, reddish, non-foul bleeding  minimal, watery, whitish, non-foul discharge  1x1 cm, single, grayish-white, welldelineated mass at the external os

Bimanual Pelvic Exam

I – few grayish pubic hairs, no ulcerations, no edema, no swelling, no erythema, parous  C – posterior, closed, firm, movable, nontender - well-delineated, soft, non-tender mass at the external os  U – not enlarged, anteverted, soft, movable, no mass, no tenderness  A – no mass, no tenderness

Extremities. (+) bipedal non-pitting edema, strong pulses

LABORATORY TESTS

Urinalysis
Color – yellow  Transparency – hazy  Albumin – trace  Blood - ++  WBC – 0-2 hpf  RBC – 5-10 hpf  Epithelial cells – rare  Bacteria – rare

Complete Blood Count (CBC)
WBC – 6.56 K/uL  Neutrophils – 3.86  Lymphocytes – 1.77  Monocytes – 0.632  Eosinophils – 0.203  Basophils – 0.107

RBC – 4.57 M/uL  HgB – 12.7 g/dL  Hct – 39.8%  Plt – 246 K/uL

Transvaginal Ultrasound findings:

The anteverted uterus is normal in size, regular in contour and heterogeneous in echopattern, with abundant echogenic calcifications distributed along the uterine walls. It measures approximately 4.8cm in longitudinal diameter, 2.4cm in AP diameter and 4.5cm in transverse diameter.

The closed heterogeneous cervix has a cervical length of 3.4cm and 3.5cm in width. Incidentally, there is a polypoid mass within the mid-cervical canal approximately 1.3 x 1.3 x 1.1cm in size, suggestive of endocervical polyp versus cervical pathology.

The heterogeneous endometrium is thin with a greatest thickness of approximately 0.5cm with an intact endometrial contour compatible with menopausal cycle.  Both ovaries were not visualized.  No evidence of adnexal nor uterine mass.  There is no free fluid in the cul de sac.

SALIENT FEATURES
 

 

82 y.o., multiparous Postmenopausal bleeding associated with vaginal discharge History of cervical polyp 1x1 cm, single, soft, non-tender, grayish-white, well-delineated mass at the external os

Transvaginal ultrasound findings
Normal-sized uterus, anteverted, with abundant echogenic calcifications around uterine walls  Thin and intact heterogenous endometrium (0.6cm), compatible with menopausal cycle  To consider endocervical polyp versus cervical pathology  Both ovaries were not visualized  No uterine nor adnexal mass

DIFFERENTIAL DIAGNOSIS
  

Atrophic vaginitis Endometrial polyp Endometrial carcinoma

ATROPHIC VAGINITIS
 

Senile vaginitis Inflammation of the vaginal epithelium due to atrophy secondary to decreased levels of circulating estrogens Most common in postmenopausal women

Pathophysiology
Decreased estrogen production Atrophy of vaginal epithelium itching burning discomfort dyspareunia

Vaginal bleeding

Decreased estrogen production Decreased collagen content Urethrovesical junction Increased abdominal pressure Urinary stress incontinence Cardinal & uterosacral ligaments Lose tonicity Uterine decensus enterocele

Endopelvic fascia rectocele

cystocele

Decreased estrogen production

Atrophic changes of the urinary tract epithelium

Urinary urge incontinenc e

Dysuria

Nocturi a

Urinary frequency

Clinical Manifestations

Vaginal symptoms
Itching  Vulvar burning  Dyspareunia  Discomfort  Vaginal bleeding

Urinary symptoms
Urinary urge incontinence  Urinary frequency  Dysuria  Nocturia  Urinary stress incontinence

Others

Cystocele, rectocele, enterocele

Basis for Inclusion
  

82 y.o. Postmenopausal bleeding Vaginal discharge

Basis for Exclusion
    

(-) Itching (-) Vulvar burning (-) Urinary symptoms (-) Cystocele, rectocele, enterocele Mass at the external os

ENDOMETRIAL POLYP

 

Are localized overgrowths of endometrial glands and stroma that project beyond the surface of the endometrium They are soft, pliable, and may be single or multiple. Most polyps arise from the fundus of the uterus

They may have a broad base (sessile) or be attached by a slender pedicle (pedunculated). The growths were discovered in all age groups, with peak incidence between the ages of 40 and 49.

Clinical manifestations
 

Majority are asymptomatic Associated with wide range of abnormal bleeding patterns Occasionally, a pedunculated endometrial polyp with a long pedicle may protrude from the external cervical os

Polyps are succulent and velvety, with a large central vascular core The color is usually gray or tan but may occasionally be red or brown The tip of a prolapsed polyp often undergoes squamous metaplasia, infection, or ulceration

The clinician cannot distinguish whether the abnormal bleeding originates from the polyp or is secondary to the frequently coexisting endometrial hyperplasia.

Basis for Inclusion
  

82 y.o. Abnormal bleeding 1x1cm, single, soft, mobile, nontender, well-delineated, grayishwhite polypoid mass at the external os

Basis for Exclusion

(-) ulcerations at the tip of polypoid mass UTZ findings of endocervical polyp

Diagnostic Procedures

Because most endometrial are asymptomatic,the diagnosis is not usually established until the uterus is opened following hysterectomy for other reasons. Are often discovered by vaginal hydrosonoraphy, hysteroscopy, and/or hysterosalphingography during the diagnostic workup of a woman with a refractory case of abnormal uterine bleeding.

ENDOMETRIAL CANCER
 

most common gynecologic CA Phil: 3rd most common gynecologic CA Occurs primarily in postmenopausal women Increasingly virulent with advancing age Any factor that increases exposure to unopposed estrogen increases risk of endometrial cancer (ovary, breast,

Increased Risk

Variants of normal anatomy and physiology
obesity  21-50 lbs = 3x  >50 lbs = 10x  nulliparity = 2x  early menarche and late menopause  >52 years = 2.5x  Tamoxifen use = 2.5 – 9x  Atypical hyperplasia = 29%

Frank abnormality and disease
DM = 3x  HTN = 1.5x

Exposure to external carcinogens and unopposed estrogen treatment

DUB, PCOD, 1° Infertility due to chronic anovulation

Decreased Risk
    

Ovulation Progestin therapy Menopause prior to 49 Normal weight Multiparity

Other Risk Factor

LYNCH family CA syndrome  nonpolyposis colorectal CA, Ovarian and Endometrial CA, Breast CA

Clinical Characteristics
   

 

75% beyond menopause 15% perimenopausal 10% still menstruating 90% will have vaginal bleeding or discharge Older patients with cervical stenosis – hematometra or pyometra 5% asymptomatic Obesity, hypertensive, diabetic

Basis for Inclusion
     

82 y.o. Postmenopausal bleeding Vaginal discharge Family history of breast cancer Hypertensive Obese

Basis for exclusion
  

Multiparity Menopause at 50 1x1 cm, single, soft, mobile, nontender, grayish-white, welldelineated mass protruding from external os UTZ findings of thin and intact heterogeneous endometrium compatible with menopausal cycle UTZ findings of endocervical polyp

Diagnostic Procedures

Office aspiration biopsy

First step in evaluation of patients with abnormal bleeding 90-98% accurate Unreliable, 30-40% will be abnormal Endocervical cells on pap smear
 

Pap test
 

6% will have endometrial cancer 13% endometrial hyperplasia

Hysteroscopy and D&C
   

Cervical stenosis Patient cannot tolerate office biopsy Bleeding recurs after negative biopsy Specimen obtained is inadequate Endometrial polyp or submucous myoma Endometrial thickness >5mm in a postmenopausal patient requires further evaluation

Transvaginal ultrasound
 

IMPRESSION

 Cervical

Polyp

CERVICAL POLYP

Most common benign neoplastic growths of the cervix Most common in multiparous women in their 40s and 50s Usually present as a single polyp, but multiple polyps do occur occasionally Majority are smooth,soft, reddishpurple to cherry red, and fragile

 

They easily bleed when touched Polyps may arise from either:

Endocervical canal – endocervical polyp
Usually have a narrow long pedicle  Occur during reproductive years  Cherry red in color

Ectocervix – cervical polyp
Usually have a short, broad base  Usually occur in postmenopausal women  Grayish-white in color

Etiology

Usually secondary to inflammation or abnormal local responsiveness to hormonal stimulation Focal hyperplasia and localized proliferation are the response of the cervix to local inflammation.

Clinical Manifestation

 

Intermenstrual bleeding, especially following contact such as coitus or pelvic exam Sometimes associated leukorrhea emanates from the infected cervix Many are asymptomatic and recognized for the first time during a routine speculum exam Often the polyp seen on inspection is difficult to palpate because of its soft consistency

Basis for inclusion
     

82 y.o., multiparous Postmenopausal bleeding Leukorrhea Previous history of polypectomy 1x1 cm, grayish-white, well-delineated mass at the external os Ultrasound findings - polypoid mass within the mid-cervical canal approximately 1.3 x 1.3 x 1.1cm in size, suggestive of endocervical polyp versus cervical pathology

Management

Most endocervical polyps may be managed in the office by grasping the base of the polyp with an appropriately sized clamp Polyp is avulsed with a twisting motion and sent to the pathology laboratory for microscopic evaluation

The polyp is usually friable. If the base is broad or bleeding ensues, the base may be treated with chemical cautery, electrocautery, or cryocautery After polyp is removed, endometrial sampling should be performed to diagnose a coexisting endometrial hyperplasia or carcinoma in both symptomatic and asymptomatic

COURSE IN THE WARD

On admission, patient was referred to IM Department for evaluation due to old age. She was diagnosed to have Essential HTN. She was given Co-Diovan 80mg 1tab OD.

Patient was operated on her first hospital day through fractional curettage with cervical punch biopsy and polypectomy under intravenous sedation. Pre-operative and postoperative diagnosis was cervical polyp.

Fractional curettage obtained a minimal amount of endometrial and endocervical tissue. Uterine depth was 8cm. EBL was 50cc. Specimen were sent for biopsy and findings showed Endometrial polyps, Chronic endocervitis and no diagnostic abnormality in the ectocervix.

Patient was discharged on her first post-operative day with improved condition – no complaints of vaginal bleeding or abnormal vaginal discharge.

. . . . . . . . . . . . . . .Thank you

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