CASE
PRESENTATION
DR KHOLA FAROOQ
PGY1
GYNAECOLOGY AND OBSTETRICS
UNIT 1
HISTORY
• 56 year old female, Para1+2 married for 32 years, last born 30 years
back housewife, resident of North Karachi , postmenopausal for 10
years ,known case of HTN for 5 years, presented in OPD with complains
of
• Lower Abdominal pain for 1 year
• Postmenopausal bleeding for 7 months
HISTORY OF PRESENTING COMPLAIN
According to my patient she was in her usual state of health one year back when she
developed mild lower abdominal pain which was insidious in onset , dull in character, non
radiating. It was associated with postmenopausal bleeding, but not associated with any
change in bowel/ micturition habits or any vaginal discharge, and relieved by taking
analgesics.
For the last 7 months, she started having spotting per vaginum , 5 episodes in the last 7
months, last episode was 10 days back,fresh red in colour, resolved on its own. It was staining
only her undergarments, not requiring any pads ,associated with dyspareunia and postcoital
bleeding; although not associated with weight loss ,abnormal vaginal discharge, vaginal
dryness or itching, no hx of any mass felt protuding per vagium
She never consulted any doctor before for this complain.
PAST GYNAECOLOGY HISTORY
• AOM 11 YEARS
• Age of menopause 46 years
• postmenopausal since 10 years
• She had irregular cycles before I.e 3-4days /2 months,
normal flow, no clots and dysmenorrhea
• NEVER HAD PAPSMEAR DONE BEFORE
• NO VAGINAL DISCHARGE
• Postcoital bleeding +ve
• Dyspareunia +ve
PAST OBSTETRIC HISTORY.
• Married for 32 years
• Para 1+2
• LASTBORN 30 YEARS BACK VIA SVD
CONTRACEPTION HISTORY
She was using barrier contraceptive before menopause
No history of any other contraceptive intake ( OCPS )
PAST MEDICAL HX
SHE is KNOWN HYPERTENSIVE for last 4 years ( ON TAB VALSARTAN 40 MG×OD ) compliant and well controlled.
NO HISTORY OF diabetes or any other chronic medical illness or cancer.
No hx of HRT intake.
PAST SURGICAL HX
• NO PRIOR SURGERY.
FAMILY HISTORY
NO HX OF Any chronic medical disorder in family
No history Of Ca of breast,ovaries, uterus,intestine
PERSONAL HX
• NO HX OF WEIGHT LOSS
• NORMAL BOWEL AND MICTURITION HABITS
• NORMAL SLEEP AND APPETITE
• NO ADDICTION
EXAMINATION
• On GPE
• An adult female of average height and morbidly obese having BMI of 38 kg/m2 oriented to time place and
person sitting comfortably on bed
• BP = 140/90 mm of Hg
• PULSE= 74 Bpm
• TEMP = 98.4 F
• R/R = 16 bpm
• Thyroid was not enlarged
• No lymphadenopathy
• NO pallor, clubbing, jaundice , cyanosis, pedal edema
• Breast examination normal
ABDOMINAL EXAMINATION
On inspection
• Abdomen uniform,obesity present
• Umblicus central and inverted
• no visible veins,pulsations,scars seen
• Hernial orifice free
• On palpation
Soft non tender
No mass palpable
No organomegaly
On percussion
No shifting dullness or fluid thrill
On auscultation
Normal bowel sound
PER SPECULUM EXAMINATION
Cervix flushed with vagina
Cervix and vagina normal looking
No lesion or abnormal discharge seen
no bleeding seen coming from cervix or vagina
BIMANUAL PV EXAMINATION
V/V atrophic With sparse hair distribution
CERVIX smooth, firm in consistency no lesion or growth noted
Uterus bulky around 10 week size anteverted non tender mobile
BILATERAL FORNIX CLEAR
RECTAL EXAMINATION
Rectal mucosa Is smooth free
No nodularity felt in Pouch of Douglas
DIFFERENTIAL DIAGNOSIS
• ENDOMETRIAL CANCER
• ENDOMETRIAL HYPERPLASIA
• ENDOMETRIAL POLYP
• ATROPHIC VAGINITIS
• CERVICAL CA
RADIOLOGICAL INVESTIGATION
TRANS VAGINAL ULTRASOUND
• Shows enlarge bulky uterus with non homogeneous uterus showing ill
defined myometrium with multiple cystic spaces.
• Endometrial thickness was 16.5mm
• Endometrium is not well demarcated and a heterogeneous mass lesion
seen within endometrial canal involving anterior wall with increased
vascularity on colour doppler.
• Above findings suggestive of neoplastic lesion arising from endometrium.
MRI PELVIS WITH CONTRAST
• Uterus enlarged measuring 104×68×49 mm
• Endometrial cavity is dilated measuring 25cm showing abnormal intensity signal
along with left lateral and posterior aspect measuring about 43×29×26mm
infiltrating less than 50 percent myometrium but not extending in to cervix.
• There were multiple small intramural fibroids in anterior and posterior wall of uterus.
• Few enhancing lymph nodes were seen in right obturator region and presacral
space.
• Findings were suggestive of Endometrial carcinoma with locoregional lymph nodes
on background of fibroids .
HYSTEROSCOPIC GUIDED BIOPSY
Histopathological examination suggestive of Endometrial carcinoma
( endometriod type FIGO Grade 1)
MANAGEMENT
• TOTAL ABDOMINAL HYSTERECTOMY PLUS BILATERAL
SALPINGOOPHRECTOMY.
• Intraoperative findings showed uterus 8-10week size, bulky, both
fallopian tubes and ovaries were normal looking.
HISTOPATHOLOGY REPORT SHOWS
College of American Pathologists (CAP) Protocol for Reporting of Primary Endometrial Carcinoma
Procedure: Total hysterectomy and bilateral salpingo-oophorectomy.
Hysterectomy type: Abdominal
Specimen integrity: Intact
Tumour site: Endometrium Tumour size: 5x2.5x2cm
Histologic Type: Endometrioid carcinoma, NOS
Histologic Grade: FIGO grade 1
Myometrial invasion Present >50%
Lower uterine segment involvement Not identified
Uterine serosa involvement Not identified
Cervical stromal involvement: Not identified not identified
Other tissue involvement: / unknown
Lymphovascular invasion not identified
FIGO stage: IB (invasion > 50% of myometrium) Additional Pathological findings: Leiomyoma
CONCLUSION: Uterus: - Endometrioid carcinoma (NOS) of Endometrium: FIGO Grade |
- FIGO stage: IB - Lymphovascular invasion: Not identified
- Additional findings: - Leiomyoma - Adenomyosis (uninvolved by carcinoma).
FOLLOWUP
• On the basis Of histopathology report our plan was to give
radiotherapy for which she was referred to Kiran hospital
THANK YOU.
