Abnormal Uterine Bleeding in a Perimenopausal Woman
A 45-year-old woman, para 2, presents with a 6-month history of heavy menstrual bleeding and intermenstrual spotting. She has no significant past medical history, BMI 34, and takes no medications. She has not had cervical screening for 5 years. Examination reveals a bulky uterus of 10 weeks size, no adnexal masses, and a normal cervix. Haemoglobin is 9.8 g/dL. Transvaginal ultrasound shows an endometrial thickness of 14 mm and a 3 cm intramural fibroid. There is no fluid in the endometrial cavity. She is keen to avoid hysterectomy if possible.
1. What is your differential diagnosis and how would you investigate this patient?
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Differential diagnosis:
- Benign: Fibroids (intramural), endometrial polyp, adenomyosis, dysfunctional uterine bleeding (ovulatory or anovulatory), endometrial hyperplasia (especially with obesity), cervical polyp or ectropion.
- Malignant: Endometrial carcinoma (postmenopausal bleeding or perimenopausal AUB with risk factors), cervical cancer (no screening for 5 years), rarely sarcoma.
Investigations:
- Pregnancy test: Exclude pregnancy.
- Blood tests: Full blood count (confirm anaemia), ferritin, coagulation screen, thyroid function, and consider serum ferritin. If irregular cycles, check FSH/LH to assess ovarian function.
- Cervical screening: Take a cervical smear (or refer for colposcopy if abnormal).
- Endometrial sampling: Indicated for AUB with risk factors (age >45, obesity, intermenstrual bleeding, thickened endometrium). Perform Pipelle biopsy or hysteroscopy with directed biopsy. Hysteroscopy is preferred to visualise cavity and exclude focal lesions.
- Imaging: Transvaginal ultrasound already done; consider saline infusion sonography or hysteroscopy for cavity assessment. MRI if fibroids are large or to assess for adenomyosis.
- Additional: If bleeding is heavy, iron studies; consider coagulation testing if personal/family history.
Counsel: Explain need to exclude endometrial hyperplasia/cancer before medical treatment. Discuss options: medical (levonorgestrel intrauterine system, tranexamic acid, NSAIDs, progestins) or surgical (hysteroscopic polypectomy, endometrial ablation, myomectomy, hysterectomy). Given desire to avoid hysterectomy, offer LNG-IUS after pathology excluded, or hysteroscopic resection of polyp/fibroid.
2. Endometrial biopsy shows endometrial intraepithelial neoplasia (EIN) without atypia. How would you manage this patient, considering her desire to avoid hysterectomy?
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EIN without atypia is a premalignant condition with a risk of progression to endometrial cancer (approximately 1–3% per year). Hysterectomy is the definitive treatment, especially in women who have completed childbearing. However, this patient wishes to avoid hysterectomy.
Management options:
- Conservative (medical) management: Suitable for women who strongly desire uterine preservation, provided they are counselled about the risk of progression and the need for close surveillance. Options include:
- Levonorgestrel intrauterine system (LNG-IUS): First-line, with high regression rates (up to 90% in some studies).
- Oral progestins: E.g., medroxyprogesterone acetate 10–20 mg daily or megestrol acetate, but less effective than LNG-IUS.
- Weight loss and lifestyle modification: Obesity is a major risk factor; bariatric surgery may be considered.
- Surveillance: Repeat endometrial biopsy at 3–6 months to assess regression. If no regression or progression, recommend hysterectomy.
- Surgical alternatives: Hysteroscopic resection of focal lesions plus LNG-IUS, but not a substitute for hysterectomy if atypia develops.
- Counselling: Explain that hysterectomy (with or without bilateral salpingo-oophorectomy depending on ovarian status) is the most effective way to prevent cancer, but conservative management is reasonable with strict follow-up. Document informed consent.
- Referral: Consider referral to gynaecologic oncology for a second opinion.
Given her age (45) and completion of childbearing, hysterectomy is generally recommended, but if she declines, LNG-IUS with 6-monthly surveillance is appropriate.