A 62-year-old with postmenopausal bleeding and a large fibroid uterus

Postmenopausal bleeding with an endometrial thickness of 22 mm is abnormal; the threshold for investigation is generally more than 4 mm on transvaginal ultrasound. A heterogeneous vascular mass may be endometrial carcinoma, a polyp or a submucosal fibroid.

Why Pipelle is not enough:

• An insufficient sample is a failed test, not a normal result. It must be repeated or replaced with a definitive test.
• Pipelle samples a small proportion of the cavity and can miss focal lesions, especially polyps and carcinoma in a large uterus with a fibroid.
• In a uterus of 16 weeks' size, office sampling is technically unreliable.

Plan:

• Hysteroscopy with directed biopsy and, if possible, resection of the lesion. This gives a histological diagnosis and treats polyps.
• If hysteroscopy is not feasible, fractional curettage under anaesthesia with a large curette is an alternative, but hysteroscopy is preferred.
• Preoperative assessment: full blood count, coagulation, renal function, group and hold; discuss apixaban timing with cardiology or the anticoagulation service (usually stop 48 hours before, depending on renal function, and bridge only if high thrombotic risk).
• Imaging: pelvic MRI if malignancy is suspected to assess myometrial invasion; chest imaging and liver function as part of staging if cancer is confirmed.
• Do not assume the fibroid explains the bleeding; both can coexist.

Staging and risk:

• Grade 1 endometrioid carcinoma with no myometrial invasion on a small sample is low risk, but the definitive specimen may upstage. MRI and, if needed, sentinel node assessment refine risk.
• Obesity and diabetes increase surgical risk, so anaesthetic and medical optimisation matter.

Surgical options:

• Total hysterectomy with bilateral salpingo-oophorectomy is the standard. A laparoscopic or robotic approach reduces morbidity in an obese woman. Consider sentinel lymph node biopsy if myometrial invasion is suspected or the grade is higher.
• Ovarian preservation is generally not advised in postmenopausal women, and the ovaries are not visualised on ultrasound.

Non-surgical options:

• Progestin therapy (e.g. levonorgestrel intrauterine system or oral progestin) can achieve regression in selected low-grade, early-stage disease, but response rates are lower and recurrence higher than with surgery, and it requires repeat sampling.
• It is usually reserved for women unfit for surgery or who decline it, after full counselling.

Counsel that the fibroid and obesity make surgery more complex, and that the decision should be made with her, documented, and reviewed by a gynaecological oncology multidisciplinary team.

Preoperative:

• Anaesthetic review and optimisation of diabetes (HbA1c) and hypertension; stop apixaban according to local protocol with a documented plan.
• Thromboprophylaxis plan: she is high risk (obesity, cancer, immobility), so use mechanical and pharmacological prophylaxis with careful timing around neuraxial anaesthesia.
• Consent must cover conversion to laparotomy, blood transfusion, ureteric or bladder injury, and possible lymph node dissection.
• Bowel preparation only if extensive adhesiolysis is anticipated.

Intraoperative:

• The 6 cm intramural fibroid and 16-week uterus may make laparoscopic access difficult; a vertical midline or extended port placement may be needed, and a senior surgeon should be present.
• Achieve haemostasis carefully; the fibroid may distort the uterine vessels.
• Send the whole uterus for histology; if myometrial invasion is found, consider completion lymph node assessment.
• Avoid morcellation of a known malignancy.

Postoperative:

• Early mobilisation, extended thromboprophylaxis, glycaemic control and wound care; she is at high risk of wound infection and dehiscence.
• Discuss the histology result and whether adjuvant treatment is needed at a multidisciplinary meeting.