Вы находитесь на странице: 1из 82



Princess Aliza Gonzales

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

 vaginal bleeding
 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

 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
 disappeared on the day when bleeding
 Relieved by bed rest
 No medications taken
 Not associated with NAV, headache,
breast pain, irritability, constipation,
 Menopause at 50 y.o. with episodes
of hot flushes, headache, fatigability
and irritability which lasted for about
half a year.
O Year A Type S Condition B Place of H Cx
r of O of e at birth W delivery and
d deliv G delive x led
e ery ry by
1 1949 FT NSVD F Good Home TBA No
2 1950 FT NSVD F Good Home TBA No
3 1952 FT CS 2° M Good 7 Hospital MD No
CPD to
4 1954 FT NSVD M Died 8 Home TBA No
30min. Lb
after birth
due to
5 1957 FT NSVD M tight
Goodcord Home TBA No
6 1959 FT NSVD F Good Home TBA No

 Nohistory of
contraceptive use
 First coitus at 23 y.o.
 Husband as the only sexual partner
 3-4 times a week
 Last sexual contact was around 55-
57 y.o.
 Not associated with dyspareunia nor
postcoital bleeding.
 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
 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
 Breast CA on the maternal side
 HTN on paternal side
 No heredofamilial diseases like DM,
TB, asthma, kidney and heart
 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
 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,
 Meals for the past 24 hours
 Aug.6,2006 – Dinner:
 2 cups rice, 1 medium-sized fish, 1 glass
of water
 Aug.7,2006 – Breakfast:
 2 pcs stuffed bread, 1 glass of milk
 Aug.7,2006 – Lunch:
 2 cups rice, 1 medium-sized fish, 1
serving vegetables, 1 glass of juice
 No change of appetite
 With dentures
 No allergy to foods, not choosy with
 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
= 74 kg
2.31 m2
= 32.0 kg/m2 ~ obese
 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
 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
 Head: symmetric, no scars, no fractures,
thin grayish hairs
 Eyes: no ptosis, pink palpebral
conjunctivae, anicteric sclerae, clear
 Ears: no discharge, no foreign body, no
 Nose: no discharge, no foreign
 Mouth and Throat: lips pink, moist
oral mucosa and tongue
 Neck. No venous engorgement, no
tenderness, no rigidity, no
 Breast.
I - symmetrical, no skin
retraction or dimpling,
no swelling or
discoloration, no discharge,
brown areola with everted
P – no tenderness, no mass,
 Chest and Lungs.
I – No gross deformities, equal
chest expansion
P – equal tactile fremitus, no
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
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, well-

delineated 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, non-
- well-delineated, soft, non-tender mass at
external os
 U – not enlarged, anteverted, soft, movable,

no mass, no tenderness
 A – no mass, no tenderness
 Extremities. (+) bipedal non-pitting
edema, strong pulses
 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
 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

 There is no free fluid in the cul de sac.
 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

 Atrophic vaginitis
 Endometrial polyp
 Endometrial carcinoma
 Senile vaginitis
 Inflammation of the vaginal
epithelium due to atrophy secondary
to decreased levels of circulating
 Most common in postmenopausal
Decreased estrogen

Atrophy of vaginal

burning dyspareunia

Vaginal bleeding
Decreased estrogen production

Decreased collagen content

Urethrovesical Cardinal &

junction uterosacral
Increased ligaments
abdominal pressure Lose tonicity

Urinary stress Uterine

incontinence decensus
cystocele rectocele enterocele
Decreased estrogen

Atrophic changes of the

urinary tract epithelium

Urinary Dysuria Nocturi Urinary

urge a 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
 Are localized overgrowths of
endometrial glands and stroma that
project beyond the surface of the
 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, non-
tender, well-delineated, grayish-
white polypoid mass at the external
Basis for Exclusion
 (-) ulcerations at the tip of polypoid
 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
 most common gynecologic CA
 Phil: 3rd most common gynecologic
 Occurs primarily in postmenopausal
 Increasingly virulent with advancing
 Any factor that increases exposure to
unopposed estrogen increases risk of
endometrial cancer (ovary, breast,
Increased Risk
 Variants of normal anatomy and
 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
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
 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, non-
tender, grayish-white, well-
delineated 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
 Pap test
 Unreliable, 30-40% will be abnormal
 Endocervical cells on pap smear
 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
 Transvaginal ultrasound
 Endometrial polyp or submucous myoma
 Endometrial thickness >5mm in a
postmenopausal patient requires further

 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
 Majority are smooth,soft, reddish-
purple 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
 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
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
 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
 After polyp is removed, endometrial
sampling should be performed to
diagnose a coexisting endometrial
hyperplasia or carcinoma in both
symptomatic and asymptomatic
 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 post-
operative diagnosis was cervical
 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
 Patient was discharged on her first
post-operative day with improved
condition – no complaints of vaginal
bleeding or abnormal vaginal
. . . . . . . . . . . . . . .Thank