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CLINICOPATHOLOGIC

CASE
PRESENTATION

Princess Aliza Gonzales


GENERAL DATA
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.
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
 Relieved 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.
OBSTETRIC HISTORY
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
r
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
coil
6 1959 FT NSVD F Good Home TBA No
CONTRACEPTIVE
HISTORY

 Nohistory 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 55-
57 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
 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
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,
 Nose: no discharge, no foreign
body
 Mouth and Throat: lips pink, moist
oral mucosa and tongue
 Neck. No venous engorgement, no
tenderness, no rigidity, no
lymphadenopathy
 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, 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-
tender
- 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

discomfort
itching
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
Endopelvic
fascia
cystocele rectocele enterocele
Decreased estrogen
production

Atrophic changes of the


urinary tract epithelium

Urinary Dysuria Nocturi Urinary


urge a frequency
incontinenc
e
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, non-
tender, well-delineated, grayish-
white 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, 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
evaluation
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, 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
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 post-
operative 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