Essay Elements:

• One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
• Brief introduction of the case
• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
• Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.

Patient Name: Sandra Parker

• Age: 55
• Sex assigned at birth: female
• Gender identity: female
• Pronouns: she/her/hers
• Mrs. Parker is a 55-year-old postmenopausal female on daily estrogen and progesterone with a history of hypothyroidism on replacement who presents with intermittent light vaginal bleeding for the past two weeks without associated cramping. Her last menstrual period was three years ago. She is a G2P2 with menarche at age 11, and she has no history of abnormal Pap tests and no family history of cancers.The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
  1. Epidemiology and risk factors (55-year-old female with no history of abnormal Pap tests and no family history of cancer)
  2. Key clinical findings about the present illness using qualifying adjectives and descriptive language:
  • Intermittent light vaginal bleeding for two weeks
  • No associated cramping
  • On daily estrogen and progesterone
  • G2P2
  • Menarche age 11
  • History of hypothyroidism on replacement

You are working with Dr. Lee. You review the medical record for your next patient, Mrs. Parker, a 55-year-old menopausal female reporting two weeks of vaginal bleeding:

Chief concern: Two weeks of vaginal bleeding

Problem list:

• Menopause
• Hypertension
• Hypothyroidism
• Obesity

Medications:

• Levothyroxine 100 mcg daily
• Lisinopril 20 mg daily
• Estrogen/medroxyprogesterone 0.625/2.5 mg daily
• Dr. Lee says, “Looking at Mrs. Parker’s chart, it appears that she is postmenopausal and has been on continuous menopausal hormonal therapy for about two years. Let’s talk a little bit about hormone therapy.”In the early 2000s, results from the Women’s Health Initiative highlighted the potential risks and benefits of hormone therapy (HT); the study was stopped early due to identified increased risks related to breast cancer and cardiovascular disease. Widespread news coverage and poor communication regarding and interpretation of the study’s results led to panic both in the medical community and general public. HT fell out of favor, even as flaws in the study were identified. Since this time, newer research and guidelines have cautiously acknowledged the benefits of HT around the time of menopause. In deciding whether HT is appropriate, factors including a patient’s age, personal and familial health history, and severity of menopausal symptoms should be considered. For those patients for whom the risk/benefit analysis favors its use, HT is recommended for no more than three to five years.

Dr. Lee tells you, “In Mrs. Parker’s case, she decided to take estrogen and progesterone two years ago after careful consideration. She has a family history of heart disease, and her mother had just been diagnosed with osteoporosis (although no one in her family has sustained a hip fracture). She weighed the increased cardiovascular risk against the benefit of protection against osteoporosis. However, the main deciding factor was that she was having severe menopausal symptoms. She was not sleeping well and was tired and irritable most of the time. She was not functioning well at work. Once she started estrogen and progesterone, she felt much better. For her, the benefits outweighed the risks of hormonal therapy. When we discussed HT last year, she really didn’t want to go off of it. Now that she is bleeding, we will need to revisit the issue of HT.”

The two of you knock and enter the room where the nurse has had Mrs. Parker get changed and onto the exam table for the pelvic exam.

Together, you and Dr. Lee examine Mrs. Parker first in the sitting position.

Vital signs:

• Pulse is 88 beats/minute
• Blood pressure is 132/80 mmHg
• Weight is 95.3 kg (210 lbs)
• Height is 163 cm (64 in)
• Body mass index is 36 kg/m2

Thyroid: No nodules and a normal-sized thyroid.

Cardiovascular: Regular rate and rhythm, normal S1 and S2, without murmurs heard.

Pulmonary: Normal, symmetrical expansion of the lungs with all areas clear to auscultation.

You have Mrs. Parker lie down and you perform an abdominal exam.

Abdominal exam: Bowel sounds are normal; no hepato-spleno-megaly or other masses. Not distended. No abdominal tenderness.

You then prepare to perform a pelvic exam.

Pelvic exam findings:

• Examination of the external genitalia reveals no lesions; there is sparse pubic hair.
• The vaginal vault has no lesions although it does have decreased rugae (a series of ridges produced by folding of the internal wall of the vagina) and a shiny appearance.
• The cervix is smooth with a small os and a small amount of blood, but no lesions. You are able to wipe away the blood.
• On a bimanual exam, the cervix is freely moveable and nontender; her ovaries can not be felt.

You are not sure as to the size of the uterus and Dr. Lee repeats the bimanual exam. When she has finished the pelvic exam, Dr. Lee tells Mrs. Parker, “We’re all done; you can sit up now.”

Dr. Lee turns to you and says, “It takes a while to learn how to assess the size of a uterus. Mrs. Parker has a normal-sized uterus, which is often described as the size of a pear.”

You both assist Mrs. Parker in sitting up, as she asks, “Did you find anything?”

Dr. Lee replies, “There was a small amount of blood, but nothing else abnormal that we could see on the exam. I am going to let you get dressed, and we will be back in to discuss the plan.”While you wait in the hall for Mrs. Parker to change, Dr. Lee explains, “

Since Mrs. Parker is bleeding, we need to stop her hormone therapy for now. However, she shows signs of atrophic vaginitis on the exam. We may need to talk to her about treatment with topical estrogen in the future if she develops symptoms and her workup is negative.”

You and Dr. Lee walk down the hall for a moment as she continues, “Her bimanual exam was a bit more difficult because of her weight. However, her uterus didn’t feel significantly enlarged. But we must first make sure she doesn’t have uterine cancer or endometrial dysplasia or hyperplasia. She definitely needs an evaluation of her endometrium, either with an ultrasound or biopsy, but it might be helpful to first review her risk factors for developing endometrial cancer.”When you return to the exam room, Dr. Lee explains her recommendations for blood tests, a transvaginal ultrasound, and a mammogram.

Dr. Lee continues, “The ultrasound may show us that your bleeding is unlikely to be from something serious, such as cancer. If that is the case, we won’t need to do further testing as long as your bleeding resolves and doesn’t come back. Sometimes, however, the results are just not definitive enough. If the ultrasound results are not reassuring enough, we will also need to sample the inside lining of your uterus. This is called an endometrial biopsy. I would like to have the blood work and ultrasound done first, and then have you return next week to discuss the results of those and do the endometrial biopsy if we need to.”

“I want you to be prepared to have the biopsy since the ultrasound does not always give us enough information. Can I tell you a little more about it?”

Mrs. Parker nods.

“What we do is to insert a small pipelle, which is like a small straw, into the cervix and then take some samples of the lining of your uterus. Patients will often have some cramping with this procedure, so I do recommend you take ibuprofen 800 milligrams 30 minutes before the procedure (that is four of the over-the-counter tablets).

This is a handout on endometrial biopsy procedures that you can review when you go home. I also would like you to stop the hormones until we get the results all back. Do you have any questions?”

Mrs. Parker states that she has one more question, “I know that when you started me on the hormone replacement we talked about how that also would help prevent bone loss. With my mother having osteoporosis, and if I stop the hormones, I wonder if I need to be screened for osteoporosis?”

It is one week later, and Mrs. Parker has returned to follow up on the results of her labs and ultrasound, and for her possible endometrial biopsy. Before going into the room, you and Dr. Lee review her chart.You and Dr. Lee greet Mrs. Parker and Dr. Lee informs her, “Before we get started, I wanted to let you know that your labs and mammogram all came back normal. Your ultrasound also didn’t show anything obvious, but the lining of the uterus was not thin enough to make this biopsy unnecessary.”

“Well, you warned me about that, so I wasn’t too upset when I got a call from your office to let me know I would need the ibuprofen for the procedure,” says Mrs. Parker.A few minutes later, you and Dr. Lee return to the room where Mrs. Parker sits, and explain that the results will be back in about a week.

Dr. Lee concludes, “In the meantime, I expect you may have some cramping and some bleeding today. You could take some ibuprofen for the cramps. Let’s schedule an appointment in a week so that we can review the results in person.”

One week later, you and Dr. Lee are about to see Mrs. Parker. You have seen the endometrial biopsy report, which confirms proliferative endometrium.

Dr. Lee greets Mrs. Parker, “The good news is that the biopsy did not show any cancer. It showed proliferative endometrium, which suggests that with the hormone therapy, your endometrium was acting as it did before menopause. This does not increase your risk of endometrial cancer and if you have no further bleeding we don’t need to do any other workup.”

“Oh, that is good news. I did stop my hormones and am now starting to have more hot flashes. I know that when we started the hormones you said there were some risks for long-term use and thus I really don’t want to go back on them. Are there some alternatives to treat hot flashes?”

“Hormone replacement is the most reliable way to treat hot flashes, but it is recommended for short-term use only. There are some other things that we can try,” Dr. Lee assures her.After a discussion of alternatives, Mrs. Parker says, “I think for now I will hold off on any treatment except maybe trying to exercise. So far the hot flashes aren’t too bad, so hopefully, they will ease off over time.”

You tell her, “That’s great–walking would be the best thing you could do for your overall health. It not only will help with the hot flashes, but it will decrease your risks of osteoporosis, and improve your sense of well-being.”

“I would like to see you back in three months to follow up on your hypertension and hypothyroidism.” Dr. Lee instructs, “Of course, if you have more bleeding you should also make an appointment. I am glad everything turned out the way it did.”

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Results:
Pap:	Normal cytology, HPV high-risk testing negative
Mammogram:	BIRADS-1: No evidence of malignancy. Routine follow-up is recommended.
Transvaginal Ultrasound:	Uterus of normal size, endometrial stripe of 6mm, no lesions identified. Ovaries of normal size and morphology for age.
Labs:
Hgb:	13.4 g/dL
Plts:	350,000/µL
TSH:	1.0 µ/mL

Dr. Lee tells you, “We have confirmed a normal blood count and thyroid status. The ultrasound does not suggest any obvious genital tract pathology, but Mrs. Parker’s endometrial thickness is > 4 mm. If you remember, a thickness of 4 mm or less is reassuring that the patient does NOT have endometrial cancer. Since that is the diagnosis we need to exclude, she will require an endometrial biopsy. The likely etiology of Mrs. Parker’s bleeding lies within the endometrium and is either proliferative endometrium, endometrial hyperplasia, or endometrial cancer. In any case, the results of the biopsy will guide our treatment.”

Differential of Abnormal Uterine Bleeding

Most Important/Most Likely Diagnoses

Cervical polyps	Most common in postpartum and perimenopausal patients; rare in premenstrual and postmenopausal patients. Although cervical polyps are rare in post-menopausal patients, they can occur and may present with vaginal bleeding.
Endometrial hyperplasia	With or without atypia can cause bleeding. Simple hyperplasia progresses to cancer in less than 5% of patients; atypical complex hyperplasia is a premalignant lesion that has a 25% probability of progressing to cancer. Therefore, careful monitoring and treatment is important with this disorder.
Hormone-producing ovarian tumors	Rare Most ovarian cancers do not cause postmenopausal bleeding or other significant symptoms, but postmenopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6-fold increased risk). Other possible symptoms of ovarian cancer include pelvic or abdominal pain, an increase in abdominal size or bloating, and early satiety.
Endometrial cancer	The fourth most common cancer in patients with uteri, and the main “can’t miss” diagnosis that must be considered in patients presenting with postmenopausal bleeding. Also must be considered in patients over the age of 35 with symptoms suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia). Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding.
Proliferative endometrium	Normal response to estrogen stimulation in premenopausal patients. Occasionally, postmenopausal patients, particularly those in higher estrogen states, can produce a similar endometrial response. On biopsy, this condition may be hard to differentiate from simple hyperplasi