Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

ENDORSEMENT CASE DISCUSSION

JULY 29, 2020
Patient # 39
I. General Data

Name Patient 39
Age 61 years old
Birthday Not available
Date of Admission July 28,2020
Address Not available
Marital Status Married
Religion Not available
Blood Type O+

II. Chief Complaint

Vaginal spotting

III. History of Present Illness

Two years prior to admission, the patient had an on and off vaginal spotting staining
her underwear with no other associated signs and symptoms. No consultation done.
Twenty five days prior to admission, the patient had her pelvic ultrasound and her
results considered calcified blood vessels versus endometrial polyp.
Twenty days prior to admission, she consulted her attending physician and was
advised for polypectomy, but the patient opted for TAHBSO thus, this admission.

IV. Obstetrical-Gynecological History

Obstetric Score G3P3 (2-1-0-3)
LMP: Not Applicable
Past Menstrual Not Applicable
Period
Menarche: 11 year old
Interval Regular
Duration 5 days
Amount 2 pads per day moderately soaked
Symptoms Dysmenorrhea, took pain relievers
Coitarche: 22 years old
Sexual Partners 1
since coitarche
Menopause 52 years old
Prenatal History Not Applicable

G1 NSVD PRETERM Unremarkable

G2 NSVD TERM Unremarkable

G3 NSVD TERM Unremarkable

● No history of sexually transmitted infection

V. Past Medical History

Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

Undergone Bilateral mastectomy for breast cancer stage 2a (2013), underwent

chemotherapy for a total of 22 cycles (2015) Patient is known to be hypertensive, maintained
on Losartan 300 mg x 1 day, Nifedipine 20 mg OD, diagnosed with mitral valve prolapse and
S/P diagnostic curettage for AUB (2016),CVD with no residuals ( lacunar , occipito and
parietal infarct (2019), maintained on clopidogrel 75 mg x 1 day.

VI. Family History

Unremarkable

VII. Personal and Social History

Occupation Unemployed
Alcohol None
Smoking None
Drugs None

VIII. Vital Signs:

● Stable
○ Blood Pressure range: 110/80 - 130/70 mmHg
■ Latest: 110/80 mmHg

IX. Physical Examination

General Survey Conscious, coherent

Skin Pinkish conjunctivae, palms and nail beds
HEENT Unremarkable
Thorax & Lungs Unremarkable
Heart Unremarkable
Abdomen Flabby, soft, nontender
Genito-urinary System Unremarkable
Anus & Rectum Unremarkable
Extremities Unremarkable
Nervous System Unremarkable

● Pelvic exam was not done as ordered by attending physician

X. Course in the Wards

● Diet as tolerated on admission
● Nothing per orem post midnight
● Started with Lactated Ringer's in 5% Dextrose (D5LR) 1L x 8 hours once on NPO
● Bisacodyl (Dulcolax) 2 tabs at bedtime
● Currently in the Operating room for stat Total Abdominal Hysterectomy Bilateral
Salpingo-oophorectomy (TAHBSO)
● Requested with 1 unit whole blood or packed red blood cells for cross matching
● Cotton Count at bedside: 2 minimally soaked pads
● Medications:
○ Cefoxitin 2g IV 30 minutes prior to OR
○ Irbesartan 300 mg OD
○ Nifedipine OD

XI. Diagnostics
A. Laboratory Tests

Parameter Result Reference Range Interpretation

Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

Hgb 128 g/L 120-158 g/L Normal

Hct 38% 35.4-44.4 % Normal

WBC 9.32x103 /mm3 3.5-9.1 x 103/mm3 Increased

Platelets 267 x109 /L 165-415 x 109/L Normal

Protime 100% 85-100% Normal

Clotting Time Normal 7-180 seconds Normal

Bleeding Time Normal < 9 minutes Normal

APTT Normal 28-38 seconds Normal

Na+ Normal 137-145 mmol/L Normal

K+ Normal 3.5-5.1 mmol/L Normal

Calcium Normal 2.10-2.55 mmol/L Normal

Magnesium Normal 0.70-1.00 mmol/L Normal

Creatinine Normal 46-92 umol/L Normal

BUN Normal 2.5-6.1 mmol/L Normal

SGPT Normal 9-52 U/L Normal

SGOT Normal 14-36 U/L Normal

● Chest X-ray: Normal

● Urinalysis Normal
● COVID-19 antibody Test: Negative
● 12-L ECG: Sinus rhythm; Left ventricular hypertrophy
● FBS: Pending
● Lipid Profile: Pending
● 2D Echo: done as OPD
● Pelvic Ultrasound: July 3, 2020
○ Uterus is anteverted, atrophic measuring 3.5 x 2.7 x 3.4 cm
○ Endometrium is thin measuring 0.2 cm isoechogenic; hyperechogenic foci
anterior to the endometrium more on the fundal area with vascularities
○ Consider calcified blood vessels versus Endometrial Polyps
○ Atrophic both ovaries
■ Right ovary: 1.2 x 0.7 x 0.9 cm
■ Left ovary: 1.1 x 0.7 x 1 cm
○ No adnexal mass
○ No free fluid in the cul de sac
○ Cervix: 1.5 x 2.5 x 2 cm

XI. Admitting Impression

Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

G3P3(2-1-0-3), AUB-P1, S/P Dilation and Curettage for Abnormal Uterine

Bleeding (2016), S/P Bilateral Tubal Ligation (1991), Breast Cancer Stage IIA (2013),
Hypertensive Cardiovascular Disease, Valvular Heart Disease (Mitral Valve
Prolapse), S/P Cerebrovascular Disease with no residuals (Lacunar Left occipito and
parietal infarcts) (2019), S/P Bilateral mastectomy (2013), S/P Chemotherapy
(Trastuzumab) x 22 cycles (2015)

XII. Differential Diagnosis

Differential Rule In Rule Out

Endometrial Malignancy ● Postmenopausal vaginal ● (-) Pelvic pain

bleeding ● (-) Vaginal discharge that
may range from pink and
watery to thick, brown,
and foul smelling
● (-) Enlarged corpus

Adenomyosis ● History of dysmenorrhea ● (-) Ultrasound: Globular

● Postmenopausal bleeding enlargement of the uterus
with coarse and
heterogenous
myometrium
● (-) Pelvic pain

Leiomyoma ● Postmenopausal bleeding ● (-) Ultrasound (TAS or

TVS): Distinct, spherical,
hypoechoic mass
● (-) Pelvic pain

Endometrial Atrophy ● Postmenopausal bleeding ● (+) Ultrasound(TAS or

● Thin Endometrium TVS): Distinct masses
within the endometrial
cavity

Endometrial Polyp ● Postmenopausal vaginal

bleeding
● History of dysmenorrhea
● (+) Ultrasound(TAS or
TVS): Distinct masses
within the endometrial
cavity

XIII. Final Diagnosis

G3P3(2-1-0-3), S/P Total Abdominal Hysterectomy Bilateral Salpingo-

oophorectomy for AUB-P1, S/P Dilation and Curettage for Abnormal Uterine
Bleeding (2016), S/P Bilateral Tubal Ligation (1991), Breast Cancer stage IIA (2013),
Hypertensive Cardiovascular Disease, Valvular Heart Disease (Mitral Valve
Prolapse), S/P Cerebrovascular Disease with no residuals (Lacunar Left occipito and
parietal infarcts) (2019), S/P Bilateral mastectomy (2013), S/P Chemotherapy
(Trastuzumab) x 22 cycles (2015)
Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

XIV. Case Discussion

ABNORMAL UTERINE BLEEDING (AUB)

Abnormal Uterine Bleeding encompasses any significant deviation from normal
frequency, regularity, heaviness (volume or amount) and duration of menstrual bleeding. It is
used to describe all abnormal menstrual signs and symptoms arising from the uterine corpus.
Postmenopausal bleeding is the recurrence of bleeding in a menopausal woman at least 6
months to 1 year after cessation of cycles.
The following are the normal limits for menstrual parameters:

Parameter Descriptive Term Normal Limits

Frequency of Menses (Days) Frequent < 24 days

Normal 24 - 38 days
Infrequent > 38 days

Regularity of Menses (Cycle to Absent ---

cycle variation over 12 months; Regular +- 2 to 20 days
in Days) Irregular > 20 days

Duration of Flow (Days) Prolonged > 8 days

Normal 4.5 - 8 days
Shortened < 4.5 days

Volume of Monthly Blood Loss Heavy > 80 ml

(mL) Normal 5 - 80 ml
Light < 5 ml

Causes of abnormal uterine bleeding are divided into nine main categories, arranged
according to acronym: PALM-COEIN. The structural or histologic causes constitute the
PALM group which stands for Polyp, Adenomyosis, Leiomyoma, Malignancy and
Hyperplasia. While the COEIN group encompasses the non-structural causes of AUB, they
stand for Coagulopathy, Ovulatory Dysfunction, Endometrial, Iatrogenic, and Not Yet
Classified. According to FIGO, the acronym AUB is followed by the letters PALM-COEIN
and a subscript 0 or 1 associated with each letter to indicate the absence or presence of the
abnormality.
In the PALM, “Endometrial Polyp” are localized overgrowths of endometrial tissue,
containing glands, stroma, and blood vessels, covered with epithelium. They are wiether
single or multiple, few to several centimeter, sessile or pedunculated. Estrogen and
progesterone are implicated in growth. They are found in all age groups, but mostly in older
women (pre-menopausal and post-menopausal). It may present as heavy menstrual,
intermenstrual, or postmenstrual bleeding, and may be associated with dysmenorrhea
depending on the size of the polyp. Risk factors include increasing age, obesity, and tamoxifen
use. It is also related to infertility. These are often asymptomatic but have been suggested to
result to some degree of AUB. Symptomatic vaginal bleeding and postmenopausal status are
associated with an increased risk of malignancy. Although the majority of them are considered
to be benign.
Adenomyosis (AUB-A) is defined by the presence of endometrial glands and stroma
in the uterine myometrium. Leiomyoma (AUB-L), or fibroids, are benign tumors of the
uterine myometrium with a complex and heterogeneous clinical presentation. Leiomyoma is
further classified into three classifications: Primary, Secondary, and Tertiary.
Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

Malignancies (AUB-M) associated with the female reproductive tract include vulvar,
vaginal, cervical, endometrial, uterine, and adnexal (ovarian or fallopian tube) cancers.
For the COEIN group, Coagulation (AUB-C) encompasses the spectrum of systemic
disorders of hemostasis that may be associated with AUB such as Von Willebrand Disease
and Prothrombin Deficiency. In ovulatory dysfunction (AUB-O), the predominant cause in
postmenarchal and premenopausal women is secondary to alterations in neuroendocrine
function and associated with non-secretory endometrium. Endometrial (AUB-E) usually
present with heavy menstrual bleeding in the absence of other abnormalities and possibly
caused by deficient vasoconstrictors endothelin 1 and Prostaglandin F2) or excessive
plasminogen activator. Iatrogenic bleeding (AUB-I) is abnormal bleeding resulting from
medications and the most common of these are hormonal preparations, including selective
estrogen receptor modulators, and gonadotropin-releasing hormone agonists and antagonists.
Not yet classified (AUB-N) Abnormal bleeding not classified in the previous categories and
examples of such conditions may include foreign bodies or trauma, chronic endometritis,
arteriovenous malformations, myometrial hypertrophy, and associations with systemic
diseases.
The patient was diagnosed to have AUB-P1, which means that her bleeding was due
to the presence of an endometrial polyp. It was based on her pelvic ultrasound last July 3,
2020 which ruled in its presence. The risk factors that predisposed our patient to the formation
of a polyp are her age which belongs to the post-menopausal age group and her probable use
of Tamoxifen as medication for her previous Breast Cancer. According to a study by Lee
(2010), among symptomatic postmenopausal women with endometrial polyps, 4.5% had a
malignant polyp compared with 1.5% in asymptomatic women. However, it was not
conclusive to our patient since the majority of endometrial polyps are benign. An endometrial
biopsy was not done as well since the patient opted to have a total abdominal hysteroscopy
with bilateral salpingo-oophorectomy (TAH BSO).

BREAST CANCER
Globally, breast cancer is the most common malignancy in women. It is caused by
accumulation of mutations in the cell’s DNA. Risk factors for breast cancer include: age
(common in 6th-8th decades of life), estrogen exposures, age at menarche, age at first birth,
late menopause, hormone replacement therapy, lifestyle, alcohol use, sedentary lifestyle,
obesity, postmenopausal weight gain, low Vit. D, abnormal day/night work patterns, breast
characteristics, familial factors - breast cancer among first-degree relatives, and exposure to
radiation. The age of our patient (54 y.o. at time of diagnosis), her early menarche (11 y.o.),
and late menopause (52 y.o.) are the risk factors she has, as mentioned in the above data,
although other factors should be considered as well.
The clinical staging of breast cancer is determined primarily through physical
examination of the skin, breast tissue, and regional lymph nodes (axillary, supraclavicular, and
internal mammary). Stage II means the breast cancer is growing, but it is still contained in the
Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

breast or growth has only extended to the nearby lymph nodes. It is further divided into two
groups: A and B. Our patient’s Stage IIA could either mean:
● No actual tumor is associated with the cancerous cells and less than four auxillary
lymph nodes have cancer cells present
● The tumor is less than 2 centimeters and less than four auxillary lymph nodes have
cancer cells present.
● The tumor is between 2 and 5 centimeters and has not yet spread to the lymph nodes

HYPERTENSIVE CARDIOVASCULAR DISEASE AND

VALVULAR HEART DISEASE (MITRAL VALVE PROLAPSE)
Hypertensive cardiovascular disease (HCVD) are heart conditions caused by high
blood pressure. Uncontrolled and prolonged elevation of BP can lead to a variety of changes
in the myocardial structure, coronary vasculature, and conduction system of the heart.
Although valvular disease does not cause hypertensive heart disease, chronic and severe
hypertension can cause aortic root dilatation, leading to significant aortic insufficiency. Some
degree of hemodynamically insignificant aortic insufficiency is often found in patients with
uncontrolled hypertension. In addition to causing aortic regurgitation, hypertension is also
thought to accelerate the process of aortic sclerosis and cause mitral regurgitation.
The patient is a diagnosed hypertensive with maintenance medications of Losartan
and Nifedipine. She also has a mitral valve prolapse. And her blood pressure has a range of
110/80 - 130/70 mmHg during admission.

CEREBROVASCULAR DISEASE WITH NO RESIDUALS

(LACUNAR LEFT OCCIPITAL AND PARIETAL INFARCT)
A stroke occurs when blood flow to the brain is interrupted or blocked. Strokes that
are caused by blockages in blood vessels within the brain are called ischemic strokes. Lacunar
stroke is a type of ischemic stroke that occurs when blood flow to one of the small arteries
deep within the brain becomes blocked. Risk of lacunar stroke increases with age. Those at
risk include people with chronic high blood pressure, heart disorders, or diabetes. African-
Americans, Hispanics, and people with a family history of stroke are also at a higher risk. In
the case of our patient, her risk factor is chronic high blood pressure and her previous infarct
was located at the left occipital and parietal area of the brain.

a. Diagnostic Tests

Complete Blood count

In a woman suffering of abnormal uterine bleeding, complete blood count will help
identify anemia and the degree of blood loss. Chronic loss will reveal microcytic hypochromic
anemia, decrease in mean corpuscular volume, mean corpuscular hemoglobin, and mean
corpuscular hemoglobin concentration. Classic iron deficiency anemia from chronic blood
loss will show elevated platelet count.

Transvaginal ultrasound

Transvaginal sonography is chosen by many as the first line tool to assess abnormal
uterine bleeding. It allows both examination of myometrium and endometrium. This offers
greater patient comfort and is suitable in detecting postmenopausal endometrial hyperplasia.
Other than endometrial thickness, there are also qualities being considered such as punctate
cystic areas in the endometrium which may indicate polyp or hypoechoic masses that distort
the endometrium from the inner myometrium which may indicate most likely submucous
leiomyomas.

Endometrial biopsy
Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

Abnormal uterine bleeding was seen in 80 to 90 percent with endometrial cancer and
postmenopausal women have a higer risk for having endometrial cancer thus a histologic
evaluation is warranted to exclude malignancy.

Saline infusion sonography

It is a simple, minimally invasive procedure that is effective in evaluating the

myometrium, endometrium, and endometrial cavity. This type of sonography allows detection
of masses associated with AUB such as endometrial polyp, submucous leiomyomas, and
intracavitary blood clots. Also, it offers superior detection of intracavitary masses and
differentiation of lesion as being endometrial, submucous, or intramural.

Hysteroscopy

Hysteroscopy is a procedure that employs the use of an endoscope which is inserted

into the endometrial cavity. Aside from inspection, it allows endometrial biopsy of abnormal
areas thus when a focal lesion has been diagnosed it can then be removed at the same time.
It’s main advantage is the detection of intracavitary lesions such as leiomyomas and polyps
which can be missed sometimes in TVS or endometrial sampling.

b. Pathophysiology of Abnormal Uterine Bleeding-Polyp

● Age of 40-50 y.o. and ● High Blood Pressure

above ● Use of Tamoxifen for
(Declining Estrogen levels) Breast Cancer (An
Estrogen Agonist)
↓ ↓
Decreased Progesterone Levels (Due to anovulation)
↓
Overgrowth of Endometrial Tissue
↓
Formation of Polyp
↓
Stromal Congestion within the Polyp
↓
Venous Stasis and Apical Necrosis
↓
Bleeding

XV. Management

Abnormal Uterine Bleeding - Endometrial Polyps

In our patient’s case, the management of choice would be polypectomy. This can be
done through a hysteroscope by dilating the patient’s cervix. Despite polypectomy being done,
there is a chance that polyps may recur. In order to prevent that, post hysteroscopic medical
management is encouraged. These include oral progestins and/or gonadotropin-releasing
hormone agonist. Even though she has a history of breast cancer, studies show that progestins
and gonadotropin-releasing hormone agonists does not increase chances of remission.
Despite the management of choice, the patient has opted for Total Abdominal
Hysterectomy Bilateral Salpingo-oophorectomy (TAHBSO). Hysterectomy is the most
Team 1: Clinical Clerks Abordo, Ansino, Betalac, Caluyo

effective treatment for heavy menstrual bleeding. Despite being the most effective, it should
not be the first treatment of choice. This procedure is reserved for those with organic
pathology such as malignancy.

Breast Cancer
Since our patient has had bilateral mastectomy and completed her chemotherapy, the
patient should do follow up check ups to check for any relapse. Follow up check up should
include:
● Yearly Primary Care Visit since it has been 5 years since her chemotherapy,
● Annual PET scans especially since she has had bilateral mastectomy,
● And monthly self breast examinations especially in the axillary and clavicular area for
abnormal masses.
Any signs and symptoms of abnormalities in the brain, bones, lungs, and liver must be
consulted immediately for the possibility of metastasis.

Hypertensive Cardiovascular Disease, Mitral Valve Prolapse, Cardiovascular disease

The target BP should be less than 150/80 mmHg to reduce the chances of developing
heart failure. The patient is already under antihypertensive medications, Losartan and
Nifedipine. Since the patient’s 2-D echocardiography shows that she has left ventricular
hypertrophy. Antihypertensives can reduce LVH, but using Angiotensin Co-enzyme (ACE)
Inhibitors has more of the advantage in reducing the hypertrophy.
Lifestyle modifications would also benefit the patient’s condition. Maintaining a BMI
of less than 25kg/m^2 is favorable to the patient. Her diet should follow the DASH diet which
means Dietary Approaches to Stop Hypertension. It emphasizes foods that are lower in
sodium as well as foods that are rich in potassium, magnesium and calcium — nutrients that
help lower blood pressure. Meals features menus with plenty of vegetables, fruits and low-fat
dairy products, as well as whole grains, fish, poultry and nuts. It offers limited portions of red
meats, sweets and sugary beverages.
Other weight loss techniques can also be done by exercising. Walking, running,
swimming, or cycling, has been shown to decrease BP and improve cardiovascular well-being
Since her ECG shows normal sinus rhythm nor any other signs and symptoms, her
mitral valve prolapse needs any treatment.

References:

1. Cunningham, F. G. (2018). Williams obstetrics 25th edition. New York: McGraw-Hill

Education.
2. Gershenson, D. M., Lentz, G. M., Lobo, R. A., & Valea, F. A. (2017). Comprehensive
gynecology. Philadelphia: Elsevier.
3. Robertson, J., &amp; Blamey, R. (2003). The use of gonadotropin-releasing hormone
(GnRH) agonists in early and advanced breast cancer in pre- and perimenopausal
women. European Journal of Cancer, 39(7), 861-869. doi:10.1016/s0959-
8049(02)00810-9