Post Gynae Long Case Exam

My patient is a 54 year-old widow of parity 1, who presented with cyclical menorrhagia of 2 years duration with mild symptoms of anaemia. I wouldn't say it's a postmenopausal bleeding despite her age (mean age of menopause for Malaysian women is 50.7 years), as her menses were regular cycles of 40 days with duration of 7 days for the past 2 years. She's recently diagnosed to be hypertensive and on medication.

Dr. S: Are you ready?
Me: (Give it to me baybehh...) Err, yes...
Dr. S: Say you are the one who saw this patient for the first time, how would you investigate her?
Me: FBC to assess anaemia, PT/APTT to see if there's any coagulation defects, blood grouping and crossmatch in case she needs transfusion. Thyroid function test for hypothyroidism as she appeared sluggish. Then, a transabdominal or transvaginal ultrasound to look for uterine and pelvic mass. Followed by cervical smear, Pipelle sampling, and hysteroscopy for direct visualisation and directed biopsy.
Dr. S: What can be done during ultrasound examination to improve ultrasonographic view?
Me: ... ... ...
Dr. S: Distend the uterus with normal saline la. Do you think a renal profile is justified in her case?
Me: No?... err Yes, actually... given her age she may have diabetes...
Dr. S: Yes! And don't forget she has hypertension too! Now, they are going to insert a Mirena into her. What's Mirena?
Me: It's a levonorgestrel intrauterine system used to treat menorrhagia and dysmenorrhoea, and is also used as contraception. It releases the hormone levonorgestrel locally in the uterus in small doses for up to 5 years, making menstruation lighter, shorter, and less painful (lucky I curi the Mirena booklet from the clinic!).
Dr. S: Other than Mirena, how would you manage the patient, medically?
Me: I would prescribe her haematinics for her anaemia. Then, mefenamic acid and tranexamic acid to reduce her menstruation. Also, hormonal preparations such as Danazol, Gestrinone, GnRH analogues, and combined oral contraceptive pills (COCs). (Was basically regurgitating facts from textbook)
Dr. S: Do you think she needs COCs at her age?
Me: Oops, sorry, no COC for her.
Dr. S: And due to her age, we don't normally prescribe Danazol, Gestrinone, and GnRH analogues. What other management options would you give her?
Me: Surgical options, and these are divided into fertility sparing and non-fertility sparing procedures...
Dr. S: Why do you want to preserve fertility in this patient?
Me: Oh yeah, 54 year-old, suppose to be menopause edy... (sh!t... again!). Then the surgical option would be more radical, such as vaginal hysterectomy, transabdominal hysterectomy, and laparoscopic-assisted vaginal hysterectomy.
Dr. S: Riiiiggght... ok tell me the physical findings.
Me: On general inspection, she's overweight with BMI of 25. She has pallor of the conjunctivae but no jaundice, clubbing, oedema, or cyanosis. Blood pressure 160/90, pulse 60, respiratory rate 16 breaths per min, afebrile. Her lungs are clear. On heart exam, apex beat is not deviated, dual rythmn heard and no murmur detected. On abdomen exam, it's soft, non-tender, no organomegaly, no uterine enlargement and no mass palpable. If given enough time, I would proceed to pelvic examination.
Dr. S: What would you look for in pelvic exam?
Me: Starting with inspection of external genitalia, I'd look for any bleeding or discharge. On speculum exam, I'd look for any ulceration or exophytic growth on the cervix, and if there's any active bleeding. I'd do a bimanual palpation to assess mobility of pelvic organs, feel if the uterus is retroverted, if there's any adnexal pathology and palpate for pelvic masses.
Dr. S: Do you expect to find anything in this patient?
Me: Not likely.
Dr. S: What's your provisional diagnosis?
Me: Given her history, I would like to entertain the diagnosis of benign growth of the endometrium, such as endometrial polyps.
Dr. S: You're not wrong, but do you think she would be given Mirena if it's a polyp?
Me: No,... no Mirena if it's polyp.
Dr. S: What's your differential diagnosis?
Me: Malignancy, such as endometrial carcinoma.
Dr. S: Yes, don't forget about malignancy. Why do you think her cycles are getting prolonged?
Me: ... err... hormonal imbalance... the ovaries are failing...
Dr. S: What do you call that?... failing ovaries and cycles getting longer?
Me: ... anovulatory cycles?
Dr. S: Yea lah, why you so scared to say that? So what's your diagnosis for this lady now?
Me: (heh heh, actually I tembak oni...) Dysfunctional uterine bleeding!
Dr. S: (polyphonic ring tone blasting loudly) Ok la, thanks.
Me: (yeahh... balik tidorrr... Oh no... Dato' S. is still in the ward...)