A 48-year-old woman presents with intermenstrual bleeding for 2 months

A 48-year-old woman presents with intermenstrual bleeding for 2 months. Episodes of bleeding occur any time in the cycle. This is usually fresh red blood and much lighter than a normal period. It can last for 1–6 days. There is no associated pain. She has no hot flushes or night sweats. She is sexually active and has not noticed vaginal dryness.
She has three children and has used the progesterone only pill for contraception for 5 years. Her last smear test was 2 years ago and all smears have been normal. She takes no medication and has no other relevant medical history.

Examination
The abdomen is unremarkable. Speculum examination shows a slightly atrophic-looking vagina and cervix but there are no apparent cervical lesions and there is no current bleeding.
On bimanual examination the uterus is non-tender and of normal size, axial and mobile. There are no adnexal masses.

Investigations: 
Haemoglobin 12.7 g/dL (Normal range 11.7–15.7g/dL)

Transvaginal ultrasound scan and hydrosonography is shows an endometrial polyp.

Questions
• What is the diagnosis and differential diagnosis?
• How would you further investigate and manage this woman?

Answers And Discussion:


The diagnosis is of an endometrial polyp, as seen by the hydrosonography . These can occur in women of any age although they are more common in older women and may be asymptomatic or cause irregular bleeding or discharge.
The aetiology is uncertain and the vast majority are benign. In this specific case all the differential diagnoses are effectively excluded by the history and examination.

Differential diagnosis for intermenstrual bleeding
• Cervical malignancy
• Cervical ectropion
• Endocervical polyp
• Atrophic vaginitis
• Pregnancy

• Irregular bleeding related to the contraceptive pill

Management
Any woman should be investigated if bleeding occurs between periods. In women over the age of 40 years, serious pathology, in particular endometrial carcinoma, should be excluded.

The polyp needs to be removed for two reasons:
1 to eliminate the cause of the bleeding
2 to obtain a histological report to ensure that it is not malignant.

Management involves outpatient or day case hysteroscopy, and resection of the polyp under direct vision using a diathermy loop or other resection technique.This allows certainty that the polyp had been completely excised and also allows full inspection of the rest of the cavity to check for any other lesions or suspicious areas.
In some settings, where hysteroscopic facilities are not available, a dilatation and curettage may be carried out with blind avulsion of the polyp with polyp forceps. This was the standard management in the past but is not the gold standard now, for the reasons explained.

Points To Remember:
• Any woman over the age of 40 years should be investigated if bleeding occurs between the periods, to exclude serious pathology, in particular endometrial carcinoma.
• Hysteroscopy and dilatation and curettage is rarely indicated for women under the age of 40 years.