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Case-series report: management of post-menopausal bleeding in the presence of an intrauterine device
Contraception 66 (2002) 383–384
Case series report
Case-series report: management of post-menopausal bleeding in the presence of an intrauterine device Narendra Pisala,*, May Mammob b
a Department of Women’s Health, Whittington Hospital, London, United Kingdom N19 5NF Department of Obstetrics and Gynaecology, Bassetlaw District General Hospital, Worksop, Nottinghamshire, United Kingdom S81 0BD
Received 25 February 2002; received in revised form 9 April 2002; accepted 20 June 2002
Abstract Post-menopausal bleeding in the presence of prolonged use of an intrauterine device should be investigated with hysteroscopy and endometrial sampling to rule out endometrial pathology. Here, we present two cases of prolonged use of intrauterine contraceptive device (IUCD), both associated with endometrial pathology, to illustrate the importance of these investigations. © 2002 Elsevier Science Inc. All rights reserved. Keywords: IUCD; Prolonged use; Endometrial hyperplasia; Endometrial carcinoma; Post-menopausal bleeding
1. Introduction The Lippes loop was commonly used as an intrauterine contraceptive device (IUCD) from 1960 to 1980. Prolonged use of this IUCD was common. Occasionally, such women present with symptoms of intermenstrual or post-menopausal bleeding. Though this abnormal bleeding may be caused by prolonged use of IUCD, it is important to carry out investigations to rule out endometrial pathology. Here, we present two cases of prolonged use of IUCD, one associated with complex endometrial hyperplasia and other with well-differentiated endometrial carcinoma.
years ago after the birth of her last child. It could not be removed in the outpatient setting and a hysteroscopy under general anesthesia was performed. A Lippes loop was seen embedded in the endometrium. A 2-cm endometrial polyp was also seen. Removal of coil, polypectomy, and endometrial curettage was performed. Histology showed complex endometrial hyperplasia limited to the endometrial polyp. The endometrium itself was atrophic. In view of risk of anesthesia because of gross obesity, a hysterectomy was deferred and the patient was commenced on progesterone. An ultrasound scan and endometrial biopsy was performed six months later and was normal. A year later, outpatient hysteroscopy showed a normal cavity and endometrium. Histology of the endometrial biopsy was normal.
2. Case reports 2.2. Patient 2 2.1. Patient 1 DW, a 60-year-old G4P4 post-menopausal woman, presented with one episode of vaginal bleeding. Her last menstrual period was 10 years ago and last smear 1 year ago was normal. She was overweight with a body mass index of 40. An ultrasound scan showed an IUCD in the uterine cavity, and the endometrial echo was thin. This IUCD was fitted 30 * Corresponding author. Tel.: ⫹20-7288-5431; fax: ⫹20-7288-5066. E-mail address: [email protected] (N. Pisal).
MH, a 55-year-old G2P2 post-menopausal woman, presented with 7-week history of brownish discharge and occasional spotting. Her menopause was 1 year ago and a cervical smear performed by a GP was negative. She gave a history of prolonged use of Lippes loop, which was fitted 22 years ago. On examination, the uterus was normal size. The Lippes loop was removed and endometrial biopsy was obtained in the outpatient clinic. Histology showed a welldifferentiated endometrial carcinoma. A preoperative hysteroscopy was carried out and confirmed the presence of the tumor and excluded cervical involvement. A staging lapa-
0010-7824/02/$ – see front matter © 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 1 0 - 7 8 2 4 ( 0 2 ) 0 0 3 6 4 - 5
384
N. Pisal, M. Mammo / Contraception 66 (2002) 383–384
rotomy was performed with total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology of the specimen showed Stage Ib Grade I endometrial adenocarcinoma. No further treatment was required according to local multidisciplinary team guidelines.
3. Discussion Post-menopausal bleeding is a symptom suggestive of endometrial pathology. Endometrial cancer needs to be excluded in all such patients. Histologic assessment of the endometrium is mandatory, even if there is an obvious explanation such as prolonged retention of IUCD. IUD invokes acute and chronic inflammatory response in the endometrium. However, epidemiologic studies have shown that use of intrauterine device is not associated with an increased risk of endometrial cancer and, in fact, it may be a protective factor [1– 4]. A negative transvaginal scan and an endometrial biopsy are considered adequate investigations to rule out endometrial carcinoma [5]. However, in the first case, a transvaginal ultrasound showed a thin endometrial echo with no other uterine pathology. It is possible that distension of the uterine cavity because of IUCD could have made measurement of endometrial thickness difficult. Complex endometrial hyperplasia was limited to the endometrial polyp and could have been easily missed by outpatient endometrial sampling as endometrial biopsy is known to be less accurate when an abnormality is focal rather than global [6,7]. Therefore, we suggest that abnormal bleeding in postmenopausal women with an IUCD should not be ignored as it can represent significant endometrial pathology. Investigations should include visualization of endometrial cavity
by hysteroscopy, as measurement of endometrial thickness may be unreliable in the presence of an IUCD. These women continued on using an IUD for no apparent clinical reason. One year after menopause, IUDs can and should be removed, as contraception is no longer necessary. In high-risk women, such as in Case 1, a levonorgestrelreleasing IUD may be inserted prophylactically at menopause. Though there is no population-based data supporting this practice, one might expect strong protection of the endometrium, given the effect of this device in women receiving tamoxifen after breast cancer [8].
References [1] Sturgeon SR, Brinton LA, Berman ML, et al. Intrauterine device use and endometrial cancer risk. Int J Epidemiol 1997;26:496 –500. [2] Hill DA, Weiss NS, Voigt LF, Beresford SA. Endometrial cancer in relation to intra-uterine device use. Int J Cancer 1997;70:278 – 81. [3] Parazzini F, La Vecchia C, Moroni S. Intrauterine device use, and risk of endometrial cancer. Br J Cancer 1994;70:672–3. [4] Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv 2002;57: 120 – 8. [5] Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998;280:1510 –7. [6] Dubinsky TJ, Parvey HR, Gormaz G, et al. Transvaginal hysterosonography: comparison with biopsy in the evaluation of postmenopausal bleeding. J Ultrasound Med 1995;14:887–93. [7] Guido RS, Kanbour A, Ruhn M, et al. Pipelle endometrial sampling sensitivity in the detection of endometrial cancer. J Reprod Med 1995;40:553–5. [8] Gardner FJ, Konje JC, Abrams KR, et al. Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel-releasing intrauterine system: a randomised controlled trial. Lancet 2000;356: 1711–7.
Case series report
Case-series report: management of post-menopausal bleeding in the presence of an intrauterine device Narendra Pisala,*, May Mammob b
a Department of Women’s Health, Whittington Hospital, London, United Kingdom N19 5NF Department of Obstetrics and Gynaecology, Bassetlaw District General Hospital, Worksop, Nottinghamshire, United Kingdom S81 0BD
Received 25 February 2002; received in revised form 9 April 2002; accepted 20 June 2002
Abstract Post-menopausal bleeding in the presence of prolonged use of an intrauterine device should be investigated with hysteroscopy and endometrial sampling to rule out endometrial pathology. Here, we present two cases of prolonged use of intrauterine contraceptive device (IUCD), both associated with endometrial pathology, to illustrate the importance of these investigations. © 2002 Elsevier Science Inc. All rights reserved. Keywords: IUCD; Prolonged use; Endometrial hyperplasia; Endometrial carcinoma; Post-menopausal bleeding
1. Introduction The Lippes loop was commonly used as an intrauterine contraceptive device (IUCD) from 1960 to 1980. Prolonged use of this IUCD was common. Occasionally, such women present with symptoms of intermenstrual or post-menopausal bleeding. Though this abnormal bleeding may be caused by prolonged use of IUCD, it is important to carry out investigations to rule out endometrial pathology. Here, we present two cases of prolonged use of IUCD, one associated with complex endometrial hyperplasia and other with well-differentiated endometrial carcinoma.
years ago after the birth of her last child. It could not be removed in the outpatient setting and a hysteroscopy under general anesthesia was performed. A Lippes loop was seen embedded in the endometrium. A 2-cm endometrial polyp was also seen. Removal of coil, polypectomy, and endometrial curettage was performed. Histology showed complex endometrial hyperplasia limited to the endometrial polyp. The endometrium itself was atrophic. In view of risk of anesthesia because of gross obesity, a hysterectomy was deferred and the patient was commenced on progesterone. An ultrasound scan and endometrial biopsy was performed six months later and was normal. A year later, outpatient hysteroscopy showed a normal cavity and endometrium. Histology of the endometrial biopsy was normal.
2. Case reports 2.2. Patient 2 2.1. Patient 1 DW, a 60-year-old G4P4 post-menopausal woman, presented with one episode of vaginal bleeding. Her last menstrual period was 10 years ago and last smear 1 year ago was normal. She was overweight with a body mass index of 40. An ultrasound scan showed an IUCD in the uterine cavity, and the endometrial echo was thin. This IUCD was fitted 30 * Corresponding author. Tel.: ⫹20-7288-5431; fax: ⫹20-7288-5066. E-mail address: [email protected] (N. Pisal).
MH, a 55-year-old G2P2 post-menopausal woman, presented with 7-week history of brownish discharge and occasional spotting. Her menopause was 1 year ago and a cervical smear performed by a GP was negative. She gave a history of prolonged use of Lippes loop, which was fitted 22 years ago. On examination, the uterus was normal size. The Lippes loop was removed and endometrial biopsy was obtained in the outpatient clinic. Histology showed a welldifferentiated endometrial carcinoma. A preoperative hysteroscopy was carried out and confirmed the presence of the tumor and excluded cervical involvement. A staging lapa-
0010-7824/02/$ – see front matter © 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 1 0 - 7 8 2 4 ( 0 2 ) 0 0 3 6 4 - 5
384
N. Pisal, M. Mammo / Contraception 66 (2002) 383–384
rotomy was performed with total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology of the specimen showed Stage Ib Grade I endometrial adenocarcinoma. No further treatment was required according to local multidisciplinary team guidelines.
3. Discussion Post-menopausal bleeding is a symptom suggestive of endometrial pathology. Endometrial cancer needs to be excluded in all such patients. Histologic assessment of the endometrium is mandatory, even if there is an obvious explanation such as prolonged retention of IUCD. IUD invokes acute and chronic inflammatory response in the endometrium. However, epidemiologic studies have shown that use of intrauterine device is not associated with an increased risk of endometrial cancer and, in fact, it may be a protective factor [1– 4]. A negative transvaginal scan and an endometrial biopsy are considered adequate investigations to rule out endometrial carcinoma [5]. However, in the first case, a transvaginal ultrasound showed a thin endometrial echo with no other uterine pathology. It is possible that distension of the uterine cavity because of IUCD could have made measurement of endometrial thickness difficult. Complex endometrial hyperplasia was limited to the endometrial polyp and could have been easily missed by outpatient endometrial sampling as endometrial biopsy is known to be less accurate when an abnormality is focal rather than global [6,7]. Therefore, we suggest that abnormal bleeding in postmenopausal women with an IUCD should not be ignored as it can represent significant endometrial pathology. Investigations should include visualization of endometrial cavity
by hysteroscopy, as measurement of endometrial thickness may be unreliable in the presence of an IUCD. These women continued on using an IUD for no apparent clinical reason. One year after menopause, IUDs can and should be removed, as contraception is no longer necessary. In high-risk women, such as in Case 1, a levonorgestrelreleasing IUD may be inserted prophylactically at menopause. Though there is no population-based data supporting this practice, one might expect strong protection of the endometrium, given the effect of this device in women receiving tamoxifen after breast cancer [8].
References [1] Sturgeon SR, Brinton LA, Berman ML, et al. Intrauterine device use and endometrial cancer risk. Int J Epidemiol 1997;26:496 –500. [2] Hill DA, Weiss NS, Voigt LF, Beresford SA. Endometrial cancer in relation to intra-uterine device use. Int J Cancer 1997;70:278 – 81. [3] Parazzini F, La Vecchia C, Moroni S. Intrauterine device use, and risk of endometrial cancer. Br J Cancer 1994;70:672–3. [4] Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv 2002;57: 120 – 8. [5] Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998;280:1510 –7. [6] Dubinsky TJ, Parvey HR, Gormaz G, et al. Transvaginal hysterosonography: comparison with biopsy in the evaluation of postmenopausal bleeding. J Ultrasound Med 1995;14:887–93. [7] Guido RS, Kanbour A, Ruhn M, et al. Pipelle endometrial sampling sensitivity in the detection of endometrial cancer. J Reprod Med 1995;40:553–5. [8] Gardner FJ, Konje JC, Abrams KR, et al. Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel-releasing intrauterine system: a randomised controlled trial. Lancet 2000;356: 1711–7.