Author Information
Shila Chakre*, N M Mayadeo**, Sachin Pardeshi*
(* Assistant Professor, ** Professor. Department of
Obstetrics and Gynecology, Seth GS Medical College and KEM
Hospital , Mumbai , India
Abstract
Postmenopausal bleeding is a common presenting
complaint of patients in the gynecology outpatient department. Its incidence is
5 to 10%.[1,2] The most common cause for postmenopausal
bleeding is atrophic vaginitis and
uncommon cause is retained or forgotten intrauterine contraceptive device.[3]
Our case report presents forgotten intrauterine contraceptive device, an
uncommon but simple to manage cause of postmenopausal bleeding, in a 58 year
old multiparous patient. Simple removal of this device resulted in resolution of
symptoms.
Introduction
Postmenopausal bleeding is genital tract
bleeding occurring more than 1 year after the last menstrual period. It is only
a presenting symptom of the underlying pathology and not specific for the site
of bleeding. Causes of postmenopausal bleeding are endometrial polyp,
endometrial hyperplasia, external use of estrogens, atrophic endometritis,
endometrial cancer, genital prolapse, forgotten intrauterine device (IUD), cervical
cancer, uterine sarcoma, granulosa cell tumor of the ovaries and urogenital
schistosomiasis.[3] As endometrial pathology like endometrial
hyperplasia or cancer is common in postmenopausal women, and hence its
evaluation is essential.[4] Management of postmenopausal bleeding
depends upon the cause. Postmenopausal bleeding due to forgotten or retained
intrauterine contraceptive device is simple to manage, as its removal leads to
resolution of the symptom.
Case Report
A 58 year woman, old para four, living four, postmenopausal
for 10 years, presented to the gynecology outpatient department with two
episodes of bleeding per vaginum. The first episode was one month back, which
lasted for two days with soakage of one pad per day. The second episode was two
days back, which was similar in nature. There was no medical or surgical
illness. There was no bowel or bladder complaint. General and systemic examination
was normal. On abdominal examination, no mass was felt. On per speculum
examination, the cervix and vagina were atrophic. On per vaginum examination,
the uterus was of less than normal size and bilateral fornices were clear. Pap
smear was atrophic. Ultrasonography was suggestive of anteverted uterus with dimension of 6×5×4 cm
with endometrial thickness of 5 mm. There was an acoustic shadow in the uterine
cavity which was suggestive of an endometrial polyp or a blood clot. A fractional
curettage was performed. The endocervical sample was scanty. While curetting the
endometrium, a grating sensation was felt. Surprisingly, a white round knob of an
IUD was seen at external os. It was held with a hemostat and removed. It was
calcified. The uterine cavity was regular. Endometrial sample was also scanty. Both
endometrial and endocervical sample sent for histopathology. Retrospectively
when asked, patient had given the history of a copper T insertion but she had
no memory of removal or expulsion of the copper T. She was discharged on day 2.
Histopathology report was normal. On follow up, patient complaint were resolved.
Discussion
Postmenopausal bleeding may be due to a serious
pathology. Among the causes, endometrial cancer is a serious cause. Its
evaluation is done with clinical examination, along with endometrial aspiration,
transvaginal ultrasonography (TV USG) and curettage. With endometrial
aspiration, serious pathology can be missed. On TV USG, endometrial thickening
and heterogeneity suggestive of endometrial cancer has false negative report.[2,5]
Hysteroscopy with dilatation and curettage is standard
investigation for postmenopausal bleeding.[6] Vaginal bleeding is
common after the insertion of IUD in younger patients, but is uncommon as a
cause of postmenopausal bleeding. IUD can lead to abnormal uterine bleeding
either by chronic inflammatory reaction or by embedding, displacing or
migrating into uterine the cavity.[7]
In our patient, its presence was not considered
preoperatively because she had not given any history of insertion or expulsion
of an IUD. TV USG was only suggestive of a polyp or a blood clot with in the
endometrial cavity, while the IUD was surprisingly not seen, though it contains
barium sulfate forradiopacity. On fractional curettage the cause of
postmenopausal bleeding was incidentally found to be forgotten IUD, and its
removal lead to cure of symptoms. Thus retained or forgotten IUD is cause of postmenopausal
bleeding. It should be included in differential diagnosis of postmenopausal
bleeding. It is very simple to manage.
References
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endometrial cancer and other endometrial abnormalities. JAMA 1998; 280:1510-1517.
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Citation
Chakre S, Mayadeo
NM