close× Email

Expand the elements to view the case or download a printable version with the big orange button!

You are a junior doctor working in the gynaecology outpatients department. Jean Therapy is a lady who has presented to the clinic concerned about recent vaginal bleeding. She states she contacted the 111 telephone service, who told her to go to A&E as she had ‘active bleeding’. Luckily Jean has common sense and has come to clinic instead.

Please take a history from Jean and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are a 60 year old lady called Jean Therapy, who is unfortunately experiencing some bleeding ‘down below’. You contacted the 111 telephone service, who told you to go to A&E as you had ‘active bleeding’. Luckily you has common sense and have come to clinic instead.

HPC: About three weeks ago, you noticed that there was some blood on the toilet paper when you wiped after going for a wee. Following this, you had some spotting of blood in your underwear, so you went to your GP. You have also noticed some brownish discharge since then. There is no pain in your abdomen and you have had no change in bowel or urinary habit. You think maybe you might be a little more bloated than usual but you just put this down to getting older. You have not noticed any bleeding after intercourse although you rarely have it nowadays!

You have had some weight loss but you have been on a diet recently so this was intentional.

PGH: You have never been pregnant, despite trying for many years and going through several rounds of IVF. The doctors said it was because your ovaries didn’t work properly. You really wanted children so have since adopted and although it wasn’t what you had originally planned or wanted, you wouldn’t change your children for the world.

You had your last period when you were 53 years old. At the time you suffered with hot flushes and mood swings but you never went on HRT and these have since settled. You started your periods age 12 and when you had them they could be quite irregular and were fairly heavy. You never used any contraception other than condoms, preferring to be “natural”. You are up to date on your smears and they have all been normal. You have never had any gynaecological infections and have no problems with prolapse or urinary continence.

PMH: High blood pressure and type 2 diabetes – you know this is because you are overweight and you are currently dieting to try and lose weight and manage your blood sugars.

DH: Amlodipine for high blood pressure. No drug allergies.

FH: Your father died of colon cancer when he was 50 years old. You can’t think of any other relevant family history.

SH: You have never smoked and rarely drink alcohol nowadays. You have recently retired and before this you worked in a secondary school kitchen. You live with your husband who is also retired: he has two sons that live nearby and visit often. You try to keep fairly active and eat healthily to help control your blood pressure and diabetes although you have occasional times where you give in and get a takeaway. You enjoy Aquafit classes at your local pool and try to walk the dog most days.

ICE: You’re not sure what is going on, you have always had gynaecological problems with your infertility and irregular periods but you don’t really know what could be causing this. You’re worried that it might be something serious. You would like to know what has caused the bleeding.

Observe the student take a history from this patient and ask them to present their findings and differential diagnosis, which should include endometrial cancer.

Points for discussion: • What are the risk factors for endometrial cancer? • How would you like to investigate this patient? • What management options would be available if a diagnosis of endometrial cancer is confirmed? • How do we stage endometrial cancer? • What is Lynch syndrome? What causes it and what cancers is it associated with? • What is Cowden syndrome? What causes it and what cancers is it associated with? • When might we consider testing for an inherited cancer syndrome? • What are some of the common causes of female infertility and what options are available for treatment?