An unusual cause of postmenopausal bleeding

Abstract

A 68-year-old postmenopausal woman presented to the gynaecology clinic with a 1-week history of vaginal bleeding. She was investigated to rule out local and systemic causes including genital malignancy. The investigations were negative for genital malignancy and her symptoms settled spontaneously. The bleeding was attributed to a corticosteroid treatment for shoulder joint pain. A short literature review of this rare side effect is discussed.

Background

Corticosteroid injections are commonly used medications. There are some rare side effects of these medications which can alarm the patients and the physicians, as in this case.

Case presentation

A 68- year-old postmenopausal woman presented to the gynaecology clinic with a history of vaginal bleeding of 1 week duration. The bleeding was moderate in amount, painless and had a sudden onset. She is para 2 and her last delivery was about 40 years ago. Her last pap smear was 10 years ago and she was on hormone replacement therapy (combined oestrogen and progestogen) for 4 years soon after her menopause at the age of 50.

She is a known hypertensive on calcium channel blocker and a β-blocker and hypothyroid on thyroxine treatment. There was a recent history of treatment of shoulder joint pain by a rheumatologist with triamcinolone acetonide (Squibb, UK) injection for supraspinatus tendinitis. There was no family history of any malignancies. A mammogram 1 year ago was reported as normal.

On examination, she was mildly obese (body mass index BMI of 31), not pale and her thyroid was normal. Examination of the breasts and abdomen was unremarkable. On speculum examination of the pelvis, the cervix was healthy and minimal bleeding was noted. The uterus was felt to be of normal size for her age and adnexa were not palpable.

Investigations

• Complete blood count

• Thyroid function tests

• Pap smear from the cervix

• Endometrial aspiration biopsy

• Ultrasound of the uterus and ovaries

• Hysteroscopy and curettage

Differential diagnosis

• Endometrial malignancy

• Atrophic vaginitis

• Hypothyroidism

• Endometrial polyp

Treatment

Conservative.

Outcome and follow-up

A bedside transvaginal ultrasound revealed an endometrial thickness of 10 mm and the ovaries were not visualised (images not available).

A pap smear was obtained and an endometrial aspiration biopsy was performed in the outpatient clinic. The pap smear was reported as negative for malignant cells and the endometrial biopsy was insufficient for evaluation. The thyroid function tests repeated were normal. Complete blood count was normal.

Her bleeding continued for a few more days and she was scheduled for a hysteroscopy and curettage. The hysteroscopy revealed an atrophic endometrium all around (figure 1). Endometrial curettings were obtained for histology. Histology of the endometrium was reported as atrophic with no specific abnormality. Her bleeding settled spontaneously in a few days with no medications. She has remained well and symptom-free since then.

Figure 1.

Hysteroscopic view of the endometrium.

Discussion

Postmenopausal bleeding of any amount necessitates a thorough investigation to rule out a genital malignancy. Apart from a history of steroid injection (triamcinolone), there was no significant change in her medications/lifestyle just prior to her complaint. Menstrual irregularities are mentioned as a side effect of triamcinolone acetate in the drug information leaflet.¹ Uterine bleeding following epidural triamcinolone was reported by Yoon and Lee.² Gitkind et al³ described a 47-year-old with menorrhagia following an injection of epidural corticosteroid injection. A history similar to this was reported by Willey et al⁴ in a study of comparison of oral prednisolone and intramuscular depot triamcinolone in patients with severe chronic asthma. Two other patients in the perimenopausal age group had similar episodes of vaginal bleeding after epidural steroid injection, as reported by Cok et al.⁵ This case report illustrates the rare side effect of this steroid medication, triamcinolone acetonide, in a postmenopausal woman, though such a history should not make the gynaecologist defer a thorough investigation for the vaginal bleeding.

Learning points.

• Bleeding in a postmenopausal woman is abnormal and should be investigated right away.

• Benign causes like hormone replacement medications, atrophic vaginitis and endometrial polyps are more common than endometrial malignancy.

• If endometrial aspiration biopsy is negative and the patient is symptomatic, hysteroscopy and curettage must be done to rule out other causes like polyps.

• A thorough history is important prior to investigations.