Cases corner – 56 year old with vaginal discharge
8th March 2019
Mrs P, a 56 year old woman, presents to you with a 1 month history of vaginal discharge. She reports no evidence of blood, pruritus, dysuria or dyspareunia She is up to date with her smear tests. She denies any other symptoms. Her last menstrual period was 4 years ago. She has a BMI of 30. You conduct an examination which is unremarkable. She has never experience vaginal discharge before.
What should you do next?
- Reassure and ask her to come back if she develops any new symptoms
- Advise over the counter clotrimazole and to come back if there is no improvement in 2 weeks
- Send swabs to rule out an infection
- Refer patient for a trans-vaginal ultrasound Scan
90% of women with endometrial cancer are over 50 years of age. Despite this, diagnosing endometrial cancer early is extremely difficult.
Approximately half of women diagnosed with endometrial cancer sufferer from obesity. In a post menopausal women, obesity can pose a significant risk due to the increased circulation of unopposed oestrogen.
Discharge can often be the precursor of vaginal bleeding in menopausal women, which is a well know red flag. Early identification of this can be transformative in diagnosing cancer of the endometrium early. Vaginal discharge is a very common presentation in primary care, although NICE and Pan-London do not require vaginal swabs to have been arranged beforehand, these are inexpensive and quick tests that can be conducted to rule out infection. The important point here is to not falsely reassure patients that new onset discharge at this age is physiological without an appropriate explanation. For this reason an ultrasound scan to evaluate the thickness of the endometrium should be conducted.
The NICE guidance reports that we should consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 or over (note that in London the age threshold has been dropped to 45) with:
- Unexplained symptoms of vaginal discharge who:
- Are presenting with these symptoms for the first time
- Have thrombocytosis
- Report haematuria
- Visible haematuria and:
- Low haemoglobin levels
- High blood glucose levels