A 64-year-old female patient presented in May 2020 after “postmenopausal vaginal bleeding for one year.” The patient had experienced menopause at the age of 53, her body mass index was 18.75, she reported no risk factors for endometrial cancer such as obesity, diabetes, hypertension, genetic diseases, she had no history of hormone drug use, and her adrenal glands were normal in size. She had one pregnancy and had delivered once.
In June 2013, 4 years after menopause, the patient had irregular vaginal bleeding without obvious cause. Transvaginal ultrasonography (TVUS) showed the endometrium was thickened, about 1.5 cm, and diagnostic curettage was performed. The pathological results suggested simple endometrial hyperplasia.
In May 2014, diagnostic curettage was performed again due to irregular vaginal bleeding, and the pathological results suggested endometrial hyperplasia disorder. The first two curettage procedures were performed at another hospital.
In June 2016, irregular vaginal bleeding occurred again. Gynecological examination showed the cervix was a normal size, the uterus was enlarged and the shape was irregular, and there were no abnormalities in the accessory area of either side. TVUS showed the size of the uterus was about 9.0 × 6.1 × 6.0 cm, the endometrium was thickened, about 1.9 cm, and the echo was uneven. There were several hypoechoic masses in the uterine area; the larger one was in the lower part of the front wall, about 2.2 × 2.1 × 1.9 cm, and the boundary was clear. The size of the left ovary was about 2.1 × 1.4 cm, and the size of the right ovary was 2.0 × 1.2 cm. There was no obvious mass in the double accessory area. Further hysteroscopy showed that the endometrium of the posterior wall of the uterus was focally thickened, and multiple polypoid lesions were seen in the uterine cavity; the larger one was about 1.5 × 1.0 cm, soft and pink with a smooth surface, and the cervical mucosa was smooth. The sex-hormone test revealed the following: estradiol (E2): 63 pg/mL (normal range: <20–40 pg/mL), human follicle stimulating hormone (hFSH): 29.01mIU/mL (normal range: 16.24-113.59mIU/mL), human luteinizing hormone (hLH): 26.54mIU/mL (normal range: 10.87-58.64mIU/mL), progesterone (Prog): 0.33 ng/mL (normal range: 0.01–0.78 ng/mL), testosterone (Testo): 0.46 ng/mL (normal range: <0.1–0.75 ng/mL). Hysteroscopic endometrial polypectomy was performed on June 27, 2016, and the pathological results revealed endometrial polyps with secretory changes. The bleeding disappeared after the operation.
In June 2019, vaginal bleeding returned and lasted intermittently for nearly 1 year. In May 2020, the patient presented to a doctor for a gynecological examination. The cervix was normal in size with a smooth surface and no cervical atrophy, the uterus was enlarged and irregular, and no abnormalities were observed in the double accessory area. TVUS (Fig. 1A) showed the uterus to be about 8.2 × 6.3 × 5.7 cm, and the endometrium was about 2.0 cm. There were several hypoechoic masses in the uterine area. A large one (3.6 × 3.4 × 2.7 cm) was in the isthmus of the anterior wall, with a clear boundary. The size of the left ovary was about 2.1 × 1.7 × 1.0 cm, and the size of the right ovary was about 1.9 × 1.3 × 1.2 cm. There was no obvious mass in the double accessory area. The results of tumor markers were normal. Hysteroscopy (Fig. 1B) showed the endometrium was extensively thickened, and the cervical mucosa was smooth. Part of the endometrium was scraped and sent to pathology, the results indicated endometrial complex hyperplasia. Pelvic magnetic resonance imaging (MRI) (Figs. 1C, D) showed the uterus was enlarged, the endometrium was thickened (about 1.6 cm), and the signal in the right corner of the uterine cavity was not uniform. The patient’s sex hormones were rechecked June 19, 2020; the results suggested the following: E2: 124 pg/mL, hFSH: 33.31mIU/mL, hLH: 26.97mIU/mL, Prog: 1.04 ng/mL, Testo: 1.10 ng/mL. Full-scale curettage under hysteroscopy was performed June 23, 2020. During the operation, the uterine cavity was found to be irregular, the endometrium was diffusely thickened, local polypoid changes were observed. The pathological results indicated endometrial complex hyperplasia, but could not exclude mild atypical hyperplasia.
As atypical hyperplasia of the endometrium was not excluded and considering the patient’s age and operation history, we decided to perform laparoscopic hysterectomy and bilateral salpingo-oophorectomy. TVUS was performed again before the operation (Fig. 2A, B). The uterus was about 8.0 × 6.4 × 5.5 cm, and the thickness of the endometrium was about 0.6 cm. There were several hypoechoic masses in the uterine area. The right ovary was about 2.2 × 1.7 × 1.5 cm, and a 1.6 × 1.2 × 1.2 cm mass was observed inside; it had clear borders and was hypoechoic inside. Blood-flow signals were detected with color Doppler flow imaging (CDFI). The left ovary was unclear. A further abdominal computed tomography (CT) scan (Fig. 2C) showed a low-density nodule of about 1.5 × 1.0 cm in the right ovary, with clear borders. Laparoscopic hysterectomy and double salpingo-oophorectomy were performed July 10, 2020. During the operation, we observed that the uterus was obviously large and irregular, with multiple fibroid nodules. On the surface of the right ovary, there was a yellow protruding lesion of about 1 cm (Fig. 2D). The whole uterus and double appendages were removed through the vagina and sent to pathology. As seen under a microscope, the tumor cells of the right ovarian lesion were spindle-shaped and bundle-like with sheet-like arrangement, and the cells were densely arranged without obvious atypia. Eosinophilic cell nests with rich cytoplasm could be seen in the focal area (Fig. 3A). Endometrial glandular hyperplasia, densely arranged, part of the glandular cavity irregular (Fig. 3B). Immunohistochemistry revealed: cytokeratin (focal +, Fig. 3C); inhibin (part +, Fig. 3D); Wilm’s tumor protein (WT1, part +, Fig. 3E); calretinin (+, Fig. 3F); Ki-67 (about 10% +, Fig. 3G); net staining showed mostly surrounding single cells (Fig. 3H). Pathological diagnosis was right ovarian cellular fibroma with hilar cell hyperplasia, focal complex endometrial hyperplasia, multiple leiomyomas of the uterus, and chronic cervicitis, the left adnexa and right fallopian tube were normal. The patient recovered well after the operation. Sex hormones the first day after the operation were E2: 22 pg/mL and testo:0.73 ng/mL; the second day, they were E2: <20 pg/mL and testo:0.30 ng/mL. The patient was discharged on the 5th postoperative day, 2 and 5 months after the operation, there was no abnormality discovered in the outpatient review.