Endometrial cancer associated with 14 years use of LNG-IUS
Doctors do not usually suspect endometrial cancer when a patient with long-term levonorgestrel-releasing intrauterine system (LNG-IUS) usage presents with intermittent vaginal bleeding because of how rare the occurrence is. This often leads to a significant delay in diagnosis and treatment. In a similar case, a 37-year-old with LNG-IUS was diagnosed with endometrial cancer. The patient presented to the gynaecology clinic with complaints of heavy menstrual bleeding with no medical history of obesity, hypertension or diabetes. She had two uncomplicated pregnancies with spontaneous vaginal deliveries in the past. According to her family history, both her grandmother and aunt were diagnosed with uterine cancer at the ages 50 and 70 years.
Doctors performed a speculum and bimanual vaginal examination, both of which showed no abnormalities in the cervix, uterus and adnexa. She underwent cervical cytology every 3 years which showed no alarming findings. The transvaginal scan also showed no significant findings. She did not have to undergo an endometrial biopsy as it is not a part of routine examinations for menorrhagia at this stage. The patient was counselled regarding treatment options for menorrhagia. She opted for IUS containing 52 mg levonorgestrel which was inserted into her uterine cavity.
6 months later she came back to the gynaecologist for follow-up and said that her period had become lighter. She was satisfied with the effect of LNG-IUS, the same type of which was replaced twice at 5-year intervals. Throughout this tenure her body mass index remained normal with no medical conditions.
At the age of 51 the patient developed intermittent vaginal bleedings associated with a backache.
She presented to her general practitioner (GP) for irregular vaginal bleeds, for which her GP requested a serum Follicle-stimulating hormone (FSH) level and a transvaginal ultrasound scan. According to her case report, The FSH was 37.3 U/L. The transvaginal ultrasound scan showed an endometrial thickness of 8.3 mm; both ovaries had normal morphology and clear outline measuring 24 mm × 21 mm × 21 mm and 25 mm × 18 mm × 22 mm”. The GP referred her to the gynaecology clinic for further review and management.
When she was reviewed at the gynaecology clinic, intermittent vaginal bleeding was the main presenting complaint. Examination showed a bulky anteverted uterus with a hypertrophic cervix and mild cystocele. The gynaecologist assumed that the returning menorrhagia symptoms were because of an expiring LNG-IUS. However, the patient’s next IUS placement was due after 12 months. The doctor advised an endometrial biopsy and referred her for a CT of the chest, abdomen and pelvis and MRI of the pelvis and abdomen. Findings of both test results were suggestive of an endometrial malignancy with no evidence of local or distant metastasis and less than 50% myometrial invasion.
The patient underwent surgery and had an uneventful recovery. She was referred for follow-ups at the gynaecology outpatient clinic for 4 months after the procedure. Repeat pelvic MRI, vaginal vault cytology and examination showed no evidence of recurrence.
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