Contributed by Dane C. Olevian, M.D. and Octavia Peck-Palmer, Ph.D.
The patient is a 56 year old G5P1223 female who presented to the hospital 10 years post menopause, complaining of recent nausea, vomiting, lower abdominal pain, and vaginal spotting. Five days prior to presentation (PTP), the patient developed nausea accompanied by occasional episodes of non-bloody, non-bilious vomiting. Three days PTP, she developed midline lower abdominal pain and remarked that she "felt pregnant." The pain was sharp, diffuse, and radiated to her lower back. Two days PTP, she began experiencing scant vaginal blood spotting. The patient reported engaging in unprotected sexual intercourse four months PTP, but no additional sexual encounters since that time.
The patient reached menarche at age 13. She had regular menstrual periods until age 37, at which point they became irregular and she developed frequent hot flashes and other perimenopausal symptoms. She eventually experienced her last menstrual period at age 46. No vaginal bleeding of any kind had occurred after age 46, until the current presentation. She had taken oral contraceptives for a 10 year period in the past and currently uses topical estrogen for vaginal dryness. However, she has never received hormone replacement therapy.
The patient has no history of abnormal pap smears, but reports a remote history of treated gonococcal and chlamydial genitourinary infection. The patient previously underwent an open myomectomy for a large uterine fibroid, fallopian tubal ligation, and left breast lumpectomy for a fibroadenoma.
A physical exam at the initial presentation showed diffusely tenderness to palpation of the abdomen, worse in the lower quadrants. The abdomen was otherwise soft and no masses were present. Pelvic examination revealed mild atrophic changes of the vulva and a vagina with evidence of estrogen effect. The remainder of the physical exam was unremarkable.
Laboratory evaluation revealed a plasma hCG concentration of 6 mIU/ml and a faintly positive qualitative urine hCG assay. Urinalysis demonstrated 3+ blood, which was regarded as a likely contaminant and was otherwise unremarkable. A vaginal wet slide preparation showed no evidence of candidal, trichomonal, or bacterial vaginitis. Gonococcal and chlamydial testing was negative.
A transvaginal ultrasound was subsequently performed, which identified a 1.3 x 1.6 cm clear fluid-filled cyst in the left ovary. No intra- or extra-uterine pregnancy was identified and the endometrial lining measured 2.9 mm in thickness.
The patient was administered intravenous fluids and antiemetics, with partial improvement of her abdominal symptoms. She was counseled that pregnancy was very unlikely and discharged with instructions to follow-up with her gynecologist.
At follow-up three days after discharge, the patient complained of continued nausea and abdominal pain, but decreased vaginal spotting. Repeat plasma hCG was found to be 7 mIU/ml. Plasma hCG was repeated again two weeks after discharge at two laboratories using different assays and was found to be 5 mIU/ml at both laboratories. It was repeated two weeks later with the same result. Plasma FSH was also measured and was found to be 118.82 mIU/ml.
The patient continued to have persistent mild nausea and abdominal pain for several weeks. An endometrial biopsy performed 1 month after discharge revealed only benign proliferative endometrium. The patient will continue to be followed on an outpatient basis, with possible future radiologic evaluation and testing for hyperglycosylated hCG and free beta hCG to exclude gestational trophoblastic disease and other neoplastic disease.