Differential Diagnosis for Enlarged Uterus, Thin Friable Vaginal Mucosa, and Vaginal Bleeding in a 66-Year-Old

• Single Most Likely Diagnosis
  • Postmenopausal bleeding due to Atrophic Endometrium: This condition is common in postmenopausal women and can cause thinning and friability of the vaginal mucosa, leading to bleeding. The enlarged uterus could be due to various factors, but in this context, it might be related to atrophy or other benign conditions.
• Other Likely Diagnoses
  • Uterine Fibroids: Although less common in postmenopausal women, fibroids can cause an enlarged uterus and, if they undergo degeneration, can lead to bleeding.
  • Endometrial Hyperplasia: This condition involves the thickening of the endometrium and can cause bleeding and an enlarged uterus. It's more common in postmenopausal women, especially those with unopposed estrogen exposure.
  • Hormone Replacement Therapy (HRT) Side Effects: If the patient is on HRT, it could lead to endometrial stimulation, causing an enlarged uterus and bleeding.
• Do Not Miss Diagnoses
  • Endometrial Cancer: Although less likely, endometrial cancer is a critical diagnosis not to miss, as it can present with postmenopausal bleeding and an enlarged uterus. It requires prompt investigation and treatment.
  • Uterine Sarcoma: A rare but aggressive form of cancer that can cause similar symptoms and must be considered to ensure timely diagnosis and management.
• Rare Diagnoses
  • Uterine Arteriovenous Malformation (AVM): A rare condition that can cause vaginal bleeding due to abnormal blood vessel formation within the uterus.
  • Metastatic Disease to the Uterus: In rare cases, cancers from other parts of the body can metastasize to the uterus, leading to an enlarged uterus and bleeding. This would be more likely in a patient with a known history of cancer.