Differential Diagnosis

The patient presents with menorrhagia, intermenstrual bleeding, and dysmenorrhea. Here are possible diagnoses categorized for clarity:

• Single Most Likely Diagnosis
  • Endometrial hyperplasia or endometrial cancer: These conditions are common causes of abnormal uterine bleeding in women of this age group and can also cause dysmenorrhea.
• Other Likely Diagnoses
  • Uterine fibroids: These are benign tumors that can cause heavy menstrual bleeding, intermenstrual bleeding, and dysmenorrhea due to their size and location.
  • Endometriosis: Although more commonly associated with infertility and pelvic pain, endometriosis can also cause dysmenorrhea and abnormal bleeding patterns.
• Do Not Miss Diagnoses
  • Cervical cancer: Although less common than other causes of abnormal vaginal bleeding, cervical cancer is a critical diagnosis not to miss due to its potential for severe outcomes if not treated early.
  • Ovarian cancer: Though less directly linked to the symptoms described, ovarian cancer can sometimes present with non-specific pelvic symptoms and abnormal bleeding, especially in postmenopausal women, but can occur in perimenopausal women as well.
• Rare Diagnoses
  • Uterine sarcoma: A rare type of cancer that can cause similar symptoms to more common uterine conditions.
  • Gestational trophoblastic disease: Although rare and typically associated with pregnancy, it can cause abnormal uterine bleeding.

Investigations in the Clinic

Two possible investigations that can be done in the clinic include:

• Pelvic Examination: To assess for any palpable masses or abnormalities.
• Pap Smear: To screen for cervical cancer, although it's noted that the patient later was diagnosed with cervical adenocarcinoma, which might not always be detected by a Pap smear.

Blood Tests and Imaging Techniques for Cervical Adenocarcinoma

Given the diagnosis of cervical adenocarcinoma:

• Blood Tests:
  • SCC (Squamous Cell Carcinoma) Antigen: Although more commonly elevated in squamous cell carcinoma, it can sometimes be elevated in adenocarcinoma.
  • CEA (Carcinoembryonic Antigen): Can be elevated in various cancers, including cervical adenocarcinoma.
• Imaging Techniques:
  • MRI (Magnetic Resonance Imaging): Provides detailed images of the cervix and surrounding tissues, helping to assess the extent of the tumor.
  • CT Scan: Useful for evaluating the spread of cancer to lymph nodes or distant organs.

Treatments and Complications for Cervical Adenocarcinoma

Two treatments available for cervical adenocarcinoma:

• Surgery: Such as radical hysterectomy, which involves removing the uterus, cervix, and part of the vagina.
• Chemoradiation: A combination of chemotherapy and radiation therapy, which can be used as a primary treatment or in addition to surgery.

Complications for each treatment:

• Surgery:
  • Bowel or bladder dysfunction: Due to the proximity of these organs to the surgical site.
  • Lymphedema: Swelling of the legs due to removal of lymph nodes.
• Chemoradiation:
  • Radiation cystitis: Inflammation of the bladder causing symptoms like frequent urination and pain.
  • Radiation proctitis: Inflammation of the rectum causing symptoms like diarrhea, bleeding, and pain.