How should a 45‑year‑old woman, five years after a total hysterectomy, presenting with vaginal bleeding and umbilical bleeding be evaluated and managed?

Urgent Evaluation for Endometriosis with Cutaneous Umbilical Manifestation

This patient requires immediate gynecologic evaluation with pelvic examination, transvaginal ultrasound, and tissue biopsy of both the vaginal vault and umbilical lesions to exclude malignancy and diagnose probable cutaneous endometriosis. 1

Initial Clinical Assessment

The simultaneous occurrence of vaginal and umbilical bleeding 5 years post-hysterectomy is highly suspicious for:

• Cutaneous umbilical endometriosis (Villar's nodule) - a rare but well-documented phenomenon where endometrial tissue implants at the umbilicus, causing cyclic or continuous bleeding
• Vaginal vault pathology requiring urgent exclusion of malignancy, as cancer can develop years after hysterectomy 1

Critical First Steps

Perform systematic pelvic examination under adequate lighting to identify: 1

• Vaginal vault granulation tissue
• Vault atrophy with friable mucosa
• Suspicious lesions or masses requiring biopsy
• Vault endometriosis
• Any remaining cervical tissue

Never assume bleeding is benign simply because the hysterectomy was remote - malignancy can develop years later. 1

Diagnostic Algorithm

1. Transvaginal Ultrasound (Primary Imaging)

Order transvaginal ultrasound immediately to: 1

• Assess for vault masses or abnormal tissue
• Evaluate adnexal structures for endometriomas
• Identify vascular lesions using color Doppler
• Detect any retained tissue or structural abnormalities

2. Mandatory Tissue Sampling

Any visible lesion on the vaginal vault requires biopsy to exclude malignancy. 1 Office vault biopsy is appropriate for accessible lesions. 1

For the umbilical bleeding: Excisional biopsy of the umbilical lesion is essential, as this will:

• Confirm or exclude cutaneous endometriosis
• Rule out umbilical metastases (Sister Mary Joseph nodule from occult malignancy)
• Provide definitive histologic diagnosis

3. Avoid Common Pitfalls

Do not: 1

• Perform blind instrumentation of the vault without visualization
• Attribute all bleeding to atrophic vaginitis without excluding structural lesions
• Assume benign etiology without tissue diagnosis

Management Based on Findings

If Granulation Tissue Identified

• Silver nitrate cauterization in office 1

If Atrophic Vaginitis Confirmed

• Topical estrogen therapy (safe after hysterectomy for non-hormone-sensitive conditions) 2

If Malignancy Detected

• Urgent gynecologic oncology referral for staging and treatment planning 1

If Endometriosis Confirmed

• Surgical excision of umbilical endometrioma
• Hormonal suppression therapy if residual disease present
• Consider imaging for other sites of endometriosis

Additional Considerations

The umbilical bleeding is the key distinguishing feature here. While post-hysterectomy vaginal bleeding has multiple potential causes (vault granulation tissue in 48% of cases 3, fallopian tube prolapse 4, or malignancy 5), the concurrent umbilical bleeding strongly suggests systemic endometriosis with cutaneous manifestation.

Timing matters: Complications can occur years after hysterectomy. Vaginal cuff dehiscence rates are 0.08% for vaginal hysterectomy 6, but this typically presents acutely, not 5 years later. The chronicity points toward either malignancy or endometriosis.

Referral threshold: If initial evaluation reveals any suspicious findings, immediate gynecologic oncology consultation is warranted rather than attempting empiric treatment. 1