Postmenopausal Bleeding SOAP Note Example

Postmenopausal Bleeding SOAP Note Example

Patient Information:

• Name: Linda Martinez
• Age: 58
• Gender: Female
• Date of Evaluation: October 25, 2023
• MRN: [Insert MRN]

Subjective (S)

Chief Complaint (CC):

“I’ve had vaginal bleeding for the past week. I went through menopause 7 years ago, so this is really worrying me.”

History of Present Illness (HPI):

• Onset and Duration: The first episode of vaginal bleeding began 7 days ago; intermittent light bleeding requiring 1-2 pads/day
• Characteristics: Bright red blood without clots, described as significantly less than menstrual periods
• Associated Symptoms: Reports mild, non-localized pelvic discomfort (rated 2/10); denies dysuria, fever, abdominal pain, or changes in bowel habits
• Timing: No pattern to bleeding; occurs randomly throughout the day
• Exacerbating/Relieving Factors: None identified; no relation to physical activity
• Prior Episodes: No previous postmenopausal bleeding
• Last Normal Menstrual Period: Age 51 (7 years ago)

Medication History:

• Current Medications:
  • Conjugated estrogens (Premarin) 0.625 mg oral daily, initiated 2 years ago for osteoporosis prevention
  • Lisinopril 10 mg oral daily for hypertension (started 5 years ago)
  • Calcium carbonate 600 mg with vitamin D 400 IU twice daily
  • Multivitamin daily
• Medication Adherence: Reports taking medications as prescribed
• Recent Medication Changes: None in the past 6 months
• Over-the-Counter Medications: Occasional ibuprofen for joint pain
• Herbal/Supplements: None

Allergies:

No known drug allergies (NKDA)

Past Medical History:

• Chronic Conditions:
  • Hypertension (ICD-10: I10) was diagnosed 6 years ago, well-controlled
  • Osteoporosis (ICD-10: M81.0) diagnosed 2 years ago, T-score -2.7 at the lumbar spine
  • Obesity (ICD-10: E66.9), BMI 32
• Past Surgical History:
  • Hysteroscopic polypectomy (2018) for benign endometrial polyp
  • Laparoscopic cholecystectomy (2010)
• Gynecological History:
  • G3P2 (2-term vaginal deliveries, 1 spontaneous abortion)
  • Menarche at age 13
  • No history of abnormal Pap smears
  • Last Pap smear: 1 year ago, normal
  • No history of sexually transmitted infections

Family History:

• Mother: Endometrial cancer diagnosed at age 62, deceased at 70
• Father: Hypertension, myocardial infarction at age 72
• Sister: Type 2 diabetes, diagnosed at age 55
• Maternal aunt: Breast cancer at age 58
• No known genetic disorders

Social History:

• Marital Status: Married for 35 years
• Occupation: Retired elementary school teacher
• Tobacco Use: Never smoker
• Alcohol Use: 1-2 glasses of wine per week (occasional)
• Recreational Drug Use: Denies
• Exercise: Walks 20 minutes, 3 times weekly
• Diet: Reports high-carbohydrate diet, limited vegetable intake
• Living Situation: Lives with husband in a single-story home
• Sexual History: Sexually active with husband; denies dyspareunia

Review of Systems:

• Constitutional: Denies fever, chills, fatigue, unintentional weight loss or gain
• Cardiovascular: Denies chest pain, palpitations, or edema
• Respiratory: Denies cough, shortness of breath
• Gastrointestinal: Denies nausea, vomiting, abdominal pain, or changes in bowel habits
• Genitourinary: Reports postmenopausal bleeding as described; denies dysuria, frequency, urgency, or incontinence
• Gynecologic: Denies dyspareunia, vaginal discharge, or vulvar lesions; reports occasional vaginal dryness
• Musculoskeletal: Reports mild lower back pain, managed with occasional ibuprofen
• Neurological: Denies headaches, dizziness, syncope, or focal weakness
• Psychiatric: Denies anxiety, depression, or mood changes
• Endocrine: Denies polydipsia, polyuria, heat/cold intolerance
• Hematologic: Denies easy bruising or bleeding
• Immunologic: Denies recurrent infections

Objective (O)

Vital Signs:

• Blood Pressure: 142/88 mmHg (elevated)
• Heart Rate: 76 bpm (regular)
• Respiratory Rate: 16 breaths/min
• Temperature: 98.6°F (37.0°C)
• Oxygen Saturation: 98% on room air
• Height: 5’4″ (162.6 cm)
• Weight: 186 lbs (84.4 kg)
• BMI: 32 kg/m² (Class I Obesity)

Physical Examination:

• General Appearance: Well-developed, well-nourished female in no acute distress
• Head and Neck:
  • Normocephalic, atraumatic
  • Thyroid non-palpable, no lymphadenopathy
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
• Respiratory: Clear to auscultation bilaterally, no wheezes or crackles
• Abdominal: Soft, non-tender, no hepatosplenomegaly or masses
• Extremities: No edema, normal peripheral pulses

Pelvic Examination:

• External Genitalia: Normal appearance, no lesions or masses
• Speculum Examination:
  • Vaginal mucosa appears pale and atrophic with decreased rugae
  • Small amount of bright red blood in vaginal vault
  • Cervix: Multiparous, no lesions, polyps, or active bleeding
• Bimanual Examination:
  • Uterus: Anteverted, normal size (8 cm), non-tender
  • Adnexa: No masses or tenderness bilaterally
  • No cervical motion tenderness
• Rectovaginal Examination:
  • No masses or nodularity
  • Rectal vault normal, no masses
  • Stool guaiac negative

Diagnostic Studies:

• Imaging:
  • Transvaginal Ultrasound (performed today):
    • Endometrial thickness: 8 mm (abnormal for postmenopausal state; normal <4 mm)
    • Uterus: 8.2 x 4.5 x 3.8 cm, normal contour
    • No focal masses were identified within the endometrium
    • Ovaries: Right ovary 2.1 x 1.8 x 1.5 cm; Left ovary 2.0 x 1.7 x 1.6 cm
    • No adnexal masses or free fluid
    • Urinary bladder normal
• Laboratory Studies:
  • Complete Blood Count (Today):
    • WBC: 7.2 x 10³/μL (normal range: 4.5-11.0)
    • Hemoglobin: 12.8 g/dL (normal range: 12.0-15.5)
    • Hematocrit: 38.2% (normal range: 36.0-46.0)
    • Platelets: 210 x 10³/μL (normal range: 150-450)
  • Comprehensive Metabolic Panel (Today):
    • Glucose: 92 mg/dL (normal range: 70-99)
    • Creatinine: 0.8 mg/dL (normal range: 0.5-1.1)
    • BUN: 15 mg/dL (normal range: 7-20)
    • All other values within normal limits
  • Pap Smear (Today):
    • Specimen collected, pending results
    • Previous Pap smear (1 year ago): Negative for intraepithelial lesion or malignancy
  • HPV Testing (Today):
    • Specimen collected, pending results
  • TSH, Free T4 (Today):
    • Pending results
  • Endometrial Sampling:
    • Pipelle endometrial biopsy scheduled within 48 hours

Assessment (A)

Primary Diagnosis:

• Postmenopausal Bleeding (ICD-10: N95.0)
  • Evidenced by: Vaginal bleeding 7 years post-menopause, abnormal endometrial thickness (8 mm)
  • Severity: Mild to moderate based on the amount of bleeding and normal hemoglobin
  • Duration: 1 week

Differential Diagnoses:

1. Endometrial Hyperplasia Without Atypia (ICD-10: N85.00)
   • Supporting Evidence: Increased endometrial thickness (8 mm), use of unopposed estrogen therapy for 2 years
   • Risk Factors: Obesity (BMI 32), unopposed estrogen use
   • Diagnostic Considerations: Pending endometrial biopsy for confirmation
   • Evidence-Based Reference: ACOG Practice Bulletin No. 149 (2015) notes that unopposed estrogen increases the risk of endometrial hyperplasia
2. Endometrial Adenocarcinoma (ICD-10: C54.1)
   • Supporting Evidence: Family history (mother with endometrial cancer), postmenopausal bleeding, endometrial thickness >4 mm
   • Risk Factors: Age 58, obesity, family history, unopposed estrogen use
   • Diagnostic Considerations: No constitutional symptoms; biopsy required for definitive diagnosis
   • Evidence-Based Reference: SGO guidelines state that endometrial thickness >4 mm in postmenopausal women with bleeding warrants further evaluation
3. Cervical or Endometrial Polyp (ICD-10: N84.0/N84.1)
   • Supporting Evidence: History of prior polyp (2018), intermittent bleeding pattern
   • Risk Factors: Previous history of polyps
   • Diagnostic Considerations: No visible polyp on speculum exam; further evaluation with saline infusion sonohysterography may be indicated
   • Evidence-Based Reference: Up to 30% of postmenopausal bleeding cases are attributed to polyps (ACOG, 2018)
4. Atrophic Vaginitis/Endometritis (ICD-10: N95.2)
   • Supporting Evidence: Atrophic vaginal mucosa noted on exam, 7 years post-menopause
   • Risk Factors: Postmenopausal status
   • Diagnostic Considerations: Bleeding typically more spotty; atrophy alone unlikely to cause endometrial thickening
   • Evidence-Based Reference: NAMS position statement (2020) notes that severe atrophy can cause abnormal bleeding but rarely with endometrial thickness >4 mm
5. Exogenous Hormone Therapy Effect (ICD-10: Z79.890)
   • Supporting Evidence: Current use of conjugated estrogens without progestin
   • Risk Factors: Unopposed estrogen use for 2 years
   • Diagnostic Considerations: ACOG recommends progestin for uterine protection in women with intact uterus
   • Evidence-Based Reference: WHI study demonstrated increased risk of endometrial pathology with unopposed estrogen

Contributing Factors:

• Obesity (ICD-10: E66.9, BMI 32)
  • Increases estrogen production in adipose tissue
  • Associated with 2-4 fold increased risk of endometrial pathology
• Unopposed Estrogen Therapy (ICD-10: Z79.890)
  • 2 years of conjugated estrogens without progestin
  • Increases risk of endometrial hyperplasia and cancer
• Family History of Endometrial Cancer (ICD-10: Z80.0)
  • First-degree relative (mother) with endometrial cancer
  • Increases lifetime risk approximately 2-3 fold
• Hypertension (ICD-10: I10)
  • Associated with increased risk of endometrial pathology
  • Current reading 142/88 mmHg indicates suboptimal control

Risk Stratification:

• Endometrial Cancer Risk: Moderate to high based on multiple risk factors (family history, obesity, unopposed estrogen, endometrial thickness >4 mm)
• Urgent Evaluation Required: Yes, due to constellation of risk factors and abnormal imaging findings

Plan (P)

1. Diagnostic Interventions:

• Endometrial Biopsy:
  • Schedule Pipelle endometrial biopsy within 48 hours
  • Rationale: Gold standard for evaluating endometrial tissue in postmenopausal bleeding
  • EBP Reference: ACOG Committee Opinion #734
• Saline Infusion Sonohysterography (SIS):
  • If biopsy is non-diagnostic or incomplete
  • Rationale: Better visualization of focal lesions (polyps, submucous fibroids)
• Pelvic MRI:
  • Consider if biopsy is inconclusive or inadequate
  • Rationale: Evaluates myometrial invasion if endometrial cancer is suspected
• Laboratory Follow-up:
  • Review pending lab results (TSH, Free T4, Pap smear, HPV)
  • Repeat CBC in 4 weeks if bleeding persists

2. Medications:

• Hormone Therapy Modification:
  • Discontinue conjugated estrogens (Premarin) 0.625 mg daily immediately
  • Rationale: Unopposed estrogen increases risk of endometrial pathology in women with intact uterus
  • EBP Reference: NAMS 2017 Hormone Therapy Position Statement
• Alternative Osteoporosis Management:
  • Initiate alendronate 70 mg oral weekly if the biopsy negative for malignancy
  • Continue calcium/vitamin D supplementation
  • Rationale: Non-hormonal management of osteoporosis
• Hypertension Management:
  • Increase lisinopril to 20 mg daily
  • Home BP monitoring twice daily
  • Rationale: Current BP 142/88 mmHg is above target; AHA guidelines recommend <130/80 mmHg

3. Consultations/Referrals:

• Gynecologic Oncology:
  • Expedited referral if endometrial biopsy shows atypia, hyperplasia, or malignancy
  • Rationale: Family history of endometrial cancer increases risk profile
• Endocrinology:
  • Referral for comprehensive osteoporosis management
  • Rationale: Need for a non-hormonal approach given contraindications to HRT
• Registered Dietitian:
  • Referral for medical nutrition therapy for weight management
  • Rationale: BMI 32 contributes to endometrial cancer risk and hypertension
• Physical Therapy:
  • Referral for weight-bearing exercise program for osteoporosis
  • Rationale: Evidence supports exercise as adjunctive therapy for bone health

4. Patient Education:

• Bleeding Red Flags:
  • Report immediately if bleeding becomes heavy (>1 pad/hour), associated with severe pain, or syncope
  • Rationale: May indicate active hemorrhage requiring urgent intervention
• Medication Changes:
  • Explained rationale for discontinuing HRT
  • Provided written instructions for new medication regimen
• Lifestyle Modifications:
  • Weight loss goal of 5-10% of current weight over 6 months
  • Mediterranean diet pattern recommended
  • Regular physical activity: aim for 150 minutes/week of moderate-intensity exercise
  • Rationale: Evidence supports these measures for reducing endometrial cancer risk
• Follow-Up Instructions:
  • Keep endometrial biopsy appointment
  • Return to clinic in 2 weeks to review all results
  • Maintain bleeding diary with pad count/saturation

5. Advanced Practice Considerations:

• Evidence-Based Practice Application:
  • Following ACOG guidelines for postmenopausal bleeding evaluation
  • Utilizing NAMS recommendations for hormone therapy management
  • Applying AHA/ACC guidelines for hypertension management in high-risk patients
• Quality Improvement Opportunity:
  • Consider office protocol development for expedited evaluation of postmenopausal bleeding
  • Track time from presentation to endometrial sampling as a quality metric
• Interprofessional Collaboration:
  • Communicate findings to the primary care provider
  • Coordinate care between gynecology, endocrinology, and dietetics
  • Case conference with gynecologic oncology if high-risk features identified
• Cultural Considerations:
  • Assessed for any cultural barriers to following the recommended plan
  • Provided educational materials in the patient’s preferred language

6. ICD-10 Coding:

• Primary Diagnosis: N95.0 (Postmenopausal bleeding)
• Secondary Diagnoses:
  • I10 (Essential hypertension)
  • M81.0 (Postmenopausal osteoporosis without current pathological fracture)
  • E66.9 (Obesity, unspecified)
  • Z79.890 (Hormone replacement therapy)
  • Z80.0 (Family history of malignant neoplasm of digestive organs)

7. Patient Response and Understanding:

• Patient verbalized understanding of:
  • Serious nature of postmenopausal bleeding
  • Need for prompt endometrial biopsy
  • The rationale for discontinuing HRT
  • Warning signs requiring immediate attention
• Patient demonstrated teach-back of key points and agreed to follow-up plan
• Patient provided with after-hours contact information

References:

1. American College of Obstetricians and Gynecologists. (2021). Practice Bulletin No. 149: Endometrial Cancer. Obstetrics & Gynecology, 137(3), e171-e190.
2. The North American Menopause Society. (2020). The 2020 genitourinary syndrome of menopause position statement. Menopause, 27(9), 976-992.
3. The American Cancer Society. (2022). Endometrial Cancer Risk Factors. Retrieved from: www.cancer.org
4. Smith, R.L., et al. (2021). Accuracy of transvaginal ultrasonography for detecting endometrial abnormalities in postmenopausal women with vaginal bleeding. JAMA Internal Medicine, 181(5), 612-619.
5. Whelton, P.K., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology, 71(19), e127-e248.

Next Steps:

• Track biopsy results through the electronic health record
• Schedule interprofessional team huddle to review case findings
• Document in the registry for postmenopausal bleeding quality metrics
• Ensure closed-loop communication for all referrals