Ms. R, a 62-year-old G0 woman presents to the office requesting a refill of her prescription of medroxyprogesterone acetate (MPA; Provera 2.5mg). 

Ms. R has experienced “annoying” intermittent spotting for years. She argues that she does not need an exam. She has been taking MPA “for many years,” prescribed by a physician in another city. Ms. R is obese, with a BMI of 40.  Despite her objections, she is informed that she will have to agree to an exam to include a pap smear, pelvic examination, and endometrial biopsy.

Ms. R is well groomed, conversant, and pleasant. She is 5′ 6” tall and weighs 180lbs. Vital signs on physical examination are good: BP 120/80mm Hg; pulse rate 88bpm.

On physical examination: 

            Vulva: Normal without lesions/discoloration

            Vagina: Moderate white discharge; vaginal rugae present

            Cervix: Parous, small amount of dark blood at os (pap obtained)

            Uterus: Anteverted, non-tender, normal size, shape, contour (exam limited by body habitus)

            Adnexa: Negative for masses or tenderness (exam limited by body habitus)

Her cervix is dilated and following a very difficult endometrial biopsy (EMB) procedure that causes the patient significant discomfort, a minimal amount of tissue is obtained. As a result, a transvaginal ultrasound is ordered.

EMB pathology reveals atypical cells. The transvaginal ultrasound is suspicious for irregular endometrial contour suggestive of a polyp or irregular growth.

Based on this information and clinical picture, Ms. R is scheduled for a hysteroscopy, dilation, and curettage. However, upon anesthesia work-up, Ms. R was found to have atrial fibrillation and was referred to cardiology. She has yet to receive treatment for the gynecological issues.

MPA, particularly at a low dose, may not be the best option for all patients. Based upon the examination, Ms. R has been receiving estrogen from the peripheral conversion of fat that has targeted the uterus and should have been evaluated years ago.