Intravascular papillary endothelial hyperplasia (IPEH) is a rare vascular lesion that can histologically mimic malignant vascular tumors, particularly angiosarcoma, often leading to misdiagnosis and overtreatment. IPEH involving the uterine myometrium is a novel finding. We describe an 83-year-old postmenopausal woman presenting with a 6-day history of spontaneous vaginal bleeding. Pelvic examination revealed a patent vagina with minimal dark red blood and an enlarged, anteverted uterus. Pelvic magnetic resonance imaging showed a well-demarcated, heterogeneous intramural lesion (6.0 × 5.5 × 5.0 cm) in the right anterior uterine wall. Based on comprehensive imaging findings and clinical presentation, the preoperative differential diagnosis included possible sarcomatous transformation of a uterine leiomyoma versus endometrial carcinoma. The patient underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic adhesiolysis. Gross examination revealed a well-circumscribed intramural cystic lesion. Histopathology demonstrated a collagenous cyst wall with residual smooth muscle, luminal organizing thrombus, and papillary structures lined by plump endothelial cells. Immunohistochemistry showed strong positivity for cluster of differentiation (CD)31 and ETS-related gene, focal positivity for CD34 and D2-40, negative hormone receptors (estrogen receptor/progesterone receptor), and a Ki-67 index of 20%. Histopathological examination confirmed a diagnosis of IPEH, a rare benign entity characterized by reactive endothelial proliferation. Complete surgical excision resulted in resolution of vaginal bleeding. At an 18-month telephone follow-up the patient was asymptomatic, and had received no adjuvant therapy, and pelvic ultrasonography demonstrated no evidence of recurrent disease. In conclusion, IPEH cannot be reliably distinguished from malignant vascular or uterine neoplasms based on preoperative clinical, imaging, or gross findings. Accurate diagnosis of this rare entity is contingent upon histopathological examination and immunohistochemical analysis. Awareness that IPEH can occur within the uterine corpus may facilitate its inclusion in preoperative differential diagnosis, thereby potentially improving diagnostic precision and alleviating patient anxiety associated with the suspicion of malignancy.

Background: Unscheduled bleeding in postmenopausal women on hormone replacement therapy (HRT) represents a common but poorly characterised clinical challenge. Whilst endometrial cancer affects approximately 9% of women with unexplained postmenopausal bleeding, existing evidence in HRT users is largely restricted to women under 60 years and short-duration regimens, leaving a critical evidence gap in contemporary all-age clinical practice. Whether the same investigative urgency is warranted for HRT users experiencing unscheduled bleeding as for women with unexplained postmenopausal haemorrhage remains unresolved. Objectives: To determine the diagnostic yield of endometrial cancer and hyperplasia amongst postmenopausal women presenting with unscheduled bleeding whilst on HRT, and to explore potential associations with HRT regimens and clinical risk factors. Methods: This retrospective observational study analysed 343 postmenopausal women presenting with unscheduled bleeding whilst on HRT at a single tertiary centre between September 2023 and February 2024. All patients underwent transvaginal ultrasound and endometrial sampling according to institutional protocol. Descriptive statistics were used to characterise outcomes, with exploratory analyses of potential risk factors. Given the symptomatic and selected nature of this cohort, all proportions represent the diagnostic yield within an investigated population rather than population-level incidence estimates. Results: Amongst 343 women (mean age 56.2 ± 7.4 years), nine cases (2.6%) of endometrial abnormalities were identified: four malignancies (1.2%), four endometrial hyperplasia without atypia (1.2%), and one complex atypical hyperplasia (0.3%). Only five cases (1.5%) required surgical intervention. All four endometrial cancers were Stage IA (FIGO 2009; three Grade 1, one Grade 2; no LVSI), corresponding to Stage IA2mNSMP under FIGO 2023. None required adjuvant therapy. Strikingly, 88.9% of all abnormal cases occurred within two years of HRT initiation, with no endometrial pathology identified amongst the 45 women using systemic HRT for more than five years-a temporal pattern not previously reported. Conclusions: In this retrospective all-age NHS cohort, the diagnostic yield of endometrial cancer was 1.2% in HRT users with unscheduled bleeding, with only 1.5% requiring surgical intervention. All cancers were early-stage (FIGO 2009 Stage IA; FIGO 2023 Stage IA2mNSMP) and required no adjuvant therapy. A previously unreported temporal clustering of pathology within the first two years of HRT initiation generates a hypothesis that early unscheduled bleeding may unmask pre-existing rather than HRT-induced endometrial abnormalities. These observations are hypothesis-generating and should not be interpreted as evidence of endometrial safety. These findings apply specifically to symptomatic women presenting for investigation and cannot be generalised to asymptomatic HRT users. Prospective validation in larger cohorts with baseline endometrial assessment is required before any clinical conclusions can be drawn. What This Study Adds: (1) A real-world cancer detection proportion of 1.2% in an all-age contemporary NHS cohort. (2) A previously undescribed temporal pattern with pathology clustering within two years of HRT initiation and no pathology in long-term users (n = 45), generating a testable hypothesis about pre-existing versus HRT-induced disease. (3) Dual FIGO 2009/2023 staging demonstrating that molecular classification added no treatment-discriminatory value in this early-detection context.

The 2025 FIGO Cancer Report updates recommendations for the diagnosis, staging, and management of the 6 major gynecologic malignancies, including cervical, endometrial, vaginal, vulvar, ovarian, and fallopian tube cancer, and gestational trophoblastic disease (GTD). The role of ultrasound differs considerably across the 6 cancers. In cases of endometrial and GTD, ultrasound is used to guide initial diagnosis, risk stratification, and surgical planning. In postmenopausal bleeding, a transvaginal ultrasound can assess endometrial thickness and determine the need for further evaluation. In cervical cancer, transrectal ultrasound allows local tumor assessment and brachytherapy guidance. Ovarian and fallopian tube cancers rely on ultrasound as the first-line tool for adnexal mass assessment and contribute to the Risk of Malignancy Index. For vaginal cancer, sonography has a complementary role in the anatomic assessment of the primary tumor. In vulvar cancer, ultrasound use is limited, as it is mainly for lymph node evaluation in early disease, when used in conjunction with clinical examination and cross-sectional imaging. Although ultrasound has limitations when assessing nodal spread or distant metastases, it can be used in combination with cross-sectional imaging and serial biomarkers to provide a complete evaluation. This review aims to summarize the ultrasound-relevant content from the 2025 FIGO update reports and serve as a practical reference for radiologists.

Primary malignant melanoma of the cervix (PMMC) is an exceptionally rare and aggressive malignancy with a poor prognosis. Due to its rarity, there are no standardized treatment guidelines. This case report presents two patients with PMMC, contributing to the literature through a novel treatment approach and literature review. Both patients presented with vaginal bleeding: one postmenopausal without obvious cervical pigmentation, the other premenopausal with a brown, friable cervical mass. Histopathology confirmed PMMC in both. The first patient underwent radical surgery without adjuvant therapy and died from recurrence 36 months later. The second patient received radical surgery, adjuvant chemotherapy, and bevacizumab maintenance, followed by a combination of carboplatin, dacarbazine, and Tislelizumab for pulmonary metastases, achieving significant tumor regression after two cycles. A review of nine reported cases treated with PD-1/PD-L1 inhibitors revealed that radical surgery was performed in 90% of patients, yet 80% did not receive chemotherapy or radiotherapy, and most (80%) still experienced disease progression with immunotherapy, underscoring its limited efficacy. PD-L1 expression, assessed in only three cases (all negative), did not reliably predict response. In conclusion, PMMC remains a formidable clinical challenge with high recurrence rates despite surgery. Response to immune checkpoint inhibitors is inconsistent, but multimodal strategies integrating surgery, chemotherapy, anti-angiogenic agents, and immunotherapy may offer clinical benefit and warrant further investigation to improve outcomes in this aggressive disease.

Vaginal foreign bodies (VFBs) can affect women of all ages, but they are most frequently observed in the pediatric population. Such cases are relatively uncommon in women of reproductive age and postmenopausal women, and the long-term retention of foreign bodies in adults is particularly rare. We report a case of a 53-year-old postmenopausal woman with a history of bipolar disorder and autism spectrum disorder who presented with persistent vaginal bleeding, discharge, and foul odor for one year. She admitted to inserting various objects into her vagina annually since her early 30s. Imaging (ultrasound and CT) revealed multiple hyperechoic structures within the vaginal canal. Hysteroscopic examination demonstrated extensive inflammatory hyperplasia and polypoid lesions. A total of 13 foreign bodies, including porcelain bottles, a button, medicine bottles, and candy wrappers, were successfully retrieved. Postoperative histopathology confirmed benign inflammatory changes, ruling out malignancy. The patient recovered uneventfully. This case highlights the diagnostic challenges and management of long-term retained VFBs in postmenopausal women with psychiatric comorbidities. It underscores the need for a high index of suspicion in such patients presenting with non-specific gynecological symptoms to prevent severe complications.

This report describes a rare presentation of embryonal rhabdomyosarcoma (ERMS) in a 76-year-old postmenopausal woman who presented with several months of unreported vaginal bleeding followed by obstructive urinary symptoms. Imaging revealed a large uterine mass, and biopsy with immunohistochemical staining confirmed ERMS characterized by high-grade histopathologic features. Given her advanced age, comorbidities, poor functional status, and extensive tumor burden, the patient opted for palliative care focused on comfort and quality of life. This case highlights the diagnostic challenges, aggressive nature, and poor prognosis associated with adult ERMS. It reinforces the importance of promptly evaluating postmenopausal bleeding and raising clinician awareness to facilitate earlier diagnosis and improve outcomes in elderly patients.