She sat primly on the exam table, ignoring the indignity of the thin gown with an air of casual familiarity. An older woman, she was not at all put off by two men in white coats, despite her lack of attire. She was here for a complaint of repetitive vaginal bleeding, a phenomenon typically standard for the female of the species, but not at the advanced age of 65, not 14 years after her menopause. We probed for details, asking about volume, frequency, color, consistency. She had undergone an endometrial biopsy, which came back anomalous, not for cancer (our biggest concern in this situation), but for its health, a far more well developed endometrium than should exist in a post-menopausal woman.
We took another look with the speculum, examining her in the indignity common to the needs of feminine health maintenance, and again found anomaly in her health. We found health, abundance, a complete lack of the atrophy that is the stigmata of age. We asked further questions, attempting to get to the bottom of this mystery. She reported no pain, no nausea, no vomiting. In fact, the only difference she had noted was a tightness in her bra. Stumbling over words, she noted an increased "perkiness." A breast exam was inconclusive, yet another finding notable only for its overstated health.
We walked out of the room, the resident and I, stumped by a bizarre presentation. The standard treatment for dysfunctional uterine bleeding (which we presumed this to be) was a dilatation and curettage, the literal scraping of the uterus clean. We walked back to present to the attending with this idea in mind, only to find an less than receptive audience to this plan. The word malignancy came up, a granulosa cell tumor that revives the lost and forgotten estrogen key to endometrial growth and menstruation. An ovarian malignancy that has different effects at the extremes of life, serving as a rapid introduction to puberty for young girls, and a sexual fountain of youth for older women. Estrogen increases breast size, maintains menstruation, and prevents vaginal atrophy, and this malignant packet of cells had provided a fountain of youth in a faustian bargain ultimately ending in death if untreated.
We went back in, planning imaging and an eventual laparotomy to remove the disease. We discussed the situation with the patient, who lowered her silvery head to consider the situation. When she looked up, a mischievous smirk stole across her face, and she asked "is there was any way to keep the big tits?"
