An 84-year-old woman comes to the office for evaluation of bleeding. The patient first noticed small amounts of blood on her underwear 2 weeks ago. She has been wearing pads that require changing once or twice a day with only a small amount of blood accumulating between changes. Her last Pap test at age 64 was normal. A small, hyperplastic rectal polyp was removed at age 80. Vital signs are normal. BMI is 38 kg/m². The speculum is difficult to insert; on examination there is mucosal pallor throughout the vagina with epithelial thinning and dryness. No mass or prolapse is visualized. Fecal occult blood test is negative.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97e5_7f0f_853d_7998abcc6ce0_MD0002_00 New-onset postmenopausal bleeding (PMB) warrants an evaluation for endometrial cancer. Although endometrial cancer is the etiology in only 5%-10% of cases, it is potentially lethal and should therefore be ruled out early in the diagnostic process. Risk factors for endometrial cancer include age >50, diabetes mellitus, unopposed exogenous estrogen, and excessive endogenous estrogen (eg, obesity, chronic anovulation). An endometrial biopsy or transvaginal ultrasound can be used as the initial test in a patient with PMB. Transvaginal ultrasound is a noninvasive method to evaluate the endometrial lining and other sources of uterine pathology. The likelihood of endometrial cancer in patients with an endometrial stripe of <4 mm on ultrasound is ~1%, and no further testing is recommended. However, an endometrial stripe of >4 mm on ultrasound requires further evaluation with an endometrial biopsy. < (Choice A) Bloodstains on a woman's underwear can result from rectal bleeding and may warrant a colonoscopy. Obesity and age >50 are risk factors for colorectal cancer; however, rectal bleeding is less likely in this patient given the negative fecal occult blood test. In addition, hyperplastic polyps are common and benign, and rarely become malignant if they are small and distal (eg, rectum, sigmoid colon). (Choice B) A colposcopy is used to obtain a magnified view of the cervix after a patient has had an abnormal Pap test. Although cervical cancer can cause PMB, this patient has not had a Pap test in 20 years and should have this test prior to a colposcopy. (Choices C and E) The most common cause of PMB is vaginal atrophy due to low estrogen levels after menopause. Features of vaginal atrophy include a pale, dry vaginal epithelium with loss of rugation. Although this diagnosis is likely based on this patient's examination findings, evaluation for endometrial cancer should occur before initiating estrogen therapy. Expectant management of PMB is inappropriate due to the increasing incidence of endometrial cancer with age. Educational objective: Postmenopausal bleeding (PMB) requires assessment with either transvaginal ultrasound or endometrial biopsy to rule out endometrial cancer. Although vaginal atrophy is the most common cause of PMB, the incidence of endometrial cancer increases with age and should be ruled out. __________ References: Postmenopausal bleeding: first steps in the workup. (http://www.ncbi.nlm.nih.gov/pubmed/23106061) ACOG Committee opinion no. 440: the role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/19623006) Endometrial thickness as measured by transvaginal ultrasound and the corresponding histopathologic diagnosis in women with postmenopausal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/27801761)

An 84-Year-Old Woman Comes to the Office for Evaluation of Bleeding