A 44-year-old woman comes to the office for evaluation of abnormal uterine bleeding. The patient has had intermenstrual bleeding over the past 3 months. Most of the time, she has had only spotting with wiping, but last week, she had slightly heavier bleeding that required her to use a menstrual pad. In addition to this intermenstrual bleeding, the patient also has monthly menses with 4-5 days of moderate bleeding and slight cramping on the first 2 days that typically resolves with ibuprofen. She has no chronic medical conditions and takes no daily medications. The patient had a bilateral tubal ligation after her last delivery at age 31. Vital signs are normal. BMI is 22 kg/m². Speculum examination reveals a multiparous cervix with a small amount of bright red blood at the os and no visible cervical or vaginal lesions. On bimanual pelvic examination, the uterus is small, mobile, and nontender. No adnexal masses are palpated. FSH, TSH, and prolactin levels are normal. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's abnormal uterine bleeding?

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11ec25c8_d99b_b62c_bc81_c32986d6a8d1_MD0003_00 This premenopausal patient with regular monthly menses and intermenstrual bleeding most likely has an endometrial polyp. Endometrial polyps are common, well-vascularized, hyperplastic endometrial gland growths that extend into the uterine cavity. Endometrial polyps typically develop in women in their 30s and 40s. Most endometrial polyps are benign and asymptomatic, but they can cause abnormal uterine bleeding (AUB) in some patients due to their friability and vascularity. Because endometrial polyps do not affect ovulation, patients typically have regular monthly menses with painless, light intermenstrual bleeding. Endometrial polyps typically remain intracavitary; therefore, patients typically have a small, nontender uterus with no visible cervical or vaginal lesions. Treatment of symptomatic endometrial polyps is with hysteroscopic polypectomy. (Choice A) Although adenomyosis is a common cause of heavy, painful menses in women age >40, affected patients have regular (ie, ovulatory) menses with no intermenstrual bleeding. In addition, patients with adenomyosis typically have a boggy, uniformly enlarged uterus. adenomyosis (Choice B) Endometrial hyperplasia typically presents as irregular, anovulatory menses in women with risk factors for excess unopposed estrogen (eg, obesity, tamoxifen). This patient has a normal BMI and regular menses, making this diagnosis less likely. (Choice D) Invasive cervical cancer can cause irregular spotting or heavy vaginal bleeding due to cervical friability from a mass. This patient has no visible cervical or vaginal lesions, making this diagnosis unlikely. cervical cancer (Choice E) This patient has regular, monthly menses with molimina (eg, cramping) and a normal FSH level, making perimenopause an unlikely cause of her AUB. (Choice F) Uterine leiomyomas (fibroids) typically cause regular (ie, ovulatory) but heavy, prolonged menses and an irregularly enlarged, bulky uterus, which are not seen in this patient. Uterine leiomyomas (fibroids) Educational objective: Endometrial polyps typically present with regular monthly menses and additional intermenstrual bleeding. Symptomatic endometrial polyps are treated with hysteroscopic polypectomy. References: Diagnosis and management of endometrial polyps: a critical review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/21783430) Abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/26803558) Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women. (http://www.ncbi.nlm.nih.gov/pubmed/15749501)

A 44-Year-Old Woman Comes to the Office for Evaluation of Abnormal