A 57-year-old woman, gravida 1 para 1, comes to the office for a routine examination. The patient has no concerns and has been feeling well. She walks for 30 minutes each morning and is planning on retiring in a few years. The patient is sexually active with her husband and has no pain during intercourse. She had a light menstrual period a month ago after a lapse since age 53. The patient has no chronic medical conditions and has had no previous surgery. Her father had colon cancer, but family history is otherwise unremarkable. She drinks alcohol socially but does not use tobacco or illicit drugs. Mammography and Pap test were normal 2 years ago. BMI is 28 kg/m². Physical examination is normal. Which of the following is the best next step in evaluation of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9ba_39e0_bc81_2d457b9205c3_MD0003_00 This patient's light menstrual period 4 years after her previous menstrual period is consistent with postmenopausal bleeding (PMB). Most cases of PMB are benign, but all women with PMB require further evaluation with (Choice E): Pap test for cervical cancer, regardless of when the last Pap test was performed, because cervical cancer can present with light vaginal bleeding and has a peak incidence in women age ~50. endometrial biopsy or transvaginal ultrasound for endometrial cancer because the most common presentation of endometrial cancer is PMB and the risk for this cancer increases with age and BMI. Endometrial biopsy is considered the gold standard for diagnosis of endometrial cancer due to its high sensitivity and specificity. However, in postmenopausal women, a transvaginal ultrasound may be performed initially; women with an endometrial thickness ≤4 mm have a low likelihood of endometrial cancer and require no additional evaluation. In contrast, women with an endometrial thickness of >4 mm require an endometrial biopsy because the likelihood of endometrial cancer is increased. Patients diagnosed with endometrial cancer undergo a hysterectomy with bilateral salpingo-oophorectomy, which treats and stages the cancer. (Choice A) Diagnostic laparoscopy is not used in the initial evaluation of PMB. It is more commonly used in evaluation of ovarian cancer, which typically presents with an adnexal mass or bulk symptoms. (Choice C) Hysterosalpingogram, which is used to evaluate for uterine abnormalities, is relatively contraindicated in patients with PMB because the procedure could spread cancerous cells into the abdomen. (Choice D) Additional imaging of the abdomen and pelvis is typically not indicated for endometrial cancer because it is usually surgically staged. However, MRI may be used in some cases where patients cannot tolerate surgery due to comorbidities. It is not used in initial evaluation of PMB. (Choice F) In women who have historic menopause (ie, no menses >12 consecutive months), a serum FSH level is not recommended because it will be elevated and does not provide diagnostic information for PMB. Educational objective: Women with postmenopausal bleeding require a Pap test for evaluation of cervical cancer and either an endometrial biopsy or transvaginal ultrasound to evaluate for endometrial cancer. References: Appropriate evaluation of postmenopausal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/30234731) Diagnosis and management of endometrial cancer. (http://www.ncbi.nlm.nih.gov/pubmed/26977831)

A 57-Year-Old Woman, Gravida 1 Para 1, Comes to the Office