A 54-year-old woman, gravida 2 para 2, comes to the office due to several months of irregular vaginal spotting. The patient has had intermittent spotting with wiping after urination and has noticed some blood stains on her underwear, but she has had no large clots or abnormal vaginal discharge. Menopause occurred over a year ago and was complicated by severe hot flashes and night sweats. The patient was prescribed a transdermal estrogen patch and cyclic progesterone-only pills. She has been using the estrogen patches consistently but stopped taking the progesterone-only pills due to severe nausea. The patient has no chronic medical conditions and has had no surgeries. A Pap test 2 years ago was normal. Family history is noncontributory. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 23 kg/m². On speculum examination, there are no cervical or vaginal lesions and there is no blood in the vagina. Bimanual examination reveals a small, mobile uterus and no adnexal masses. Which of the following is the best next step in management of this patient?

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11ec25c8_d9bb_4b52_bc81_67005a920734_MD0003_00 Women with severe hot flashes during menopause, such as this patient, are often started on estrogen therapy (eg, estrogen transdermal patch) for symptom control. Although the estrogen helps with hot flashes, it can have a negative effect on the uterine lining by allowing for uncontrolled endometrial proliferation; therefore, women with a uterus require progesterone to protect the endometrium. However, progesterone can have intolerable side effects (eg, severe nausea) that may lead to its discontinuation. When the endometrial lining becomes thickened, women can develop postmenopausal bleeding (PMB), as seen in this patient's irregular vaginal spotting a year after menopause. Although most cases of PMB are benign, the most concerning cause is endometrial cancer, particularly in patients on unopposed estrogen therapy. Therefore, patients with PMB require evaluation of the endometrial lining with either a transvaginal ultrasound (TVUS) or endometrial biopsy. Postmenopausal women should have a thin endometrium; a TVUS is a reasonable first step in evaluation as it is predictive of pathology and is not as invasive or uncomfortable as an endometrial biopsy. Women with an endometrium ≤4 mm require no additional evaluation. In contrast, those with an endometrium >4 mm require an endometrial biopsy. (Choice B) Endometrial ablation is a procedure that destroys and scars the endometrium. It is not used as a treatment for PMB because it can prevent future endometrial evaluation and obscure malignancy. (Choices C and D) If this patient has a normal TVUS or endometrial biopsy, a progestin-containing intrauterine device can be placed to protect the endometrial lining while she continues estrogen therapy. In contrast, if the endometrial biopsy shows hyperplasia or cancer, the patient would require hysterectomy with bilateral salpingo-oophorectomy. (Choice E) Vaginal estrogen is used for vulvovaginal atrophy; it does not treat hot flashes. In addition, it should not be used until patients have completed the PMB evaluation. Educational objective: Patients with postmenopausal bleeding require evaluation for endometrial cancer with either a transvaginal ultrasound (TVUS) or endometrial biopsy. In women who initially undergo a TVUS, those with an endometrium ≤4 mm require no additional evaluation. In contrast, women with an endometrium >4 mm require an endometrial biopsy. References: Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/24377427) ACOG committee opinion No. 734 summary: the role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/29683904)

A 54-Year-Old Woman, Gravida 2 Para 2, Comes to the Office