A 45-year-old woman comes to the office for an annual well-woman visit. She feels well and has no concerns. The patient takes a combined estrogen/progestin oral contraceptive and has regular monthly menses. She has no chronic medical conditions and has had no prior surgeries. The patient had 2 term vaginal deliveries in her 30s, and her last Pap smear with human papillomavirus cotesting was normal 5 years ago. The patient does not use tobacco, alcohol, or illicit drugs. Her last menstrual period started 2 days ago. Blood pressure is 110/60 mm Hg and pulse is 70/min. BMI is 23 kg/m². Pelvic examination shows a multiparous cervix without lesions. Pap testing reveals benign-appearing endometrial cells and no intraepithelial lesions. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d9bc_5cc3_bc81_fda80635cdd8_MD0003_00 This patient has benign-appearing endometrial cells on Pap testing. Pap test reporting varies by age: In women age <45, endometrial cells are not reported on Pap test results because this is a common, benign finding, particularly during the first 10 days of the menstrual cycle (as in this patient). In women age ≥45, endometrial cells are reported because this finding is more concerning for endometrial hyperplasia or cancer, particularly in patients who are postmenopausal, symptomatic (ie, abnormal uterine bleeding), or at high risk (eg, unopposed estrogen from obesity, chronic anovulation). Although this patient is age 45, she is premenopausal (ie, regular monthly menses), asymptomatic (ie, no abnormal uterine bleeding), and has no risk factors (eg, normal BMI). In addition, she is taking a combined estrogen/progestin oral contraceptive, which decreases the risk of endometrial hyperplasia and cancer (Choice C). Therefore, she does not require additional evaluation (eg, endometrial biopsy) and can continue routine Pap testing. (Choices A and B) Cervical conization and colposcopy are used to evaluate for cervical cancer in patients with either cervical intraepithelial lesions on Pap testing or gross abnormalities (eg, fungating lesion) of the cervix, which are not seen in this patient. Cervical conization colposcopy (Choice D) Pelvic ultrasound can be performed in patients with postmenopausal bleeding to assess the risk of endometrial cancer (ie, as an alternative to endometrial biopsy). However, ultrasound is not used to assess the risk of cancer in asymptomatic or premenopausal patients, such as this one. Educational objective: Endometrial cells on Pap testing are a normal finding in premenopausal women, particularly within the first 10 days of the menstrual cycle. These patients can continue routine Pap testing and do not require additional evaluation (eg, endometrial biopsy) unless they are symptomatic (ie, abnormal uterine bleeding) or at high risk for endometrial hyperplasia and cancer (eg, obesity). References: 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. (http://www.ncbi.nlm.nih.gov/pubmed/23635684) Histologic follow-up in patients with Papanicolaou test findings of endometrial cells: results from a large academic women's hospital laboratory. (http://www.ncbi.nlm.nih.gov/pubmed/22706861) Evaluating the age cutoff criterion for reporting benign-appearing endometrial cells in routine Pap tests: an 8-year retrospective review. (http://www.ncbi.nlm.nih.gov/pubmed/28486237)

A 45-Year-Old Woman Comes to the Office for an Annual