An 18-year-old woman comes to the emergency department due to heavy vaginal bleeding. The patient previously had regular monthly menses; however, for the past month, she has had daily vaginal bleeding with passage of clots. Today, the patient developed dizziness and shortness of breath. She has no chronic medical conditions and has had no surgeries. The patient's grandmother was recently diagnosed with endometrial cancer. Blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 16/min. BMI is 44 kg/m². She appears pale. There is continuous, heavy vaginal bleeding on pelvic examination. Pregnancy test is negative. Hemoglobin is 8 g/dL. The patient undergoes emergency dilation and curettage, and her vaginal bleeding resolves. She has an uncomplicated postoperative course. The pathology report shows endometrial hyperplasia without atypia. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d9bc_f904_bc81_e5bac4685dbf_MD0003_00 This patient with abnormal uterine bleeding underwent an emergency dilation and curettage due to heavy vaginal bleeding and hemodynamic instability. Although young patients do not typically undergo endometrial sampling, endometrial tissue is often sent for pathology after surgery. This patient was found to have endometrial hyperplasia, likely due to chronic unopposed estrogen, which causes uncontrolled endometrial proliferation. The most common cause is obesity (as in this patient) due to the peripheral conversion of androgens to estrogens in adipose tissue. Other risk factors include nulliparity and early menarche. Without treatment, endometrial hyperplasia can progress to cancer. In patients (such as this one) who may desire future fertility, initial management is with progestin therapy (eg, progestin-releasing intrauterine device), which counteracts estrogen's effects by inhibiting endometrial proliferation and promoting differentiation. Follow-up is with repeat endometrial biopsy (eg, every 3 months). Patients with stable or improved disease continue progestin therapy, whereas those with progression to cancer typically require hysterectomy (Choice C). progestin-releasing intrauterine device (Choice A) Clomiphene citrate, a selective estrogen receptor modulator, induces ovulation in anovulatory patients (eg, polycystic ovary syndrome) to promote fertility. It is not used in the management of endometrial hyperplasia. (Choices B and E) Endometrial ablation (ie, cauterization of the uterine lining) and uterine artery embolization can treat abnormal uterine bleeding. However, neither procedure treats endometrial hyperplasia because neither reverses endometrial tissue proliferation due to unopposed estrogen. In addition, these procedures can cause intrauterine adhesions, interfering with future biopsies required for disease monitoring. Also, neither procedure is performed in patients who may desire future fertility due to the increased risk of future obstetric complications (eg, spontaneous abortion). Educational objective: Patients with endometrial hyperplasia are at risk for progression to endometrial cancer. Patients who desire future fertility are treated with progestin therapy (eg, progestin-releasing intrauterine device). References: Management of endometrial precancers. (http://www.ncbi.nlm.nih.gov/pubmed/23090535) The efficacy of intrauterine versus oral progestin for the treatment of endometrial hyperplasia. A prospective randomized comparative study. (http://www.ncbi.nlm.nih.gov/pubmed/23724525)

An 18-Year-Old Woman Comes to the Emergency Department Due to Heavy