A 63-year-old woman comes to the office for evaluation of postmenopausal bleeding. The patient initially had post-coital bleeding only, but it has become more frequent despite the use of over-the-counter vaginal lubricants and moisturizers. For the last month, the patient has had daily vaginal spotting and is beginning to have pain with intercourse. Until 6 months ago, she had not been sexually active for 10 years. The patient has had no routine health care since the birth of her children over 30 years ago. She smokes a pack of cigarettes a day. BMI is 30 kg/m². The vagina appears atrophic with minimal rugation and has a 1-cm ulcerated lesion in the upper third of the posterior wall. There is a malodorous watery discharge in the vagina. Numerous squamous epithelial cells with rare leukocytes are seen on wet mount microscopy. Potassium hydroxide test is negative. Pelvic ultrasound shows an anteverted uterus with a 3-mm endometrial stripe. Which of the following is the best next step in management of this patient?

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11ec25c8_d9f2_131c_bc81_eb9a5fa2e513_MD0003_00 This patient's vaginal bleeding, malodorous discharge, and ulcerated vaginal lesion are concerning for vaginal squamous cell carcinoma. Additional clinical features may include pelvic pain, urinary symptoms (eg, hematuria), and bulk symptoms (eg, constipation), which are suggestive of metastatic disease. Risk factors for vaginal cancer are similar to those of cervical cancer and include chronic tobacco use, persistent human papillomavirus infection, and age >60. Lesions typically appear as an irregular plaque or ulcer located in the upper third of the posterior vagina. In this patient, the best next step in management is biopsy of the lesion. The biopsy evaluates the depth of invasion of atypical cells and differentiates between vaginal intraepithelial neoplasia (ie, noninvasive) and vaginal cancer (ie, invasive). Patients with noninvasive disease can be treated conservatively with topical therapy or a wide local excision (Choice F). In contrast, those with invasive disease require an extensive procedure (ie, radical hysterectomy, vaginectomy, pelvic lymph node dissection) and/or chemoradiation. (Choice A) Endometrial biopsy is indicated to evaluate for endometrial cancer in women with postmenopausal bleeding and an endometrial lining >4 mm on ultrasound. This patient has a thin endometrium and therefore does not require further evaluation for endometrial cancer. (Choice B) Oral metronidazole is used to treat bacterial vaginosis, which typically presents with a malodorous vaginal discharge. This patient had a negative potassium hydroxide test and no clue cells on wet mount microscopy, making this diagnosis unlikely. (Choice C) Topical corticosteroids are the treatment for desquamative inflammatory vaginitis, which often presents with copious watery discharge. In contrast to this patient, those with desquamative inflammatory vaginitis have an inflamed erythematous vagina on pelvic examination and a predominance of leukocytes on wet mount microscopy. (Choice E) Vaginal estrogen therapy is indicated for atrophic vaginitis, which can cause vaginal bleeding, malodorous discharge, and dyspareunia. However, atrophic vaginitis rarely causes ulcerative lesions and requires further evaluation prior to estrogen therapy. Educational objective: Vaginal squamous cell carcinoma typically presents with vaginal bleeding, malodorous discharge, and an irregular lesion. Risk factors include age >60, chronic tobacco use, and persistent human papillomavirus infection. Diagnosis is by biopsy of the lesion, which determines the depth of invasion of atypical cells. References: Squamous cell carcinoma of the vagina: natural history, treatment modalities and prognostic factors. (http://www.ncbi.nlm.nih.gov/pubmed/25476235) Primary carcinoma of the vagina. (http://www.ncbi.nlm.nih.gov/pubmed/20658716)

A 63-Year-Old Woman Comes to the Office for Evaluation of Postmenopausal