A 58-year-old woman comes to the office for her annual examination. The patient is feeling well. She reports 3 days of light vaginal spotting 2 months ago but has had no other episodes. The patient previously had not had a menstrual period for over a year. Her medical history includes symptomatic uterine fibroids, which were controlled with oral contraceptive pills until her early 50s. She has no other chronic medical conditions, and her only surgeries were 2 cesarean deliveries. The patient is current on her cervical cancer screening and has had no abnormal tests. Vital signs are normal, and BMI is 31 kg/m². On speculum examination, there is no blood at the cervical os, and the cervix has no masses or areas of friability. The vagina appears pale and has minimal rugation. On bimanual examination, the uterus has multiple nontender masses consistent with fibroids. There are no areas of nodularity or palpable adnexal masses. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d265_dac2_bc81_7d3443487b04_MD0003_00 Uterine fibroids are a common cause of abnormal uterine bleeding in premenopausal women, typically causing heavy, prolonged menses. This patient's vaginal spotting occurring more than a year after her last menstrual period (ie, postmenopausal bleeding [PMB]) is not likely due to her fibroids, which typically decrease in size and become asymptomatic after menopause (Choice E). Because PMB is a common presenting finding for endometrial hyperplasia or cancer (particularly in older women with obesity), all patients with PMB require endometrial evaluation. Endometrial evaluation for PMB is with either transvaginal ultrasound or endometrial biopsy. Endometrial biopsy can supply a histologic diagnosis, but it is an invasive and uncomfortable procedure. Therefore, PMB can also be evaluated initially with transvaginal ultrasound. Patients with an endometrial thickness ≤4 mm on ultrasound have a low likelihood of endometrial cancer and require no additional evaluation. In contrast, patients with an endometrial thickness >4 mm require an endometrial biopsy to assess for endometrial hyperplasia or cancer. Patients with endometrial hyperplasia may be managed medically (eg, progestin) or surgically (eg, hysterectomy); those with endometrial cancer are typically managed surgically. (Choice A) Serum FSH levels are ordered in patients with abnormal uterine bleeding to differentiate between hypothalamic (eg, functional hypothalamic amenorrhea) and ovarian (eg, perimenopause, primary ovarian insufficiency) causes of irregular bleeding. This patient most likely has an elevated FSH (ie, postmenopausal). However, this test is not useful in the evaluation of her abnormal bleeding. (Choice C) Progestin-containing intrauterine devices can treat endometrial hyperplasia without atypia, which may present with PMB. They are contraindicated in women with unexplained vaginal bleeding; therefore, this patient requires endometrial evaluation as the best next step in management. (Choice D) A progesterone withdrawal test is used in premenopausal women with secondary amenorrhea to determine estrogen status (ie, no withdrawal bleed with low estrogen levels). It is not used in the evaluation of PMB because it cannot distinguish between benign and malignant causes. progesterone withdrawal test Educational objective: Postmenopausal bleeding is a common presenting finding of endometrial cancer. Therefore, all patients with postmenopausal bleeding require endometrial evaluation with either endometrial biopsy or transvaginal ultrasound. References: Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/24377427) Appropriate evaluation of postmenopausal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/30234731) 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 58-Year-Old Woman Comes to the Office for Her Annual