A 56-year-old woman comes to the office for a routine health maintenance examination. She has been postmenopausal for 4 years and is not using hormone therapy. The patient had a normal screening mammogram last year. Pap testing 3 years ago was normal, but human papillomavirus testing was not performed. The patient has well-controlled hypertension and hyperlipidemia. She had 2 cesarean deliveries and a tubal ligation with her last delivery at age 30. Blood pressure is 130/90 mm Hg and pulse is 72/min. BMI is 38 kg/m². Physical examination is normal. Speculum examination shows no cervical abnormalities. Her Pap test shows endometrial cells and no cervical intraepithelial lesions. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This postmenopausal woman has endometrial cells on Pap testing. The reporting of endometrial cells on Pap tests is age based: Women age <45 do not have endometrial cells reported on their Pap tests because this is a common, benign finding, particularly if Pap testing is performed during the first 10 days of the menstrual cycle. In contrast, women age ≥45 do have endometrial cells reported on their Pap tests because this finding is more concerning for an abnormality. In this age group, particularly in postmenopausal women, endometrial shedding may be due to endometrial hyperplasia/cancer, regardless if the patient has no other symptoms (eg, postmenopausal or abnormal uterine bleeding). The risk of endometrial hyperplasia/cancer is further increased if the patient has additional risk factors (eg, obesity, prior chronic anovulation). Therefore, postmenopausal women with endometrial cells on Pap testing require further evaluation with an endometrial biopsy. Patients diagnosed with endometrial cancer typically undergo a hysterectomy with bilateral salpingo-oophorectomy for treatment (Choice C). (Choices A and D) Colposcopy and loop electrosurgical excision procedure evaluate for cervical cancer in patients with either abnormal cervical cytology (ie, cervical intraepithelial lesions) or gross abnormalities of the cervix (eg, friable or fungating lesion). This patient has a normal-appearing cervix and no cervical intraepithelial lesions on Pap testing. Colposcopy loop electrosurgical excision procedure (Choice E) This patient with no cervical intraepithelial lesions (ie, negative cervical cytology) on Pap testing may resume a normal cervical cancer screening schedule (eg, 3-5 years, depending on presence of HPV cotesting). Repeat cervical cancer screening in 1 year is not indicated in this patient. Educational objective: Postmenopausal women with endometrial cells on Pap testing require an endometrial biopsy to evaluate for endometrial hyperplasia/cancer. 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) Significance of finding benign endometrial cells in women 40-45 versus 46 years or older on Papanicolaou tests and histologic follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/29021811) 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) 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)

A 56-Year-Old Woman Comes to the Office for a Routine