An 88-year-old woman is brought to the emergency department due to postmenopausal bleeding. The patient has had bright red vaginal bleeding and pelvic pain for the past week. She lives in a nursing home and was brought by her caregiver, who states that she is also refusing to bathe or leave her room. Vital signs are normal. BMI is 36 kg/m². The abdomen is soft and nontender. The vulva is edematous and tender and there is a friable posterior perineal laceration. The vagina is dry and pale, and the cervix is stenotic. The remainder of the physical examination is unremarkable. On ultrasound, the uterus is small with a 3-mm endometrial lining, the ovaries are not visualized, and no adnexal masses are present. Which of the following is the best next step in management of this patient?

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Quizplus · Accepted Answer

11ec25c8_d9e2_0d70_bc81_fdf2e4dab33d_MD0003_00 This elderly woman has postmenopausal bleeding (PMB), which can occur due to a variety of etiologies but is most concerning for endometrial cancer, particularly in obese patients (such as this one). Initial evaluation for endometrial cancer is with pelvic ultrasonography, which in this patient revealed a normal endometrial thickness (ie, ≤4 mm), indicating a low likelihood of cancer and therefore no additional need for endometrial biopsy (Choice A). At this point, other causes of PMB require consideration. In the setting of a friable perineal laceration and multiple risk factors (ie, age >80, female, nursing home resident), this patient's PMB is concerning for possible elder sexual abuse. For multiple reasons (eg, fear, cognitive impairment), elderly patients do not typically report their abuse. Instead, they commonly present with somatic symptoms (eg, pelvic pain) and vaginal bleeding (due to trauma to atrophic vulvovaginal tissue). Other red flags include unexplained behavioral changes, particularly surrounding hygiene (eg, refusing to bathe), and signs of genital trauma (eg, perineal laceration, vulvar edema). Concerning findings should prompt sexual abuse screening and be reported immediately to adult protective services. (Choice B) Pelvic MRI can be used to evaluate for causes of pelvic pain (eg, endometriosis) but is not a first-line test for PMB. In addition, further imaging is not necessary for this patient with a normal pelvic ultrasound. (Choice C) A pessary can be used to treat pelvic organ prolapse (POP), which may present with PMB if prolapsed tissue (eg, vaginal mucosa) encounters friction and becomes denuded or friable. However, patients with POP typically have a bulge or mass at the vaginal introitus, which is not seen in this patient. pessary (Choices E and F) Perineal lesions may be caused by vulvar lichen sclerosus, which is treated with topical corticosteroids, or vulvar cancer, which requires vulvar biopsy for diagnosis. However, these conditions are typically preceded by months to years of vulvar pruritis and plaque-like vulvar lesions, not acute-onset vulvar edema and tenderness, as seen in this patient. vulvar lichen sclerosus Educational objective: Sexual abuse of the elderly may present with postmenopausal bleeding, pelvic pain, behavioral changes, and signs of genital trauma (eg, perineal laceration). Concerning findings should prompt sexual abuse screening and be reported immediately to adult protective services. References: ACOG committee opinion no. 568: elder abuse and women's health. (http://www.ncbi.nlm.nih.gov/pubmed/23787938) The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/29878101) Elder abuse. (http://www.ncbi.nlm.nih.gov/pubmed/26559573)

An 88-Year-Old Woman Is Brought to the Emergency Department Due