A 52-year-old woman, gravida 3 para 3, comes to the office with irregular vaginal bleeding for the past 8 months. She has had vaginal bleeding for the last 10 days, with passage of large clots on the first 2 days. Today, she has minimal spotting. Previously, menses were regular and occurred every 30 days with 4 days of bleeding. She also has frequent hot flashes, difficulty sleeping, and occasional headaches. The patient was diagnosed with type 2 diabetes mellitus 16 years ago and has good blood glucose control with insulin therapy. She had a tubal ligation after her last pregnancy. The patient's last Pap test was 2 years ago, and there is no history of abnormal results. She has not been sexually active for several years. Family history is significant for breast cancer in her maternal aunt at age 72 but is otherwise noncontributory. She does not use tobacco and has no drug allergies. Blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 16/min. BMI is 35 kg/m². Pelvic examination shows a small amount of dark red blood in the vaginal vault and a multiparous cervix without any visible lesions. On bimanual examination, there is a small, mobile, anteverted uterus with no cervical motion tenderness. There are no adnexal masses. Hemoglobin is 12 g/dL. The patient asks for an explanation of her symptoms and what should be done for evaluation. Which of the following is the most appropriate response?

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Explanation: 11ec2b69_c146_ddce_8f63_3f180e2e1f1c_MD0005_00 Menopause is the permanent cessation of menses due to the loss of ovarian function. The median age of menopause is 51 and the diagnosis is made after >1 year of amenorrhea. Most women experience symptoms of menopause (eg, hot flashes, irregular menses, sleeping difficulties) over several years prior to the cessation of menses. Anovulatory bleeding (eg, heavy, irregular menses) occurs due to oocyte depletion and decreased progesterone secretion. However, the endometrium may continue to proliferate due to unopposed estrogen secretion and progress into endometrial hyperplasia or cancer. Because the risk of endometrial hyperplasia and cancer increases with age and long periods of anovulation, women age >45 with anovulatory bleeding are evaluated for malignancy with an endometrial biopsy. endometrial biopsy (Choice A) This patient's symptoms may be due to menopausal transition. However, she has several risk factors for endometrial hyperplasia and cancer (eg, obesity, age >45, anovulation, diabetes mellitus) and requires evaluation with an endometrial biopsy. (Choice B) After endometrial hyperplasia and cancer are ruled out, treatment of anovulatory bleeding can be offered in the absence of contraindications. Treatment options for anovulatory bleeding include low-dose oral contraceptives, cyclic progestins, or a levonorgestrel-containing intrauterine device, all of which provide endometrial protection. (Choice C) Coagulopathies typically present as heavy, regular menstrual periods rather than anovulatory bleeding. In addition, inherited coagulopathies (eg, von Willebrand disease) typically present in adolescence. Therefore, coagulation factor studies are not indicated for this patient. (Choice E) Menopause is a clinical diagnosis and an FSH level is not required. Educational objective: The menopausal transition is characterized by anovulatory bleeding, hot flashes, and sleeping difficulties prior to the cessation of menses. An endometrial biopsy is indicated in women age >45 with anovulatory bleeding to evaluate for endometrial hyperplasia or cancer. References: Incidence of endometrial hyperplasia. (http://www.ncbi.nlm.nih.gov/pubmed/19393600) Obesity and endometrial hyperplasia and cancer in premenopausal women: A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26829507)

A 52-Year-Old Woman, Gravida 3 Para 3, Comes to the Office