An otherwise healthy 61-year-old nulliparous female seeks medical advice due to a recent e… — USMLE Step 2 CK

An otherwise healthy $61$ -year-old nulliparous female seeks medical advice due to a recent episode of brownish vaginal discharge. She states that the discharge appeared on her undergarments intermittently over the last $4$ days. Her last menstrual period occurred a decade ago. She currently takes a daily multivitamin and calcium supplement. Her body mass index is $23 \text{ kg/m}^2$ . On pelvic examination, the external genitalia and vagina are atrophic. A scant amount of dark blood is visible at the cervical os, but the cervix is otherwise grossly normal and smooth. Bimanual palpation reveals a small, anteverted uterus and no palpable adnexal abnormalities. Transvaginal ultrasonography reveals an echogenic endometrial stripe measuring $7 \text{ mm}$ . Which of the following is the most appropriate next step in the management of this patient?

Endometrial biopsyAnswer
B
Repeat transvaginal ultrasound in 6 months
C
Hysteroscopic endometrial ablation
D
Empirical cyclic progestin therapy
E
Total abdominal hysterectomy

Answer

Endometrial biopsy

Postmenopausal bleeding is the cardinal symptom of endometrial cancer, present in up to 90% of cases. The initial evaluation typically involves a transvaginal ultrasound. An endometrial thickness

> 4 \text{ mm}

in a postmenopausal patient requires histologic sampling to evaluate for endometrial hyperplasia or carcinoma. Therefore, an endometrial biopsy is the definitive next step.

Step-by-Step Solution

Identify the primary clinical presentation.

The patient is experiencing postmenopausal bleeding a decade after her last menstrual period.

Any vaginal bleeding in a postmenopausal woman is considered abnormal and raises high suspicion for endometrial pathology, including malignancy.

Evaluate the imaging findings in the context of the presentation.

Transvaginal ultrasonography shows an endometrial thickness of

7 \text{ mm}

In postmenopausal women, an endometrial stripe thickness of

\leq 4 \text{ mm}

generally excludes malignancy. A thickness

> 4 \text{ mm}

is abnormal and necessitates further investigation.

Determine the definitive next step in management.

Tissue sampling via an endometrial biopsy must be performed.

Because the imaging is abnormal and the patient is symptomatic, histologic confirmation is required to rule out endometrial hyperplasia and adenocarcinoma before any medical or surgical treatment is initiated.

Key Concept

Evaluation and management of postmenopausal bleeding

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