Examkin

Question

Difficulty: MediumGynecologic Oncology

A 72-year-old resident of an assisted living facility is brought to the gynecology clinic by her daughter due to the recent discovery of blood-stained undergarments. The daughter noticed the spotting on three separate occasions over the past month. The patient has a medical history of mild Alzheimer dementia and hypertension, and she denies any abdominal or pelvic pain. Vital signs are within normal limits. On physical examination, the physician notes mild anterior vaginal wall prolapse and a smooth, 1.5-cm red, friable mass protruding through the external cervical os. A transvaginal ultrasound is performed during the visit, demonstrating normal-appearing ovaries and an endometrial thickness of 8 mm. Which of the following is the most appropriate next step in the management of this patient?

  1. Endometrial biopsyAnswer
  2. B
    Cervical polypectomy and observation
  3. C
    Initiation of topical vaginal estrogen therapy
  4. D
    Reassurance and repeat transvaginal ultrasound in 6 months
  5. E
    Magnetic resonance imaging of the pelvis

Answer

Endometrial biopsy
The correct next step is to perform an endometrial biopsy. This patient presents with postmenopausal bleeding and a thickened endometrial stripe (8 mm). According to current clinical guidelines, any endometrial thickness greater than 4 mm in a patient with postmenopausal bleeding requires immediate tissue sampling to evaluate for endometrial hyperplasia or carcinoma. The visualized cervical polyp is a 'red herring'—while it may be contributing to the spotting, it does not exempt the clinician from investigating the abnormally thickened endometrium.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has new-onset postmenopausal bleeding.
Postmenopausal bleeding is the classic presenting symptom of endometrial cancer and always warrants thorough evaluation.
2
Evaluate the imaging results.
Transvaginal ultrasound reveals an endometrial thickness of 8 mm.
An endometrial stripe greater than 4 mm in a postmenopausal woman with bleeding is considered abnormal and highly suspicious for underlying pathology.
3
Synthesize findings to determine the next management step.
Histologic evaluation via endometrial biopsy is required.
The presence of a concurrent cervical polyp, while a potential source of bleeding, does not negate the absolute requirement to sample an abnormally thickened endometrium.

Key Concept

Evaluation of Postmenopausal Bleeding
Rate this question

Topics

Gynecologic Oncology

More questions from this topic