A 64-year-old woman, G2P2, comes to the office due to a 2-week history of vaginal bleeding. She describes the bleeding as spotting that occasionally requires a panty liner. Her last menstrual period was 12 years ago, and she did not receive hormone replacement therapy. She has a medical history of obesity, essential hypertension, and type 2 diabetes mellitus. Her current medications include lisinopril and metformin. Vital signs are within normal limits. Pelvic examination shows a normal-appearing vagina and cervix with no visible lesions. A small amount of dark blood is noted in the posterior vaginal fornix. Which of the following is the most appropriate next step in management?
- Endometrial biopsyAnswer
- BCervical cytology
- CReassurance and routine follow-up
- DInitiation of cyclic progestin therapy
- ETotal abdominal hysterectomy
Answer
Endometrial biopsy
The correct answer is endometrial biopsy. Any episode of postmenopausal bleeding must be considered a potential sign of endometrial carcinoma until proven otherwise. This patient has multiple risk factors for endometrial cancer, including advanced age, obesity, and type 2 diabetes (which contributes to hyperestrogenism through the peripheral conversion of androgens to estrogens in adipose tissue). Endometrial sampling is the most appropriate and definitive diagnostic step to rule out malignancy. A transvaginal ultrasound is an acceptable alternative first step (to measure endometrial thickness), but among the choices provided, endometrial biopsy is the definitive next step in management.
Step-by-Step Solution
Key Concept
Any postmenopausal bleeding requires prompt evaluation with an endometrial biopsy (or transvaginal ultrasound) to rule out endometrial carcinoma, especially in patients with risk factors like obesity and diabetes.