Obstetrics & Gynecology>>>>>Benign and Malignant Disorders of the Breast and Pelvis
Question 59#

A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and does not consume alcohol or drugs. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for mild dysplasia. She has had three cesarean deliveries and a tubal ligation. On physical examination, her uterus is 12 weeks in size, mobile, nontender, and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative.

Which of the following is the most reasonable next step in the evaluation of this patient?

A. Schedule her for a hysterectomy
B. Insert a progesterone-containing intrauterine device (IUD)
C. Arrange for outpatient endometrial ablation
D. Perform an office endometrial biopsy
E. Arrange for outpatient conization of the cervix

Correct Answer is D

Comment:

Given this patient’s age and symptoms, she is probably undergoing menopausal transition or “perimenopause.” Menopause is defined as the absence of menses for 12 months. Women with perimenopausal or postmenopausal bleeding should be evaluated with an endometrial biopsy to rule out hyperplasia or malignancy. A pelvic ultrasound may also be helpful to provide information regarding the size and location of any uterine fibroids. In addition, the endometrial stripe thickness could be evaluated (it should be less than 5 mm in a postmenopausal patient). Endometrial polyps as a cause for her irregular bleeding may be diagnosed with an office hysteroscopy or a saline infusion sonohysterogram. Conization of the cervix is performed for evaluation and treatment of severe cervical dysplasia, and is not indicated in this patient. Progesterone-containing IUDs may be used for contraception or for the treatment of menorrhagia. Endometrial ablation is used to treat heavy menstrual bleeding in premenopausal patients. There is no indication for hysterectomy.