A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An office endometrial biopsy shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound demonstrates multiple, large uterine fibroids.
Which of the following is the best next step in management for this patient?
A. MyomectomyPostmenopausal patients with atypical complex hyperplasia of the endometrium have a 25% to 30% risk of having an associated endometrial carcinoma in the uterus. Given the high risk of malignancy, the next best step in management is hysteroscopy with dilation and curettage. This allows the entire uterus to be evaluated for malignancy. If there is no malignancy on the D&C pathology, the next best step in a patient who has completed childbearing or who is menopausal is simple hysterectomy. If a malignancy is identified on the D&C specimen, the patient would be referred to a gynecologic oncologist for a staging surgery, which includes hysterectomy. If hysterectomy is not medically advisable, progesterone treatment can be used. Myomectomy, or surgical removal of fibroid, is a treatment option for premenopausal women with symptomatic uterine fibroids. There is no role for the use of oral contraceptives in the treatment of postmenopausal bleeding.