Question of the Week # 368

368)  A 58 year old post-menopausal woman presents to your office with intermittent vaginal bleeding for the past 1 month. She has not had a menstrual period for the past six years.  She  has never taken hormone replacement therapy. She reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. A transvaginal ultrasound reveals endometrial stripe thickness of 2mm. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

12 Responses

  1. B

  2. endometrial biopsy

  3. A

  4. a

  5. b

  6. B) Vaginal Estrogen Cream

    • Hi Dr.Red, I don’t see the difference between this and the previous question except the pelvic us finding which is normal.Can you please explain this one??

      • Yes, what do you think – what was missing in the question # 367? Can post-menopausal bleeding be attributed to atrophic vaginitis without further evaluation? Even if the clinical features suggest atrophic vaginitis and even though it’s the most common cause of vaginal bleeding – should not we do some form of investigation ( either trans vaginal u/s or endometrial biopsy) in evaluating post-menopausal bleeding in women > 45 years of age?

  7. b, this is atrophic vaginitis

  8. Thanks Dr.Red!! Now i get it! 🙂

  9. Transvaginal usg – endometrial thickness
    answer B

  10. transvaginal usg <4mm endometrial thickness – has negative predictive value of 98% and does not need to do endometrial biopsy. This lady has feature of atrophic vaginitis.
    Answer B. vaginal estrogen cream

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