Question of the Week # 369

369)  A 56 year old post-menopausal woman presents to your office for evaluation of occasional vaginal spotting for past two weeks. She has not had a menstrual period for the past five years.  She  has never taken hormone replacement therapy.  She denies any fever or dysuria. She is sexually active and enjoys it. Her bleeding is unrelated to sexual activity. She has no other past medical problems and otherwise, feels healthy. Physical examination is unremarkable. A transvaginal ultrasound reveals endometrial stripe thickness of 3mm. She is reassured and sent home. Two months later she is re-evaluated in your office for persistent vaginal spotting that has not resolved. She has seen another primary care physician a week ago for a second opinion because she was concerned. He repeated a transvaginal ultrasound which showed endometrial stripe thickness unchanged at 3 mm.  Which of the following is the most appropriate management recommendation?

A) A trial of vaginal estrogen

B) Reassure and Observe

C) Vaginal pH testing

D) Oral Progestin Trial

E) Endometrial Biopsy

13 Responses

  1. e

  2. b

  3. Atrial or vaginal estrogen ans. A ?

  4. E) Endometrial Biopsy

  5. e

  6. E) Endometrial Biopsy

  7. e

  8. ANS. E :

    For women not on HRT, any postmenopausal bleeding requires endometrial biopsy……….

    Woman on cyclic HRT, we need to obtain endometrial biopsy if bleeding occurs irregularly and/or unpredictably, or if bleeding is unusually heavy or prolonged

    With continuous HRT, we need to obtain endometrial biopsy if bleeding is heavy or extended, or if light bleeding or spotting continues more than 12 months after starting therapy

    For women using unopposed estrogen, we should evaluate any vaginal bleeding with an endometrial biopsy

  9. ACOG Recommendations

    Any vaginal bleeding in a postmenopausal woman requires assessment to exclude malignancy.
    Women with postmenopausal uterine bleeding may be assessed initially with either endometrial biopsy or transvaginal ultrasonography; this initial evaluation does not require performance of both tests.
    When endometrial biopsy is performed and tissue is reported as insufficient for diagnosis, some further investigation is necessary and transvaginal ultrasonography may be performed.
    When transvaginal ultrasonography is performed for patients with postmenopausal bleeding and an endometrial thickness of less than or equal to 4 mm is found, endometrial sampling is not required.
    Endometrial thickness of greater than 4 mm in a patient with postmenopausal bleeding should trigger alternative evaluation (such as sonohysterography, office hysteroscopy, or endometrial biopsy), as should an inability to adequately visualize thickness.
    Meaningful assessment of the endometrium by ultrasonography is not possible in all patients. In such cases, alternative assessment should be completed.
    When bleeding persists despite negative initial evaluations, additional assessment usually is indicated.
    The significance of an endometrial thickness of greater than 4 mm in an asymptomatic, postmenopausal patient has not been established, and this finding need not routinely trigger evaluation.
    Her bleeding does not relate with sexual activity —> atrophic vaginitis is unlikely a) is out. She was sent home with reassurance and observation but still bleeding. I don’t want to sent her with reassurance again. so b) is out. oral progestin trial done in premenopausal women with anovulatory cycle. post menopausal women has deficient estrogen so d) is out.
    She doesn’t have vaginal infection, no need to do vaginal pH or wet mount, or KOH test.
    only e left. It is reasonable because according to ACOG, when bleeding persists despite negative initial evaluations, additional assessment usually is indicated.
    Answer would be EE.
    please tell me if I got wrong.

  10. is it correct

  11. Is it E?

    Endometrial biopsy is required if:
    • The endometrial lining is thicker than 4 mm
    • The endometrium shows diffuse or focal increased echogenicity (heterogeneity)
    • The endometrium is not adequately visualized
    • The woman has persistent bleeding.

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