Question of the Week # 370

370)  A 47  year old woman presents to your office with complaints of change in her menstrual cycles. Lately, she has had very irregular periods and sometimes, they have been heavy. She reports her cycles have been irregular for past 8 months. Her most recent period was two weeks ago and was much heavier than usual. She also has started experiencing hot flashes. She is not on oral contraceptive pills. She does not smoke or use alcohol. She has no other past medical problems and otherwise, feels healthy. Her family history is unremarkable. Physical examination including pelvic examination is unremarkable. A urine pregnancy test and Thyroid stimulating hormone are within normal limits. Urinalysis is normal. Which of the following is the most appropriate initial step in management?

A) Reassure that she is menopausal transition and observe

B) Obtain Serum FSH level

C) Start Oral Contraceptive Pills

D) Endometrial Biopsy

E) Oral Progestin

17 Responses

  1. a

  2. A

  3. Since the bleeding patern has changed Endometrial biopsy may be the next approperate management. Ans D

  4. B) Obtain Serum FSH level

    • She is probably going through perimenopause during when irregular periods is common.When bleeding is heavy or frequent (less than every 3 weeks)it should be investigated.First step is to confirm menopause with Serum FSH(will be high) then US- if endometrial stripe thickness is >/= 5 mm do biopsy.

  5. b

  6. A, this is climacteric

  7. endometrial biopsy i guess

  8. A

  9. B)FSH

  10. B

  11. Ans. D : she is presenting with features of DUB & since they already ruled out pregnancy & thyroid dysfunction, the only thing missing is PROLACTINE so if its in the option I would choose it…… Now comes whats next ….she is older than 35….. so we need to rule out endometrial dysplasia.

    If that come back negative….then we will start her on OCP. PLEASE correct me if I am wrong

  12. DUB + ANY of the following : [[[[ Morbid Obesity, DM or chronic HT, age>35, longstanding an ovulation]]]]] ———-> ENDOMETRIAL BIOPSY

  13. I think D. Let’s exclude endometrial cancer first!

  14. Dr Red —what is the explanation??

  15. http://www.aafp.org/afp/1999/1001/p1371.html
    Initial approach to perimenopausal bleeding
    1)history,PE with/without CBC
    2)check bhcg, gentital tract lesion, uterine enlargement
    Genital tract lesion + , treat biopsy
    uterine enlargement+ —> USG —> confirm diagnosis
    not confirm dx —> hysteroscopy
    bhcg + –> preg
    bhcg – —> endometrial biopsy,
    normal pathology –> observation
    endometrial hyperplasia —> cyclical progesterone Rx
    endometrial ca/atypia —-> refer the patient for Tx

    Answer : D

  16. we are ignoring h/o hot flashes here
    doesnt it point to menopause
    so check fsh

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