Approach to postmenopausal bleeding Quiz: Ace Your Exams

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A 66-year-old woman presents with two episodes of vaginal spotting over the past two weeks. Past medical history is notable for estrogen-receptor-positive breast cancer two years ago, treated surgically and with adjuvant tamoxifen, which she still takes daily. The patient’s last cervical cancer screening was 3 years ago, and she has never had an abnormal screening test. Vital signs are within normal limits, and body mass index is 27 kg/m². Pelvic exam shows loss of vaginal rugae, and a small, mobile uterus; the adnexa are not palpable. Pelvic ultrasound shows endometrial thickness of 7 mm and homogeneous myometrial echotecture; the adnexa are not visualized. A saline infusion sonohysterogram (SIS) shows a freely mobile filling defect. Which of the following is the best next step in management?

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Hysteroscopy

Office endometrial pipelle biopsy

Hysterectomy with bilateral salpingo-oophorectomy (BSO)

Culture of endocervical secretions

Repeat pap smear and colposcopy