Approach to postmenopausal bleeding Quiz: Ace Your Exams

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A 53-year-old postmenopausal woman presents with vaginal bleeding and pelvic pain for the past week. The bleeding is light to moderate, and the pain is experienced as severe cramping and achiness deep within the pelvis. Previously, when she was menstruating regularly, this patient’s cycles were heavy and painful. Review of systems is notable for constipation. Past medical history is significant for mild hypertension, managed with nifedipine. Her last cervical cancer screening was 3 months ago and showed atypical squamous cells of undetermined significance (ASC-US) with negative human papillomavirus (HPV) testing. The patient reports that both her mother and older sister had hysterectomies in their 40s for heavy bleeding and pelvic pain. Vital signs are stable, and body mass index (BMI) is 29 kg/m2. On exam, the uterus has an irregular contour, is mildly enlarged, and is tender to palpation. No adnexal masses are appreciated, and the cervix and vagina appear grossly normal. Which of the following should be performed next to confirm the most likely underlying pathology? 

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