Kaplan USMLE Step 3: 62-year-old has vaginal bleeding

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

A 62-year-old woman with a past medical history of diabetes and hypertension presents to the office for vaginal bleeding over the past two months. She states that she had her last menstrual period in her early 50s. She was never pregnant and had no children. Physical exam is unremarkable, including no vulvar, vaginal or cervical lesions, and a normal-sized uterus. Which of the following is the next step in the management of this patient?

A. Estrogen cream

B. Estrogen therapy alone

C. Estrogen and progestin therapy

D. Pap smear only

E. Pap smear with endocervical canal curettage

F. Endometrial biopsy

The correct answer is F.

This patient is experiencing postmenopausal bleeding. Post-menopausal bleeding is considered endometrial cancer until proven otherwise. Endometrial cancer is the most common gynecological cancer in the United States. It is associated with states that have unopposed estrogen, such as obesity, nulliparity, early menarche/late menopause, chronic anovulation (i.e., polycystic ovarian syndrome), tamoxifen use, diabetes and hypertension, use of estrogen hormone replacement without progesterone in combination. All patients with postmenopausal bleeding should have an endometrial evaluation as the initial step in management, either via office biopsy or dilation & curettage (D&C). Most patients tolerate endometrial biopsy very well and it is nearly as sensitive as D&C. When patients find it too painful, then D&C is used for endometrial evaluation. Transvaginal ultrasound is another excellent tool to evaluate the endometrial lining in postmenopausal women. Endometrial stripe thickness on ultrasound represents the possibility of thickened and abnormal cells in the uterine lining. Ultrasound, however, does not provide tissue sampling, which is essential.

Choice A, B. Estrogen cream is the treatment of choice for vaginal atrophy. Atrophy of the uterus, endometrium and vagina can lead to vaginal bleeding. The uterus can collapse and the atrophic endometrium can rub against each other, causing inflammation and bleeding. Estrogen cream may be used once the endometrial biopsy returns with atrophic results. Estrogen therapy alone is never given to a woman with a uterus. Unopposed estrogen can lead to endometrial hyperplasia and endometrial cancer.