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A 31-year-old woman presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to 3 months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are planning to have children in the near future. What is the next best step?
Total abdominal hysterectomy with bilateral salpingo-oopherectomy
Partial, cervix-sparing hysterectomy
Start combination estrogen and progestin therapy
Start progestin-only therapy
Observation with annual endometrial biopsies
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