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Review Question - QID 221276

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QID 221276 (Type "221276" in App Search)
A 68-year-old woman presents to her primary care physician for a wellness exam. She noticed mild spotting a few days prior to her presentation. Her last menstrual period was when she was 55 years of age, and she denies any trauma to the area. She is sexually active with 1 male partner and does not use condoms. Her medical history is significant for type 2 diabetes mellitus and hypertension for which she takes metformin and lisinopril. Her blood pressure is 115/70 mmHg, pulse is 85/min, and respirations are 15/min. Pelvic examination demonstrates a normal-sized uterus with no adnexal masses. There are no vulvar, vaginal, or cervical lesions. Stool testing for blood is negative and an endometrial biopsy is performed, which is shown in Figure A. Which of the following is the most appropriate next step in management?
  • A

Anastrozole

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Estrogen-progestin contraceptives

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Hysterectomy

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Megestrol acetate

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Nafarelin

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  • A

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This patient's post-menopausal bleeding was assessed with a biopsy that demonstrated endometrial hyperplasia with atypia. In patients who have completed fertility, a hysterectomy should be performed to prevent progression to endometrial carcinoma.

Endometrial hyperplasia can result in non-neoplastic endometrial gland proliferation and neoplastic endometrial changes. These findings can be determined by endometrial sampling, which dictates management. Postmenopausal women with endometrial hyperplasia without atypia are typically managed with progestin-only therapy. Progestins will oppose the continuous estrogen stimulation of the endometrium. In patients who have atypia, hysterectomy should be performed if fertility is complete. Patients who are younger and seek pregnancy in the future can also be treated with progestins until fertility is complete.

Ferrando et al. review the evidence regarding the diagnosis of endometrial hyperplasia without atypia. They discuss how there is low concordance between hysteroscopic exams and biopsy results. They recommend office hysteroscopy to identify lesions.

Figure/Illustration A is a histological slide demonstrating hyperplasia with atypical cells that have large nuclei and mitotic figures (red circle). These findings are consistent with endometrial hyperplasia with atypia.

Incorrect Answers:
Answer 1: Anastrozole is an aromatase inhibitor. Although there have been studies using this medication in patients with endometrial hyperplasia, this is not standard clinical practice.

Answer 2: Estrogen-progestin contraceptives would not be appropriate in postmenopausal women with endometrial hyperplasia due to the estrogen contained within this medication.

Answer 4: Megestrol acetate is a progestin compound that could be used to treat patients who have hyperplasia without atypia. It is not as effective as hysterectomy.

Answer 5: Nafarelin is a gonadotropin-releasing hormone (GnRH) agonist that has been studied in endometrial hyperplasia. However, it is not standard clinical practice.

Bullet Summary:
The treatment for endometrial hyperplasia with atypia in postmenopausal women is a hysterectomy.

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