Obstetrics and gynaecology · Easy
This case is fictional and exists for study. It describes no real patient.
58 years · female
A 58-year-old woman presents to the general practice clinic complaining of a two-week history of light, painless vaginal bleeding. Her last natural menstrual period was six years ago. She has a history of essential hypertension and a body mass index (BMI) of 32 kg/m². Her regular medication is amlodipine. She denies pelvic pain, fever, weight loss, or postcoital bleeding. Abdominal examination is unremarkable. Speculum examination demonstrates a normal-appearing cervix with a minimal amount of dark blood visible in the vaginal vault. Bimanual examination reveals an anteverted, non-tender uterus of normal size with no palpable adnexal masses.
Vital signs
- HR
- 76 bpm
- BP
- 134/84 mmHg
- RR
- 15/min
- Temp
- 36.7 °C
- SpO₂
- 99%
Examination findings
- Normal-appearing cervix with small volume dark blood in the vaginal vault
- Anteverted, non-tender uterus of normal size without adnexal tenderness or mass
Investigations
| Haemoglobin | 12.5 g/dL | reference: 12.0-15.5 |
| Platelets | 250 10^9/L | reference: 150-400 |
Question 1 of 3
Which of the following is the most appropriate initial investigation for this patient?
Transvaginal ultrasound (TVUS) is the non-invasive initial investigation of choice for postmenopausal bleeding to assess endometrial thickness. An endometrial thickness of 4 mm or less has a high negative predictive value for endometrial cancer. CT scanning is not first-line for evaluating the endometrium. Hysteroscopy with endometrial biopsy is indicated if the ultrasound shows endometrial thickness >4 mm, but endometrial ablation is a surgical procedure for heavy menstrual bleeding, not a diagnostic test. Serum CA-125 is used primarily for suspected ovarian carcinoma.
Teaching point: Transvaginal ultrasound is the first-line diagnostic investigation to evaluate endometrial thickness in postmenopausal bleeding.
Question 2 of 3
A transvaginal ultrasound is performed and demonstrates an endometrial thickness of 7 mm. What is the next best management step?
In a postmenopausal woman presenting with bleeding, an endometrial thickness greater than 4 mm on transvaginal ultrasound requires tissue diagnosis via an endometrial biopsy (e.g., outpatient Pipelle sampling or hysteroscopy with biopsy) to rule out endometrial carcinoma or hyperplasia. Reassurance or repeat imaging is unsafe given the risk of malignancy. Hysterectomy is a definitive surgical treatment performed after a histological diagnosis is established, not an initial step.
Teaching point: An endometrial thickness greater than 4 mm on ultrasound in postmenopausal bleeding requires an endometrial tissue biopsy.
Question 3 of 3
Histological sampling demonstrates endometrial hyperplasia without atypia. Edit 1 — replace the question prompt at line 74: "prompt": "Histological sampling demonstrates endometrial hyperplasia without atypia. Which of the following is the strongest risk factor for the development of this condition?" (Do not alter the vignette, the options, or answer_index. This removes the "in her history" presupposition, leaves Multiparity as a legitimate protective-factor distractor that the explanation already handles, and invents no obstetric data.) Edit 2 — same file, explanation at line 82, correct the US spelling to British for a PLAB item: "...adipose tissue contains aromatase, which converts adrenal androgens into oestrone."
Obesity is a major risk factor for endometrial hyperplasia and adenocarcinoma because adipose tissue contains aromatase, which converts adrenal androgens into estrone. In postmenopausal women, this produces an excess of un-opposed oestrogen that stimulates continuous endometrial proliferation. Amlodipine and hypertension do not directly cause endometrial proliferation. Multiparity is actually protective against endometrial disease due to high progesterone levels during pregnancy.
Teaching point: Obesity causes increased peripheral conversion of steroids to oestrogen, leading to unopposed endometrial stimulation and hyperplasia.
Key learning points
- Postmenopausal bleeding must always be investigated urgently to exclude endometrial carcinoma.
- Transvaginal ultrasound is the initial imaging modality; an endometrial thickness >4 mm mandates an endometrial biopsy.
- Unopposed oestrogen exposure due to obesity significantly increases the risk of endometrial hyperplasia and carcinoma.
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