Mayo Clinic 34th Annual Internal Medicine Board Review 2025 (Only Qbank)

Sample Quetsion

Question 95:

A 42-year-old woman with long history of obesity (BMI 30 kg/m²) presents to clinic for a follow-up on abnormal uterine bleeding. Prior to these episodes, she had heavy menstrual periods lasting 4 days with dysmenorrhea. Pelvic exam during her initial evaluation 6 months ago was normal. Her Pap smear and results of a transvaginal ultrasound were also negative. Her complete blood count, coagulation labs, and thyroid-stimulating hormone levels were normal. Since then, she has had three more episodes of bleeding between periods.

She denies any easy bruising or other bleeding problems. She does not have any other medical problems and does not take any medications.
Which of the following is the most appropriate next step in management of this patient?
a.
Perform an endometrial biopsy
b.
Place a progesterone intrauterine device
c.
Start a course of naproxen
d.
Recommend uterine artery embolization
Answer:
a.
Perform an endometrial biopsy

Explanation: Abnormal uterine bleeding (AUB) is defined as uterine bleeding in the absence of pregnancy that is abnormal in regularity, volume, frequency, or duration. Causes of AUB are now classified as structural (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia) or non-structural related abnormalities (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified).

The patient should be evaluated next with an endometrial biopsy given persistent AUB and obesity.

Endometrial biopsy should be the first line test in patients 45 years or
older due to the increasing risk of endometrial cancer.

In those younger than 45 years, endometrial biopsy is also recommended if there is a history of exposure to unopposed estrogen (polycystic ovarian syndrome, obesity), those who fail medical management and have persistent AUB, or those with endometrial abnormalities on ultrasound. Uterine artery embolization is typically utilized for heavy bleeding associated with uterine fibroids. Given the normal pelvic exam and ultrasound, fibroids are likely not the cause of the patient’s presentation. Placement of a progesterone intrauterine device and NSAIDs will likely both be effective for decreasing bleeding in non-anatomic causes of AUB. However, endometrial biopsy should be performed to rule out AUB related structural abnormalities first.

Matthews ML. Abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol Clin North Am. 2015;42(1):103-115