A 62-year-old post-menopausal woman on long-term tamoxifen for breast cancer presents with per-vaginal bleeding. Pelvic ultrasound shows endometrial thickness of 10 mm. What is the next most appropriate investigation?
- A Diagnostic hysteroscopy with directed endometrial biopsy ✓
- B Serum CA-125 measurement
- C MRI pelvis for staging
- D Repeat pelvic ultrasound in 6 weeks
Correct answer: A. Diagnostic hysteroscopy with directed endometrial biopsy
Explanation
Post-menopausal bleeding in a woman on tamoxifen (which acts as an oestrogen agonist on the endometrium) with an endometrial thickness 5 mm or greater requires histological evaluation. Hysteroscopy with directed biopsy is the gold standard — it allows direct visualisation and targeted sampling. CA-125 is non-specific. MRI is used for staging after histological diagnosis. Delaying investigation risks missing malignancy.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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