A 52-year-old obese woman on tamoxifen for breast cancer for 5 years develops postmenopausal bleeding. Pelvic ultrasound shows endometrial thickness of 10 mm. What is the MOST appropriate next step?

• A Hysteroscopy and endometrial biopsy ✓
• B Reassure — endometrial thickness up to 12 mm is normal in tamoxifen users
• C Pelvic MRI to characterize the endometrium
• D Discontinue tamoxifen and repeat ultrasound in 3 months

Explanation

Tamoxifen has a paradoxical agonist effect on the endometrium in post-menopausal women, increasing risk of endometrial polyps, hyperplasia, and carcinoma. Any postmenopausal bleeding in a tamoxifen user mandates investigation regardless of endometrial thickness — hysteroscopy with directed biopsy is the gold standard as it allows direct visualisation and targeted sampling of abnormal areas. MRI is complementary but not the primary diagnostic tool. Discontinuing tamoxifen without histological diagnosis is not appropriate.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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