A 55-year-old postmenopausal woman on continuous combined menopausal hormone therapy (estradiol 1 mg plus norethisterone acetate 0.5 mg daily) presents with vaginal spotting at her 3-month follow-up. Transvaginal ultrasound shows endometrial thickness of 3 mm. What is the most appropriate next step?
- A Perform endometrial biopsy immediately
- B Stop hormone therapy permanently
- C Reassure the patient and continue the current regimen; breakthrough bleeding is common in the first 6 months ✓
- D Switch to a sequential (cyclic) combined regimen
Correct answer: C. Reassure the patient and continue the current regimen; breakthrough bleeding is common in the first 6 months
Explanation
Breakthrough bleeding is common in the first 3-6 months of continuous combined HRT and, with a thin endometrium (<4-5 mm) and reassuring ultrasound, reassurance is appropriate. Endometrial biopsy is indicated if bleeding persists beyond 6 months, is heavy, or if endometrial thickness is elevated on sequential therapy. Stopping therapy or switching regimens is premature at 3 months without further investigation.
Reference: Scottish Intercollegiate Guidelines Network (SIGN) / NICE NG23, 2015 (updated 2024) ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.