28. A 52-year-old woman comes to the physician for a routine health maintenance examination. One year ago, she was started on daily hormone replacement therapy (estradiol and medroxyprogesterone) to treat severe vasomotor symptoms. But she has been taking the medroxyprogesterone intermittently because of severe depression and mood changes when taking it. Menses had stopped for the first 6 months on the original regimen, but since she changed her regimen, she has had vaginal spotting two to three times monthly. Which of the following is the most appropriate next step in management?

1.Discontinue medroxyprogesterone therapy only
2.Increase the dosage of estradio
3.Add an antidepressant to the medication regimen
4.Endometrial ablation
5.Endometrial biopsy

The answer is 5. Endometrial biopsy. In a any woman >35 years of age with evidence of Dysfunctional Uterine Bleeding it is always mandatory to perform an endometrial biopsy, more so in a post menopausal woman. Although her spotting could be from withdrawal bleeding due to cessation of medroxyprogesterone, it is highly imperative to rule out endometrial hyperplasia (or worse, carcinoma) with a biopsy.

1. and 2. Discontinuation of medroxyprogesterone or increasing the dose of estradiol should not be done as it will increase the chances for endometrial hyperplasia from unopposed or excessive estrogen stimulation.

3. An antidepressant will be indicated only if signs and symptoms of major depression are present.

4. Endometrial ablation is contraindicated at this point as it will interfere with the findings of an endometrial biopsy in the future.

hi my exam is due this month I would like to know which NBME forms I should take before exam and If anyone has those forms offline)kindly send em to me at the following address.thanks
[email protected]