American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the initial assessment for postmenopausal women experiencing vaginal bleeding?

1. Physical examination only

2. Transvaginal ultrasonography or endometrial biopsy

3. Hormonal therapy immediately

4. Pelvic MRI scan

The correct answer is: Transvaginal ultrasonography or endometrial biopsy

In the initial assessment of postmenopausal women experiencing vaginal bleeding, transvaginal ultrasonography or endometrial biopsy is the most appropriate step. This is due to the need to evaluate the endometrial lining and determine if there are any abnormalities such as hyperplasia or endometrial cancer, which are significant concerns in this population. The use of transvaginal ultrasound allows for a visualization of the endometrial thickness—typically, an endometrial thickness of greater than 4 mm in a postmenopausal woman warrants further investigation. Performing an endometrial biopsy provides histological evaluation, establishing a definitive diagnosis of any pathological conditions present. Given that postmenopausal bleeding can have serious underlying causes, the accuracy and efficacy of these diagnostic methods are crucial. The other approaches mentioned do not offer immediate or adequate assessment for this situation. For instance, a physical examination alone will not provide enough information about the endometrial lining. Immediate hormonal therapy without initial assessment could mask significant underlying issues. An MRI is generally not the first-line imaging modality for this condition, as ultrasound provides sufficient initial information.