A 65-year-old woman visits you for the first time to complain of vaginal bleeding for the first time since her natural menopause 15 years ago. The bleeding began 2 weeks ago and is mild in flow. Which of the following is the most critical question to be asked in completing the history?
(A) Are there cramps associated with the bleeding?
(B) How many pads per days are needed to keep abreast of the bleeding?
© Are you taking hormone therapy of any type?
(D) Have you developed light-headedness upon standing after sitting for prolonged periods of time?
(E) Is there bleeding with intercourse?
The answer is C. Postmenopausal bleeding must be assumed to be caused by endometrial carcinoma until proven otherwise. If a postmenopausal woman has been on hormone replacement therapy (HRT), three possible answers each determine different pathways investigation. If the patient has been on estrogen cycled with nrogesterone (HRT), the combination is relatively (but not absolutely)protective against endometrial carcinoma, and early in the course of HRT, there may be mild breakthrough bleeding.If the patient has been taking estrogen replacement or in the past without progesterone and has an intact uterus,the chances of endometrial carcinoma are heightened beyond those inherent in having an intact uterus without hormonal influence. Each of the other questions is relevant but only at a secondary level, after an opinion is formed as to what causes the bleeding. Postural lightheadedness in the present setting is possibly a symptom of relative hypovolemia and therefore anemia caused by blood loss. In the present vignette that is unlikely, given the history of only recent and modest blood loss. Therefore, also unlikely is the relevance of number of pads required. Having associated cramps generally is related to the volume of flow of vaginal bleeding. Bleeding with intercourse is a nonspecific symptom that could relate to vulvar or uterine causes, including cervicitis