In a postmenopausal patient with two months of intermittent vaginal spotting, what is the most appropriate next step?

• A. Reassurance
• B. Pap smear
• C. Pelvic ultrasound
• D. Endometrial biopsy

Answer: (C)

Vaginal bleeding after menopause always needs evaluation for endometrial pathology. The best next step is a transvaginal pelvic ultrasound to measure the endometrial stripe and look for uterine abnormalities. This noninvasive test helps determine whether the endometrium is thickened or if there are focal lesions, guiding further management. If the endometrial thickness is beyond a certain threshold (commonly around 4–5 mm) or a lesion is seen, an endometrial biopsy is indicated to obtain tissue for histology and to assess for hyperplasia or cancer. If the stripe is thin and no suspicious features are found, further evaluation may be considered, but persistent bleeding would still warrant investigation. Reassurance isn’t appropriate because postmenopausal bleeding is never normal. Pap smears screen cervical, not endometrial, pathology and don’t address the bleeding workup. Endometrial biopsy is more invasive and is typically guided by ultrasound findings rather than done as the first test.