What is the best next step in management for a 45-year-old woman with a Pap test showing benign-appearing endometrial cells and no intraepithelial lesions?

From the Guidelines

The best next step in management of this patient's Pap test results is no additional follow-up or evaluation. The finding of benign-appearing endometrial cells on a Pap test during menstruation in a premenopausal woman is considered a normal variant and does not require further investigation, as noted in the 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests 1. Since this 45-year-old woman is currently menstruating (her last period started 2 days ago), the presence of endometrial cells on her Pap test is expected as these cells are naturally shed during menstruation. Additionally, she has no concerning clinical features such as abnormal bleeding, pelvic pain, or other gynecologic symptoms that would warrant further evaluation. She is at low risk for endometrial pathology given her age, normal BMI, regular menses, and absence of risk factors for endometrial cancer. In premenopausal women with regular cycles, endometrial cells are only considered abnormal when found outside the expected time of menstruation (typically days 8-21 of the cycle) or when they appear atypical, as discussed in the context of cervical cancer screening in average-risk women 1. The patient should simply continue with routine gynecologic care and age-appropriate cancer screening. Key points to consider in this case include:

• The patient's age and menstrual status
• The absence of risk factors for endometrial cancer
• The expected shedding of endometrial cells during menstruation
• The low risk of endometrial pathology in premenopausal women with regular cycles.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Profile

• The patient is a 45-year-old woman with no chronic medical conditions and no history of abnormal Pap tests.
• She is taking combined estrogen/progestin oral contraceptive pills and has regular monthly menses.
• Her last menstrual period started 2 days ago, and her pelvic examination shows a multiparous cervix without lesions.

Pap Test Results

• The patient's Pap test demonstrates benign-appearing endometrial cells and no intraepithelial lesions.
• The presence of benign-appearing endometrial cells in a premenopausal woman is not uncommon and can be associated with various conditions, including endometrial hyperplasia 2.

Management Options

• The management of the patient's Pap test results depends on various factors, including her age, medical history, and the presence of any symptoms.
• Endometrial biopsy is a safe and efficient method to evaluate the endometrium for a variety of indications, including abnormal uterine bleeding and postmenopausal bleeding 3.
• However, the patient is premenopausal and asymptomatic, which may affect the decision to perform an endometrial biopsy.
• Studies have shown that the frequency of adequate endometrial biopsy in premenopausal women with benign endometrial cells on Pap test is relatively low 4.

Next Steps

• Given the patient's age and asymptomatic status, a conservative approach may be considered, with monitoring of her symptoms and follow-up Pap tests.
• However, if the patient's symptoms change or if she develops abnormal uterine bleeding, an endometrial biopsy may be necessary to rule out endometrial hyperplasia or malignancy 5.
• The decision to perform an endometrial biopsy should be based on individual patient factors, including her medical history, symptoms, and risk factors for endometrial cancer.
• A simplified classification system for endometrial hyperplasia may aid in improving interobserver reproducibility and guiding management decisions 6.