7 4 year old woman, gravida 5 para 5, comes to the office due to vaginal spotting and discharge for several months

7 4 year old woman, gravida 5 para 5, comes to the office due to vaginal spotting and discharge for several months. She reports a
mass coming out of her vagina. She is now having difficulty defecating; increased straining causes the mass to increase in size. The
patient has hypertension, type 2 diabetes mellitus, and NYHA class Ill heart failure. Her last hemoglobin A1c was 11.8. She had 5
spontaneous vaginal deliveries and has no history of abnormal Pap tests. The patient has a 40-pack-year smoking history Blood
pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 16/min. Oxygen saturation is 89% on room air. BMI is 41 kg/m2

Cardiopulmonary examination reveals decreased breath sounds bilaterally. The abdomen is nontender and has no palpable masses.
Pelvic examination reveals the cervix at the level of the vaginal introitus. The vaginal mucosa is thin with multiple areas of excoriation
and erosion. Ultrasonography reveals a thin endometrial stripe Which of the following is the best next step in management of this
patient?

  • QA Endometrial biopsy
  • 0 B. Hormone replacement therapy
  • 0 C. Pelvic floor muscle exercises
  • 0 D. Pessary fitting
  • 0 E. Surgical repair

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