A 55 year old lady presenting to out patient depament with postmenopausal bleeding for 3 months has a 1 x 1 cm nodule on the anterior lip of cervix. Which of the following is the most appropriate investigation to be done subsequently in this care?

**Core Concept:** Postmenopausal bleeding in a 55-year-old lady can be due to various causes, including hormonal imbalances, endometrial hyperplasia, or malignancy. The cervical nodule warrants further investigation to determine its nature.

**Why the Correct Answer is Right:** The correct answer is a Papanicolaou (Pap) test followed by a Hysteroscopy.

**Why Each Wrong Option is Incorrect:**

A. Transvaginal ultrasound (TVUS) is not sufficient to differentiate between benign and malignant lesions. A Pap test is required first.
B. Pap test is essential but not sufficient to guide further management. Hysteroscopy is needed to visualize the uterine cavity.
C. TVUS can be used to evaluate the uterus and cervix, but it cannot provide a definitive diagnosis. A Pap test and hysteroscopy are necessary.
D. Pap test is important but not sufficient to evaluate the cervix, especially in postmenopausal women with cervical lesions. Hysteroscopy is also required.

**Clinical Pearl:** A combination of Pap test and hysteroscopy allows for a more accurate diagnosis and management of postmenopausal women with cervical nodules, as cervical lesions may be missed on transvaginal ultrasound alone.

**Correct Answer:** C. Pap test followed by hysteroscopy.

✓ Correct Answer: B. Punch biopsy