A 44-year-old gravida 2, para 2 presents for evaluation of a four-month history of intermenstrual bleeding. Menses occur at regular, 28-day intervals, and last 4–5 days with recently heavy flow. For the past four months she has had painless intermenstrual bleeding at unpredictable times throughout her cycle. Intermenstrual bleeding ranges from spotting to moderate flow and lasts one to two days. Her last menstrual period was three weeks ago. She is up to date on cervical cancer screening and routine gynecologic care. Medical history is significant for hypothyroidism, two prior cesarean deliveries, and bilateral tubal ligation. She is on levothyroxine and denies any medications allergy. She is sexually active with one male partner and denies any history of sexually transmitted infections or recent exposures.