What is the workup for vaginal bleeding in a 70-year-old female (F)?

From the Guidelines

The workup for vaginal bleeding in a 70-year-old female should begin with a thorough history and physical examination, followed by transvaginal ultrasound to evaluate endometrial thickness and identify any structural abnormalities, as recommended by the most recent guidelines 1. The initial evaluation should focus on ruling out endometrial cancer, which is a significant concern in postmenopausal women with vaginal bleeding.

• A thorough history and physical examination are essential to identify any risk factors for endometrial cancer, such as obesity, hypertension, or a family history of cancer.
• Transvaginal ultrasound is the preferred imaging modality to evaluate endometrial thickness, with a threshold of >4mm indicating the need for further evaluation 1.
• Endometrial biopsy is essential and should be performed for any postmenopausal woman with vaginal bleeding, as it is the most accurate method to diagnose endometrial cancer.
• Laboratory tests should include a complete blood count to assess for anemia, thyroid function tests, and a pregnancy test despite low likelihood.
• Cervical cytology (Pap smear) and HPV testing are important to evaluate for cervical pathology, although the risk of cervical cancer is lower in this age group, according to the american cancer society guidelines for the early detection of cancer 1. If the endometrial stripe is thickened (>4mm) on ultrasound, even with a negative biopsy, further evaluation with hysteroscopy and directed biopsy may be necessary.
• Additional imaging such as CT or MRI may be indicated if there is concern for advanced disease. This comprehensive approach is critical because postmenopausal bleeding is associated with approximately a 10% risk of endometrial cancer, with risk increasing with age, as stated in the acr appropriateness criteria® abnormal uterine bleeding 1. Atrophic vaginitis is the most common benign cause, but malignancy must be excluded before attributing bleeding to benign etiologies. Timely evaluation is essential as early detection of gynecologic malignancies significantly improves outcomes.

From the FDA Drug Label

Adequate diagnostic measures, including directed or random endometrial sampling when indicated, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding Have your healthcare provider check any unusual vaginal bleeding to find out the cause. Vaginal bleeding after menopause may be a warning sign of cancer of the uterus (womb).

The workup for vaginal bleeding in a 70-year-old female should include adequate diagnostic measures to rule out malignancy, such as:

• Directed or random endometrial sampling when indicated
• Checking any unusual vaginal bleeding to find out the cause, as it may be a warning sign of cancer of the uterus (womb) 2, 2

From the Research

Evaluation of Postmenopausal Bleeding

The workup for vaginal bleeding in a 70-year-old female involves several steps to rule out endometrial cancer and other potential causes.

• Clinical risk factors for endometrial cancer, including age, obesity, use of unopposed estrogen, and family history of gynecologic malignancy, should be considered when evaluating postmenopausal bleeding 3.
• Transvaginal ultrasonography is a reasonable initial evaluation for postmenopausal bleeding, and an endometrial thickness of 4 mm or less has a high negative predictive value for endometrial cancer 3, 4.

Transvaginal Ultrasonography

• Transvaginal ultrasonography can measure endometrial thickness, which is used as a biomarker for estrogen exposure 5.
• An endometrial thickness of less than or equal to 4 mm is associated with a low risk of endometrial cancer, and further testing may not be necessary in asymptomatic women 4, 6.
• However, if the endometrial thickness is greater than 4 mm, further testing such as endometrial biopsy or hysteroscopy with dilation and curettage may be warranted 3, 6.

Endometrial Biopsy and Hysteroscopy

• Endometrial biopsy is an important diagnostic tool for evaluating postmenopausal bleeding, but it may not always detect endometrial cancer or polyps 4, 6.
• Hysteroscopy with dilation and curettage may be necessary to confirm the diagnosis and rule out other potential causes of bleeding 3, 6.

Risk Factors and Associations

• Factors such as body mass index (BMI), hormone replacement therapy (HRT) use, and history of uterine fibroids are associated with increased endometrial thickness 5.
• Current HRT use and higher BMI are independently associated with thicker endometrium, suggesting a potential link to estrogen exposure 5.