From the Guidelines
Postmenopausal bleeding requires prompt evaluation to rule out endometrial cancer, which occurs in approximately 10% of cases, and the most recent guidelines recommend a step-wise approach starting with transvaginal ultrasound (TVUS) to measure endometrial thickness, followed by endometrial sampling if necessary 1. The initial assessment should include a thorough history focusing on bleeding characteristics, risk factors (obesity, diabetes, hypertension, tamoxifen use), and physical examination including pelvic exam.
- Key points to consider in the history include:
- Duration and characteristics of bleeding
- Risk factors for endometrial cancer
- Symptoms suggestive of other conditions (e.g., pelvic pain, vaginal discharge)
- The physical examination should include:
- Pelvic exam to assess for any abnormalities
- Assessment of overall health status
TVUS is the first-line imaging test to measure endometrial thickness; a measurement ≤4mm has a high negative predictive value for malignancy, as supported by the study published in the Journal of the National Comprehensive Cancer Network 1.
- If endometrial thickness is >4mm or bleeding persists despite a thin endometrium, endometrial sampling is necessary, typically via office endometrial biopsy using a Pipelle device.
- For inadequate samples or persistent bleeding, hysteroscopy with directed biopsy should be performed, as recommended by the guidelines 1.
Management depends on the underlying cause:
- Endometrial cancer requires referral to gynecologic oncology
- Endometrial hyperplasia with atypia may be treated with progestin therapy (medroxyprogesterone acetate 10-20mg daily for 14 days/month or levonorgestrel IUD) or hysterectomy
- Atrophic vaginitis can be treated with local estrogen (estradiol vaginal cream 0.01%, 1g inserted vaginally 1-3 times weekly)
- Structural abnormalities like polyps require surgical removal All patients should have follow-up to ensure resolution of bleeding, with persistent or recurrent bleeding warranting further investigation, as emphasized in the guidelines 1.
From the Research
Assessment of Postmenopausal Bleeding
- Postmenopausal bleeding (PMB) is a common gynecologic complaint that requires thorough assessment to rule out underlying malignancies, with endometrial cancer present in about 10% of patients with PMB 2.
- The assessment of PMB involves evaluating the patient's medical history, performing a physical examination, and conducting diagnostic tests such as endometrial biopsy or transvaginal ultrasonography 3.
Diagnostic Tests for Postmenopausal Bleeding
- Endometrial biopsy is a safe and efficient method to evaluate the endometrium for abnormal uterine bleeding and postmenopausal bleeding, with high specificity for diagnosing atypical hyperplasia and endometrial cancer in postmenopausal women 4, 5.
- Transvaginal ultrasonography is also a useful diagnostic tool, allowing patients with an endometrial echo complex thickness of 4 mm or less to be managed expectantly 3, 6.
- Hysteroscopy may be recommended by some authors, but there is strong evidence to suggest that transvaginal ultrasound scanning, with or without endometrial biopsy, is a safe and more cost-effective initial tool in investigating postmenopausal bleeding 6.
Management of Postmenopausal Bleeding
- The management of PMB depends on the underlying cause, with treatment options ranging from expectant management to surgical intervention 2, 3.
- Patients with PMB should be referred for further evaluation if the initial diagnostic tests are inconclusive or if symptoms persist or recur, even if the initial biopsy results are normal 4, 5.
- Topical cervical analgesia and oral nonsteroidal anti-inflammatory drugs can be used to reduce discomfort during endometrial biopsy, and patients should be informed about aftercare instructions and how they will receive their results 4, 5.