From the Guidelines
For post-menopausal bleeding with a 5 mm endometrial lining, endometrial biopsy is recommended as the next step. This is because an endometrial thickness of 5 mm or greater in a post-menopausal woman with bleeding is considered abnormal and requires further evaluation to rule out endometrial cancer or hyperplasia, as stated in the study by 1.
Procedure
- Perform an in-office endometrial biopsy using a Pipelle or similar device, as recommended by 1.
- If the biopsy is inadequate or inconclusive, proceed to hysteroscopy with directed biopsy.
Follow-up
- If the biopsy is normal, monitor the patient closely with follow-up in 3-6 months.
- If hyperplasia or cancer is found, refer to a gynecologic oncologist for further management, as suggested by 1.
Additional considerations
- Transvaginal ultrasound should have already been performed to measure endometrial thickness, as mentioned in 1.
- Consider other causes of post-menopausal bleeding, such as vaginal atrophy or polyps.
- Discuss the importance of prompt evaluation of any recurrent bleeding with the patient.
The 5 mm endometrial thickness threshold is used because it provides a good balance between sensitivity and specificity for detecting endometrial pathology in post-menopausal women, as noted in 1. Endometrial biopsy is a minimally invasive procedure that can provide a tissue diagnosis, which is crucial for determining appropriate management and ruling out malignancy. According to 1, office endometrial biopsies have a false-negative rate of about 10%, thus a negative endometrial biopsy in a symptomatic patient must be followed by a fractional dilation and curettage (D&C) under anesthesia.
From the Research
Management of Post-Menopausal Bleeding
The management of post-menopausal bleeding with an endometrial lining thickness of 5 millimeters is a critical issue in gynecologic practice. According to the study by 2, the prevalence of endometrial hyperplasia and cancer was not significantly different at the 5 mm cut-off thickness of the endometrium. However, the study by 3 suggests that for initial management of spontaneous postmenopausal bleeding, primary assessment may be with either endometrial sampling or transvaginal ultrasonography, allowing patients with an endometrial echo complex thickness of 4 mm or less to be managed expectantly.
Diagnostic Approaches
The diagnostic approaches for post-menopausal bleeding include:
- Transvaginal ultrasonography to measure endometrial thickness 3, 4
- Endometrial biopsy to exclude endometrial hyperplasia and carcinoma 2, 4
- Saline infusion sonohysterography or hysteroscopy may be used in certain cases 4
Risk of Cancer
The risk of cancer in post-menopausal women with an endometrial thickness of 5 mm is approximately 7.3% 5. However, the study by 5 suggests that an endometrial thickness of 11 mm or more is associated with a higher risk of cancer, and biopsy should be considered in such cases.
Clinical Practice Recommendations
The clinical practice recommendations for the management of post-menopausal bleeding include: