What is the initial workup for an elderly female presenting with vaginal bleeding?

From the Guidelines

The initial workup for an elderly female presenting with vaginal bleeding should include a thorough history, physical examination, and targeted diagnostic tests, with a focus on ruling out endometrial cancer, which occurs in approximately 10% of cases, as recommended by the most recent guidelines 1. The workup should begin with a detailed history focusing on bleeding characteristics (onset, duration, amount), associated symptoms, medication use (especially hormone therapy or anticoagulants), and past medical history including cancer risk factors. Some key points to consider in the history include:

• Bleeding characteristics, such as the onset, duration, and amount of bleeding
• Associated symptoms, such as pelvic pain or pressure
• Medication use, including hormone therapy or anticoagulants
• Past medical history, including cancer risk factors Perform a complete physical examination including vital signs and a pelvic examination with visualization of the cervix. Laboratory tests should include:
• A complete blood count to assess for anemia
• Coagulation studies if on anticoagulants
• A pregnancy test if appropriate despite age Transvaginal ultrasound is the first-line imaging study to evaluate endometrial thickness and identify structural abnormalities, as recommended by the American College of Radiology Appropriateness Criteria 1. Endometrial sampling is crucial and should be performed in all postmenopausal women with bleeding, typically via endometrial biopsy in the office setting or dilation and curettage if office biopsy is not feasible. Other common causes of postmenopausal bleeding include atrophic vaginitis, endometrial polyps, and hormone therapy effects, but malignancy must be excluded first given the high stakes of delayed diagnosis in this population, as noted in previous studies 1. It is essential to prioritize the evaluation of endometrial cancer due to its significant prevalence in postmenopausal women with vaginal bleeding, and to use the most recent and highest-quality guidelines to inform the workup, such as those from the American College of Radiology Appropriateness Criteria 1.

From the Research

Initial Workup for Vaginal Bleeding in Elderly Females

The initial workup for an elderly female presenting with vaginal bleeding involves several diagnostic tests to determine the cause of the bleeding.

• The most common causes of abnormal vaginal bleeding in elderly females include endometrial carcinoma, fibroids, polyps, and endometrial atrophy 2.
• Transvaginal sonography is a cost-effective and sensitive method for evaluating abnormal vaginal bleeding in postmenopausal women, and it can help identify benign and malignant conditions 3.
• The diagnostic evaluation of abnormal vaginal bleeding should include a physical examination, transvaginal sonography, and endometrial biopsy or hysteroscopy as indicated 3.

Diagnostic Tests

• Transvaginal sonography is preferred over uniform biopsy of postmenopausal women with vaginal bleeding because it is a less invasive procedure, generally painless, and has no complications 3.
• Endometrial sampling is less successful in women with a thin endometrial stripe on ultrasound than in women with real endometrial pathologic condition 3.
• Hysteroscopy is likely to become the new gold standard in the future because of its ability to visualize directly the endometrium and perform directed biopsies as indicated 3.

Evaluation Plan

• An evaluation plan using transvaginal sonography as the initial screening evaluation followed by endometrial biopsy or hysteroscopy is likely to become the standard of care 3.
• The emergency physician should approach vaginal bleeding in terms of whether the patient is stable or not, and subsequent evaluation should exclude or treat problems that might cause the patient's condition to deteriorate 4.
• The pelvic exam may not always be necessary in the emergency department, and its use should be evaluated on a case-by-case basis 5.