What is the management approach for a 61-year-old female (YOF) with new postmenopausal bleeding?

From the Guidelines

A 61-year-old female with new postmenopausal bleeding should undergo prompt evaluation to rule out endometrial cancer, starting with a thorough history and physical examination, followed by transvaginal ultrasound to measure endometrial thickness, as recommended by the most recent guidelines 1. The initial management approach should prioritize the exclusion of endometrial cancer, which is present in approximately 10% of postmenopausal bleeding cases.

• Key steps in the diagnostic pathway include:
  • Transvaginal ultrasound to measure endometrial thickness, using a cut-off point of 3 or 4 mm, as suggested by 1 and 1
  • Endometrial sampling via office endometrial biopsy if the endometrial stripe is ≥4mm or if bleeding persists despite a thin endometrium
  • Hysteroscopy with directed biopsy for patients with inadequate office sampling or persistent bleeding despite negative biopsy, as recommended by 1 and 1
• Laboratory tests should include a complete blood count to assess for anemia and thyroid function tests if clinically indicated.
• Symptomatic treatment may include tranexamic acid 1300mg orally three times daily during bleeding episodes or a short course of medroxyprogesterone acetate 10mg daily for 10-14 days to temporarily control bleeding.
• If endometrial hyperplasia is found, treatment depends on the presence of atypia, ranging from progestin therapy for non-atypical hyperplasia to hysterectomy for atypical hyperplasia, as suggested by the guidelines.
• For benign causes of bleeding, treatment options include cyclic progestins, low-dose combined hormonal contraceptives (if no contraindications), or levonorgestrel intrauterine system placement. The most recent and highest quality study 1 prioritizes the measurement of endometrial thickness and endometrial sampling as the initial steps in the diagnostic pathway, which should guide clinical decision-making in this scenario.

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

The management approach for a 61-year-old female with new postmenopausal bleeding should include adequate diagnostic measures to rule out malignancy, such as:

• Directed or random endometrial sampling This is to investigate the cause of the abnormal genital bleeding and determine the best course of treatment 2, 2.

From the Research

Management Approach for Postmenopausal Bleeding

The management approach for a 61-year-old female with new postmenopausal bleeding involves a thorough evaluation to exclude or diagnose endometrial carcinoma and other potential causes of bleeding. The following steps are recommended:

• Take a detailed history to identify risk factors for endometrial cancer, such as age, obesity, use of unopposed estrogen, and family history of gynecologic malignancy 3, 4, 5
• Perform a physical examination, including abdominal and pelvic examinations, to look for masses and assess for atrophic changes in the vagina 5
• Conduct a speculum examination to identify the source of bleeding and assess for cervical malignancy or polyps 5, 6
• Use transvaginal ultrasonography to measure endometrial thickness and identify structural abnormalities of the uterus, endometrium, and ovaries 3, 4, 5, 6
• Perform an endometrial biopsy to obtain a histological diagnosis, especially if the endometrial thickness is greater than 4 mm or if bleeding recurs 3, 4, 5, 7, 6

Diagnostic Criteria

The following diagnostic criteria are used to evaluate postmenopausal bleeding:

• Endometrial thickness of 4 mm or less has a greater than 99% negative predictive value for endometrial cancer 3, 4
• Endometrial thickness greater than 4 mm requires further evaluation, such as endometrial biopsy or hysteroscopy with dilation and curettage 3, 4, 5, 6
• Presence of atypical endometrial cells on cytological smear arouses suspicion of endometrial carcinoma 6

Further Evaluation

If the initial evaluation does not reveal a cause of bleeding, further testing may be warranted, such as:

• Hysteroscopy with dilation and curettage to evaluate the uterine cavity and obtain a tissue sample 3, 4, 6
• Saline infusion sonohysterography (SIS) to supplement transvaginal ultrasonography and aid in decision-making for further invasive measures 6