What are the evaluation and treatment options for postmenopausal bleeding?

Evaluation and Management of Postmenopausal Bleeding

All women with postmenopausal bleeding should be urgently evaluated to exclude endometrial cancer, which is present in approximately 10% of cases.

Initial Assessment

• Clinical history focus points:

  • Duration and amount of bleeding
  • Associated symptoms (pain, discharge)
  • Risk factors for endometrial cancer (obesity, diabetes, hypertension, history of unopposed estrogen exposure, tamoxifen therapy)
  • Medication history (HRT, tamoxifen, anticoagulants)

• Physical examination:

  • Abdominal examination for masses
  • Speculum examination to identify source of bleeding, assess vaginal atrophy, and evaluate for cervical lesions or polyps
  • Bimanual examination to assess uterine size and adnexal masses

Diagnostic Algorithm

First-line Investigations:

1. Transvaginal ultrasound (TVUS):

   • Measures endometrial thickness
   • Endometrial thickness ≤4mm has a negative predictive value for endometrial cancer of nearly 100% in postmenopausal women 1
   • Endometrial thickness >4mm requires further evaluation with endometrial sampling 1
   • Can identify structural abnormalities of the uterus, endometrium, and ovaries

2. Endometrial biopsy:

   • Office endometrial biopsy is the standard diagnostic procedure for tissue sampling
   • Has a false-negative rate of approximately 10% 1
   • If negative in a symptomatic patient, proceed to fractional dilation and curettage (D&C) under anesthesia

Management Based on Findings:

If Endometrial Thickness ≤4mm and Normal Examination:

• If bleeding has stopped, no further action needed 2
• Follow-up if symptoms recur

If Endometrial Thickness >4mm or Abnormal Findings:

• Proceed with endometrial biopsy
• If biopsy is negative but bleeding persists, consider D&C for definitive diagnosis

If Endometrial Hyperplasia:

• Cyclic progestogens for 3-6 months can revert hyperplasia to normal endometrium in up to 96% of cases 3
• Follow-up endometrial biopsy after treatment
• Consider hysterectomy for persistent hyperplasia or if associated with other pathology like leiomyomata

If Endometrial Cancer:

• Refer to gynecologic oncology for staging and treatment

If Atrophic Vaginitis/Endometritis:

• Consider local estrogen therapy if not contraindicated
• Estradiol administration should be initiated at the lowest effective dose 4
• Add a progestin when a woman has not had a hysterectomy to prevent endometrial hyperplasia 4

Special Considerations

Fibroids with Postmenopausal Bleeding:

• In postmenopausal patients with abnormal uterine bleeding and fibroids, uterine sarcoma and endometrial cancer must be ruled out before considering minimally invasive therapies 5
• Hysterectomy is usually appropriate for postmenopausal patients with uterine fibroids who are symptomatic with heavy uterine bleeding or bulk symptoms and have negative endometrial biopsy 5

Hemorrhagic Cysts:

• Hemorrhagic cysts should not occur in the postmenopausal population
• When typical hemorrhagic cysts <10 cm are encountered in postmenopausal women, further evaluation by ultrasound specialist, referral to gynecologist, or MRI is suggested 5

Lynch Syndrome Considerations:

• Patients with Lynch syndrome (particularly MLH1 gene) have increased risk of endometrial and ovarian cancer
• Consider hysterectomy with bilateral salpingo-oophorectomy starting at age 40 5
• Patients should be educated regarding prompt reporting of postmenopausal bleeding 5

Follow-up Recommendations

• Follow-up visit within 1-2 weeks if bleeding persists 1
• Urgent evaluation if heavy bleeding, severe pain, or fever develops 1
• For patients with resolved bleeding and normal findings, no specific follow-up is required unless symptoms recur

Pitfalls to Avoid

1. Dismissing postmenopausal bleeding as benign without proper evaluation

   • All postmenopausal bleeding requires urgent assessment to exclude malignancy

2. Relying solely on endometrial biopsy without considering endometrial thickness

   • The two tests are complementary; both should be used in evaluation

3. Failing to consider rare causes of bleeding

   • Consider non-gynecologic sources (urinary, gastrointestinal)
   • Rare causes include vaginal vault endometriosis, vaginal vault dehiscence, and fistulas from adjacent organs 1
   • Trauma-related causes like malunited pelvic fractures can cause vaginal wall laceration 6

4. Inadequate follow-up of persistent bleeding despite negative initial evaluation

   • A negative endometrial biopsy in a symptomatic patient requires further investigation with D&C 1