Does postmenopausal (after menopause) hematuria (blood in urine) warrant a computed tomography (CT) scan of the pelvis to look for ovarian cancer?

Postmenopausal Hematuria Evaluation: CT Pelvis Not Warranted for Ovarian Cancer Screening

Postmenopausal hematuria does not warrant CT of the pelvis specifically to look for ovarian cancer, as CT urography (CTU) is the recommended imaging modality for evaluating hematuria regardless of menopausal status. 1

Appropriate Evaluation of Postmenopausal Hematuria

First-Line Imaging

• CT Urography (CTU) is the recommended first-line imaging for evaluating hematuria in patients with risk factors 1
  • Includes unenhanced images followed by IV contrast-enhanced images with nephrographic and excretory phases
  • Provides comprehensive assessment of the entire urinary tract
  • Superior to ultrasound for urgent diagnoses (89% vs 70% sensitivity) 2

Initial Diagnostic Approach

1. Complete urinalysis to confirm hematuria (≥3 RBCs per high-power field) 3
2. Exclude benign causes (UTI, menstruation, vigorous exercise, etc.)
3. Assess risk factors for urologic malignancy:
   • Age >35 years
   • History of smoking
   • Occupational exposures
   • Prior pelvic radiation
   • Cyclophosphamide exposure
   • Family history of urologic malignancy

Why CT Pelvis Alone Is Not Appropriate for Ovarian Cancer Screening

1. Hematuria primarily indicates urinary tract pathology

   • The ACR guidelines emphasize evaluating the entire urinary tract with CTU rather than focusing on gynecologic causes 1, 2
   • It is essential not to assume hematuria is solely from gynecologic origin 2

2. Low diagnostic yield for ovarian cancer

   • The prevalence of urinary tract malignancy in postmenopausal women with microscopic hematuria is already low (1.4%) 3
   • Ovarian cancer rarely presents with hematuria as the primary symptom
   • When ovarian cancer does cause hematuria, it's typically due to advanced disease with direct bladder invasion 4

3. Appropriate imaging for suspected adnexal masses

   • For suspected adnexal/ovarian pathology, transvaginal and transabdominal ultrasound are the recommended first-line imaging modalities 1
   • MRI pelvis without and with IV contrast is the appropriate next step for indeterminate adnexal masses found on ultrasound 1

When to Consider Gynecologic Causes of Hematuria

Consider gynecologic causes when:

• Urologic evaluation (CTU and cystoscopy) is negative
• Other gynecologic symptoms are present
• Pelvic examination reveals abnormalities

In these cases:

• Pelvic ultrasound (transvaginal and transabdominal) should be performed first 1
• MRI pelvis with contrast may be indicated for further characterization of abnormal findings 1

Important Clinical Considerations

• Risk of malignancy with gross hematuria is >10%, warranting prompt urologic referral 5
• Microscopic hematuria most commonly has benign causes but requires thorough evaluation if persistent 5
• Avoid unnecessary testing - 28.7% of postmenopausal women in one study underwent evaluation without meeting guideline criteria for asymptomatic microscopic hematuria 3
• Consider rare presentations - While rare, there are case reports of ovarian cancer metastasizing to the bladder and causing hematuria 6, 4

In conclusion, while hematuria requires thorough evaluation, CT of the pelvis specifically to screen for ovarian cancer is not the appropriate first step. CTU is the recommended imaging modality for evaluating the source of hematuria, followed by appropriate gynecologic imaging if urologic causes are ruled out.