What is the appropriate workup for postmenopausal (after menopause) bleeding?

Workup for Postmenopausal Bleeding

Transvaginal ultrasound (TVUS) followed by endometrial biopsy is the appropriate initial workup for postmenopausal bleeding, with urgent referral recommended due to the 10% risk of endometrial cancer. 1

Initial Evaluation

• All women with postmenopausal bleeding (bleeding 12 months or more after the last menstrual period) should be referred urgently for evaluation 1
• The primary goal of evaluation is to rule out endometrial cancer, which occurs in approximately 10% of women with postmenopausal bleeding 1, 2
• A thorough history should identify risk factors for endometrial cancer and include medication history (especially HRT, tamoxifen, and anticoagulants) 1
• Physical examination should include abdominal and pelvic examination to identify masses and speculum examination to assess for vaginal atrophy, cervical lesions, or polyps 1

Diagnostic Algorithm

Step 1: Transvaginal Ultrasound (TVUS)

• TVUS is the recommended first-line imaging test to measure endometrial thickness and identify structural abnormalities of the uterus, endometrium, and ovaries 3
• If endometrial thickness is ≤4 mm, the risk of endometrial cancer is low 4
• If endometrial thickness is >4 mm or cannot be adequately measured, proceed to endometrial sampling 4

Step 2: Endometrial Sampling

• Office endometrial biopsy is the standard method for obtaining tissue for histological assessment 3
• If office endometrial biopsy is negative but bleeding persists, or if the biopsy is non-diagnostic, a fractional dilation and curettage (D&C) under anesthesia should be performed 3
• Office endometrial biopsies have a false-negative rate of approximately 10% 3

Step 3: Additional Evaluation (if needed)

• Hysteroscopy may be helpful in evaluating the endometrium for lesions such as polyps in patients with persistent or recurrent undiagnosed bleeding 3
• Saline infusion sonohysterography (SIS) can be used as a supplement to TVUS to better visualize endometrial polyps or focal lesions 4
• If TVUS cannot adequately evaluate the endometrium due to patient factors (body habitus, uterine position) or pathology (fibroids, adenomyosis), MRI can be considered 3

Important Considerations

• In postmenopausal patients with abnormal uterine bleeding, even in the presence of fibroids, uterine sarcoma and endometrial cancer must be ruled out 3
• Continued fibroid growth or bleeding after menopause should raise suspicion for uterine sarcoma 3
• The risk of unexpected uterine sarcoma is higher in older patients (up to 10.1 per 1,000 in patients 75-79 years of age) 3
• Endometrial cancer is the most serious etiology of postmenopausal bleeding and is the main focus of evaluation 3

Common Causes of Postmenopausal Bleeding

• Endometrial cancer (10% of cases) 1, 2
• Endometrial hyperplasia with or without polyps 1
• Cervical polyps 1
• Vaginal atrophy 1
• Hormone-producing ovarian tumors 1
• Exogenous hormone use (HRT, tamoxifen) 1

Warning Signs and FDA Warnings

• The FDA warns that unopposed estrogen therapy increases the risk of endometrial cancer in women with a uterus 5
• Adequate diagnostic measures, including endometrial sampling, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding 5
• Women should report any unusual vaginal bleeding right away while using estrogen therapy, as it may be a warning sign of cancer of the uterus 5