What are the treatment options for postmenopausal bleeding?

Treatment for Postmenopausal Bleeding

The first-line approach for postmenopausal bleeding requires ruling out endometrial cancer through endometrial sampling or transvaginal ultrasonography before proceeding with specific treatments based on the underlying cause. 1

Diagnostic Evaluation (Required Before Treatment)

• All postmenopausal women with abnormal uterine bleeding must undergo workup to rule out endometrial cancer prior to proceeding with any treatment 1
• Initial assessment may include either:
  • Endometrial sampling (biopsy) 2
  • Transvaginal ultrasonography (TVUS) with endometrial thickness measurement 1
    • If endometrial thickness ≤4 mm, expectant management may be appropriate 2, 3
    • If endometrial thickness >4 mm or not measurable, histological investigation is required 3
• Hysteroscopy should be used as the final step in the diagnostic pathway when needed 1

Treatment Options Based on Diagnosis

For Endometrial Cancer

• Hysterectomy is the definitive treatment when endometrial cancer is diagnosed 1

For Endometrial Hyperplasia

• Cyclic progestogens for 3-6 months with repeat endometrial sampling to confirm resolution 4
• Hysterectomy may be considered for persistent hyperplasia after progestogen therapy 4

For Fibroids Causing Postmenopausal Bleeding

1. Hysteroscopic Myomectomy

   • Indicated for submucosal fibroids associated with postmenopausal bleeding 1
   • Involves transvaginal, transcervical removal of fibroids using electrosurgical wire loop 1
   • Associated with shorter hospitalization and faster recovery compared to other surgical approaches 1
   • Risks include uterine perforation, fluid overload, need for blood transfusion, and bowel/bladder injury 1

2. Uterine Artery Embolization (UAE)

   • Safe and effective for treating fibroids in postmenopausal patients with negative endometrial biopsy 1
   • Evidence shows complete fibroid necrosis with symptom resolution (urinary frequency and vaginal bleeding) in 89% of cases 1
   • Must rule out endometrial cancer before proceeding 1

3. Laparoscopic or Open Myomectomy

   • May be helpful for postmenopausal patients with fibroids causing bulk symptoms 1
   • Limited specific literature for postmenopausal patients 1

4. Hysterectomy

   • Definitive treatment that eliminates risk of recurrent bleeding 1
   • Appropriate when other treatments fail or when malignancy is suspected 1

For Atrophic Endometrium/Vagina

• Topical or systemic estrogen therapy may be considered if no contraindications exist 5
• For women with history of breast cancer or other estrogen-sensitive conditions, non-hormonal options should be prioritized 1

Important Considerations and Pitfalls

• Continued fibroid growth or bleeding after menopause should raise suspicion for uterine sarcoma 1
• Risk of unexpected uterine sarcoma increases with age (up to 10.1 per 1,000 in patients 75-79 years) 1
• For women on anticoagulation therapy with postmenopausal bleeding, progestin-only methods are preferred 6
• Tranexamic acid and nonsteroidal anti-inflammatory drugs may be used for acute bleeding episodes but are not long-term solutions for postmenopausal bleeding 6
• Saline infusion sonohysterography can help distinguish between focal and diffuse pathology when TVUS findings are inconclusive 1, 3

Treatment Algorithm

1. Perform diagnostic evaluation to rule out malignancy
2. If endometrial cancer: proceed with hysterectomy and appropriate oncologic management
3. If benign structural cause (fibroids, polyps): consider hysteroscopic removal, UAE, or hysterectomy
4. If endometrial hyperplasia: treat with progestogens or consider hysterectomy
5. If atrophic changes: consider topical estrogen if no contraindications
6. Follow-up evaluation after 3 months or sooner if bleeding recurs 3