What is the recommended evaluation and management approach for postmenopausal bleeding?

Evaluation of Postmenopausal Bleeding

Transvaginal ultrasound should be the first-line imaging test for women with postmenopausal bleeding, followed by endometrial biopsy if endometrial thickness is ≥5 mm or if bleeding persists despite a normal ultrasound. 1

Initial Diagnostic Approach

• All women with postmenopausal bleeding should be referred urgently as endometrial cancer is present in approximately 10% of cases 2
• Transvaginal ultrasound (TVUS) is recommended as the first-line imaging test to measure endometrial thickness and identify structural abnormalities of the uterus, endometrium, and ovaries 1
• An endometrial thickness of ≤4 mm on TVUS has a negative predictive value for cancer of nearly 100% 1, 3
• If endometrial thickness is ≥5 mm or not measurable, endometrial tissue sampling is indicated 1, 3
• Office endometrial biopsy is the standard method for obtaining tissue for histological assessment, with a false-negative rate of approximately 10% 4, 1

Follow-up Evaluation

• 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 4, 1
• Hysteroscopy should be used as the final step in the diagnostic pathway for women with postmenopausal bleeding, especially when structural abnormalities are suspected 4, 1
• Saline infusion sonography can be used to distinguish between focal and diffuse pathology 4, 3
• In patients with extrauterine disease, a serum CA-125 assay may be helpful in monitoring clinical response, though it has limitations 4

Causes of Postmenopausal Bleeding

• Endometrial cancer (approximately 10% of cases) 2
• Endometrial hyperplasia with or without polyps 2
• Cervical cancer or polyps 2
• Vaginal atrophy 2
• Hormone-producing ovarian tumors 2
• Uterine sarcoma (risk increases with age, up to 10.1 per 1,000 in patients 75-79 years) 1
• Medication-related causes (e.g., hormone replacement therapy, tamoxifen) 5, 2

Important Considerations

• Women taking hormone replacement therapy who have a uterus should also take progestin to reduce the risk of endometrial cancer 5
• Postmenopausal women taking selective estrogen receptor modulators (SERMs) like tamoxifen should be advised to report any vaginal spotting or bleeding due to increased risk of endometrial cancer 1
• When evaluating postmenopausal bleeding in women with fibroids, uterine sarcoma and endometrial cancer must still be ruled out 1
• Pap smear is not indicated specifically for evaluation of postmenopausal bleeding as it is designed to screen for cervical cancer, not endometrial cancer 1

Clinical Pitfalls to Avoid

• Relying solely on Pap smear for evaluation of postmenopausal bleeding may miss endometrial pathology 1
• Using endometrial thickness cutoffs higher than 4 mm may miss cases of endometrial cancer 1, 3
• Failing to pursue further evaluation when initial tests are negative but bleeding persists 1, 6
• Not evaluating the ovaries during ultrasound examination, potentially missing ovarian pathology 3, 6
• Performing D&C without hysteroscopy may miss focal lesions 3

Diagnostic Algorithm

1. Urgent referral for all women with postmenopausal bleeding 2
2. Transvaginal ultrasound to measure endometrial thickness 1
3. If endometrial thickness ≤4 mm and bleeding has stopped: observation with follow-up in 3 months 3
4. If endometrial thickness ≥5 mm or not measurable: proceed to endometrial biopsy 1, 3
5. If endometrial biopsy is negative but bleeding persists: proceed to hysteroscopy with D&C 4, 1
6. If structural abnormalities are identified: hysteroscopic-guided biopsy or resection 3