What is the best course of action for a 53-year-old postmenopausal (postmenopause) woman with spotting for 9 days, 2 years after menopause?

Postmenopausal Bleeding Requires Urgent Evaluation

This 53-year-old woman with 9 days of spotting, 2 years postmenopausal, requires urgent referral and diagnostic workup to exclude endometrial cancer, which is present in approximately 10% of postmenopausal bleeding cases. 1, 2

Immediate Action Required

• All postmenopausal bleeding (defined as bleeding ≥12 months after last menstrual period) mandates urgent referral and evaluation 2
• The primary concern is endometrial cancer, though most cases (90%) have benign causes 2
• This patient's age places her in the peak incidence range for endometrial carcinoma (65-75 years), making evaluation critical 2

First-Line Diagnostic Approach

Start with transvaginal ultrasound (TVUS) to measure endometrial thickness: 1

• If endometrial thickness ≤4 mm: Risk of endometrial cancer is low; expectant management is acceptable with 3-month follow-up 1, 3, 4
• If endometrial thickness >4 mm or not measurable: Proceed immediately to endometrial sampling 1, 3, 4

Perform office endometrial biopsy as the standard tissue sampling method: 1

• Sensitivity of 99.6% for detecting endometrial carcinoma 1
• However, carries approximately 10% false-negative rate 1
• This is now preferred over traditional hospital-based dilation and curettage for initial evaluation 4

If Initial Workup is Negative But Bleeding Persists

Escalate to more invasive evaluation: 1

• Perform fractional dilation and curettage (D&C) under anesthesia if office biopsy is negative but bleeding continues or if biopsy is non-diagnostic 1
• Consider hysteroscopy to evaluate for focal lesions such as polyps in cases of persistent or recurrent undiagnosed bleeding 1
• Saline infusion sonography can distinguish between focal and diffuse endometrial pathology when TVUS findings are unclear 1, 3

Additional Diagnostic Considerations

MRI should be considered if: 1

• TVUS cannot adequately evaluate the endometrium due to patient factors
• Pathology such as fibroids or adenomyosis obscures visualization 1

Even if fibroids are present, both uterine sarcoma and endometrial cancer must be ruled out - the risk of unexpected uterine sarcoma increases with age, reaching up to 10.1 per 1,000 in patients 75-79 years 1

Critical History and Examination Elements

Document these specific risk factors for endometrial cancer: 1

• Obesity (BMI >30)
• Unopposed estrogen exposure
• Tamoxifen use
• Nulliparity
• Diabetes mellitus
• Hypertension
• Lynch syndrome (lifetime risk 30-60%) 1

Perform speculum examination to: 2, 3

• Identify the source of bleeding
• Assess for vaginal atrophy
• Exclude cervical malignancy or polyps
• Rule out non-genital sources (urological or rectal bleeding) 2, 3

Common Pitfalls to Avoid

• Do not assume bleeding is benign based on patient age alone - while most causes are benign, the 10% cancer risk necessitates thorough evaluation 2
• Do not rely solely on endometrial biopsy - the 10% false-negative rate means persistent bleeding requires repeat sampling or more invasive evaluation 1
• Do not skip TVUS evaluation of the adnexa - hormone-producing ovarian tumors can cause postmenopausal bleeding 2, 3
• Do not perform D&C alone without hysteroscopy when more invasive evaluation is needed, as hysteroscopy improves diagnostic accuracy 3