Management of Postmenopausal Bleeding
All women with postmenopausal bleeding require urgent evaluation to exclude endometrial cancer, which is present in approximately 10% of cases. 1, 2, 3
Initial Diagnostic Workup
First-Line Imaging
- Transvaginal ultrasound (TVUS) is the initial test of choice to measure endometrial thickness and identify structural abnormalities of the uterus, endometrium, and ovaries 1, 4
- If endometrial thickness is ≤4 mm, the risk of endometrial cancer is extremely low (>99% negative predictive value), and no further evaluation is needed if bleeding has stopped and examination is normal 1, 4
- If endometrial thickness is >4 mm, proceed immediately to tissue sampling 1, 5
Tissue Diagnosis
- Office endometrial biopsy (using Pipelle or Vabra devices) is the standard method for obtaining tissue, with sensitivity of 99.6% and 97.1% respectively for detecting endometrial carcinoma 1, 5
- The false-negative rate is approximately 10%, which mandates further evaluation if bleeding persists despite negative biopsy 1, 5
Management Algorithm for Persistent or Recurrent Bleeding
When Initial Biopsy is Negative or Non-Diagnostic
- Fractional dilation and curettage (D&C) under anesthesia must be performed if office biopsy is negative but bleeding persists, or if the sample is inadequate or non-diagnostic 1, 5
- Hysteroscopy with directed biopsy should be considered to evaluate for focal lesions such as polyps that may be missed on blind sampling 1, 5
Critical Pitfall to Avoid
- Never accept an inadequate or negative endometrial biopsy as reassuring in a symptomatic postmenopausal woman—persistent bleeding mandates further evaluation with D&C or hysteroscopy 5
Special Considerations
High-Risk Populations Requiring Aggressive Evaluation
- Age >50 years (>90% of endometrial cancers occur in this age group) 1
- Obesity (BMI >30), unopposed estrogen exposure, tamoxifen use 1, 4
- Lynch syndrome type II: 30-60% lifetime risk of endometrial cancer; requires annual endometrial biopsy starting at age 30-35 years 1, 5
- Women on tamoxifen: require annual gynecologic assessment and immediate reporting of any vaginal spotting due to increased endometrial cancer risk 1
When Fibroids are Present
- Even in the presence of fibroids, uterine sarcoma and endometrial cancer must be ruled out before proceeding with any treatment 6, 1
- The risk of unexpected uterine sarcoma increases with age, reaching 10.1 per 1,000 in women aged 75-79 years 6, 1
- Continued fibroid growth or bleeding after menopause should raise suspicion for uterine sarcoma 6
- If fibroids are confirmed as the cause after malignancy is excluded, hysteroscopic myomectomy may be appropriate for submucosal fibroids associated with bleeding 6
Advanced Imaging
- MRI should be considered if TVUS cannot adequately evaluate the endometrium due to body habitus, uterine position, or pathology such as large fibroids or adenomyosis 1
- Saline infusion sonography can distinguish between focal and diffuse endometrial pathology with high sensitivity (96-100%) 5
Treatment Considerations After Diagnosis
If Endometrial Hyperplasia is Found
- Progestin therapy (progesterone 200 mg daily for 12 continuous days per 28-day cycle) significantly reduces hyperplasia risk when used with estrogen therapy, reducing incidence from 64% to 6% 7
- Hysterectomy may be indicated for atypical hyperplasia or if medical management fails 6
If Malignancy is Confirmed
- Surgical management with hysterectomy is typically indicated, but hysterectomy is premature without tissue diagnosis 5
- Proceeding directly to hysterectomy without establishing diagnosis exposes patients to unnecessary surgical risk if pathology is benign 5