What is the next step for a 63-year-old postmenopausal woman presenting with vaginal bleeding, with a history of smoking, and not on any hormonal therapy (hormone replacement therapy, HRT)?

From the Guidelines

The next step for a 63-year-old postmenopausal woman presenting with vaginal bleeding who is a former smoker and not on hormonal therapy is to measure the endometrial thickness using transvaginal ultrasound, with a cut-off point of ≤3 mm, followed by endometrial sampling if the thickness exceeds this threshold. This approach is supported by the study by Timmerman et al. 1, which found that the use of ultrasonography with a cut-off level of ≤3 mm is justified in the diagnostic pathway of women with post-menopausal bleeding. The study also highlights the importance of endometrial sampling, which can be performed using a Pipelle or Vabra device, with a high sensitivity for detecting endometrial carcinoma 1.

Prior to the ultrasound and potential biopsy, a thorough history and physical examination should be conducted, including a pelvic exam to visualize the cervix and vagina. This will help identify any other potential causes of the bleeding and ensure that the patient is a good candidate for the procedure.

The patient's history of smoking and postmenopausal status increase her risk for endometrial cancer, making prompt evaluation and diagnosis crucial 1. Early diagnosis of endometrial cancer significantly improves prognosis, and the use of endometrial biopsy and ultrasonography can help identify the disease at an early stage.

Key points to consider in the diagnostic workup of this patient include:

• The importance of measuring endometrial thickness using transvaginal ultrasound with a cut-off point of ≤3 mm
• The use of endometrial sampling, such as Pipelle or Vabra device, if the endometrial thickness exceeds the cut-off point
• The need for a thorough history and physical examination, including a pelvic exam, prior to the procedure
• The increased risk of endometrial cancer in postmenopausal women with a history of smoking, and the importance of prompt evaluation and diagnosis.

From the FDA Drug Label

For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding The next step is to undertake adequate diagnostic measures, such as endometrial sampling, to rule out malignancy in the case of und diagnosed persistent or recurring abnormal vaginal bleeding 2.

• The patient should be evaluated for signs of endometrial cancer.
• Appropriate diagnostic measures should be taken to rule out malignancy.
• The patient's vaginal bleeding should be further investigated.

From the Research

Next Steps for Postmenopausal Bleeding

The patient, a 63-year-old postmenopausal woman, presents with vaginal bleeding and has a history of smoking, but is not on any hormonal therapy. Given these symptoms, the next steps should focus on ruling out endometrial cancer and other potential causes of the bleeding.

• Diagnostic Approach:
  • The most common symptom of endometrial cancer is postmenopausal bleeding 3, 4, 5.
  • Diagnostic approaches may include endometrial biopsy, dilation and curettage (D&C), vaginal ultrasound, hysteroscopy, or transvaginal sonohysterography to evaluate the endometrium 3, 5.
  • For women with postmenopausal bleeding, an endometrial thickness of more than 4 mm is often considered a threshold for further investigation 6.
• Risk Factors and Considerations:
  • Age is a significant risk factor, with women over 65 having a higher chance of endometrial cancer or complex hyperplasia 3.
  • Smoking history may also increase the risk of various health issues, including potentially gynecological cancers, though the direct link to endometrial cancer in this context is not specified in the provided studies.
  • The presence of recurrent postmenopausal bleeding, even after an initial benign tissue diagnosis, warrants further investigation due to the increased risk of endometrial cancer or complex hyperplasia 3, 7.
• Management and Follow-Up:
  • If initial diagnostic results are negative, consideration should be given to total hysterectomy with bilateral salpingo-oophorectomy to reduce the risk of endometrial cancer in women with recurrent bleeding 3.
  • Women with postmenopausal bleeding and endometrial hyperplasia without atypia on biopsy may have a significantly increased risk of being diagnosed with endometrial cancer during follow-up 7.
  • All cases of endometrial atypical hyperplasia and cancer had an endometrial thickness of ≥10 mm, suggesting this could be a useful threshold for prompting investigations in asymptomatic postmenopausal women 6.