What are the causes of postmenopausal (post-menopause) vaginal bleeding?

From the Guidelines

If you experience vaginal bleeding after menopause, you should see your healthcare provider promptly for evaluation with a transvaginal ultrasound (TVUS) as the first-line screening test for endometrial cancer. The TVUS measures the thickness of the endometrium, and if it is greater than 4-5mm, an endometrial biopsy is typically recommended to rule out endometrial cancer 1. This approach is supported by the American College of Radiology, which suggests that TVUS should be combined with transabdominal US to fully assess the pelvic structures 1.

The use of TVUS as the initial diagnostic step is justified due to its high sensitivity and negative predictive value for endometrial cancer, with an endometrial thickness of 4 mm conveying a negative predictive value for cancer of nearly 100% 1. However, TVUS cannot reliably determine the etiology of endometrial thickening, and therefore, a thickened endometrium (≥5 mm) generally prompts evaluation by endometrial tissue sampling 1.

Some studies have suggested the use of other diagnostic methods, such as hysteroscopy with biopsy, which is highly accurate and clinically useful in diagnosing endometrial cancer 2. However, the most recent and highest quality study recommends TVUS as the first-line screening test, followed by endometrial biopsy if necessary 1.

Key points to consider in the evaluation of postmenopausal bleeding include:

• TVUS as the first-line screening test for endometrial cancer
• Endometrial biopsy for endometrial thickness greater than 4-5mm
• Pelvic exam and Pap test during the initial visit
• Possible additional tests, such as hysteroscopy or dilation and curettage (D&C), to collect tissue samples
• The importance of prompt evaluation, as approximately 10% of postmenopausal bleeding cases are due to endometrial cancer, and early detection significantly improves treatment outcomes 2, 1.

From the FDA Drug Label

Vaginal bleeding after menopause may be a warning sign of cancer of the uterus (womb). Report any unusual vaginal bleeding right away while you are using Estradiol Vaginal Cream, 0. 01%. Have your healthcare provider check any unusual vaginal bleeding to find out the cause. Do not start using Estradiol Vaginal Cream, 0. 01% if you: have unusual vaginal bleeding. Vaginal bleeding after menopause may be a warning sign of cancer of the uterus (womb).

Vaginal bleeding post menopause is a warning sign that may indicate cancer of the uterus.

• Report any unusual vaginal bleeding right away to the healthcare provider.
• The healthcare provider should check any unusual vaginal bleeding to determine the cause. 3

From the Research

Vaginal Bleeding Post Menopause Test

• Vaginal bleeding in postmenopausal women is a common gynecologic complaint that requires thorough evaluation, as it can be a symptom of possible gynaecological malignancy 4.
• The causes of postmenopausal bleeding (PMB) can be benign, such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions, but endometrial cancer is present in about 10% of patients with PMB 5.
• The management of PMB involves a thorough history, examination, and interpretation of endometrial histology, with the aim of excluding the most significant cause of PMB, i.e., adenocarcinoma of the endometrium 6.

Diagnostic Procedures

• Transvaginal scanning is recommended as the first-line investigation to select those who need further diagnostic evaluation, with hysteroscopy being the gold standard modality of investigation to visualize the uterine cavity 4.
• Endometrial biopsy is not indicated when endometrial thickness is ≤ 4 mm on transvaginal ultrasound in postmenopausal women with bleeding, as the risk of malignancy is low 7.
• Disposable suction piston biopsy devices have virtually replaced dilatation and curettage, despite little scientific validation, and have false-negative rates ranging from 2.5-32.4% in patients with known carcinoma 7.

Evaluation and Management

• Women presenting with postmenopausal bleeding should be referred urgently to a team specializing in the management of gynaecological cancer, and be seen within two weeks of referral 4.
• The evaluation and management of PMB should be able to exclude malignancy, while being acceptable to the patient and cost-effective 4.
• Estrogen therapy is usually contraindicated in cases of postmenopausal bleeding, and endometrial hyperplasia is considered a precursor lesion to endometrial carcinoma, but the incidence of progression is not great 6.