What is the best treatment for a typical postmenopausal woman presenting with bleeding, not on hormone therapy and without obvious infection?

Management of Postmenopausal Bleeding

The best treatment for postmenopausal bleeding is not a single therapy but rather a diagnostic algorithm that prioritizes exclusion of endometrial cancer through transvaginal ultrasound measurement of endometrial thickness, followed by endometrial sampling when indicated, with subsequent treatment directed at the underlying cause identified. 1

Diagnostic Pathway (Not Treatment)

The critical point is that postmenopausal bleeding is a symptom requiring diagnosis, not a condition requiring empiric treatment. The primary goal is cancer exclusion, as endometrial cancer is present in approximately 10% of cases. 2, 3

Step 1: Initial Assessment

• Urgent referral is mandatory for all women with postmenopausal bleeding (defined as bleeding ≥12 months after last menstrual period). 2
• Document medication history specifically for hormone replacement therapy, tamoxifen, and anticoagulants, as these alter cancer risk and bleeding patterns. 2
• Perform speculum examination to identify cervical sources (polyps, cervical cancer), vaginal atrophy, or other non-endometrial bleeding sources. 2, 4
• Obtain Pap smear and verify bleeding is truly from the genital tract rather than urological or rectal sources. 4

Step 2: Transvaginal Ultrasound as Primary Triage Tool

• Measure endometrial thickness in the longitudinal section at maximum thickness. 1, 4
• If endometrial thickness ≤3-4 mm AND examination is normal AND bleeding has stopped: no further action is required. This has a 99% negative predictive value for endometrial carcinoma. 1, 2, 3
• The most recent ESMO guidelines (2013) recommend using a ≤3 mm cutoff for highest specificity, though ≤4 mm remains acceptable. 1
• If endometrial thickness >4 mm or not measurable: proceed to endometrial sampling. 1, 4

Step 3: Endometrial Sampling When Indicated

• Pipelle or Vabra endometrial biopsy devices are the preferred first-line sampling methods, with sensitivities of 99.6% and 97.1% respectively for detecting endometrial carcinoma. 1
• These office-based methods have largely replaced hospital-based dilation and curettage. 1, 5
• Saline infusion sonohysterography can distinguish focal (polyps) from diffuse pathology when ultrasound shows polypoid lesions or asymmetric thickening, helping guide whether simple biopsy versus hysteroscopic resection is needed. 1, 4

Step 4: Hysteroscopy with Biopsy as Final Step

• Hysteroscopy should be used as the final diagnostic step if endometrial sampling is non-diagnostic or if imaging suggests focal lesions requiring targeted removal. 1
• Hysteroscopy is highly accurate for diagnosing (rather than excluding) endometrial cancer and allows direct visualization with targeted biopsy or polypectomy. 1

Treatment Based on Diagnosis

Once the diagnostic workup identifies the cause, treatment is etiology-specific:

For Benign Causes (Most Common)

• Vaginal/endometrial atrophy (most common cause): Can be managed expectantly or with topical vaginal estrogen if symptomatic. 3
• Endometrial polyps: Hysteroscopic removal is curative. 1
• Endometrial hyperplasia without atypia: Conservative management with repeat histologic examination to monitor progression risk, though progression to carcinoma is not common. 6

For Malignant Causes

• Endometrial carcinoma: Requires surgical staging and oncologic management per cancer treatment protocols. 1

Critical Pitfalls to Avoid

• Never assume bleeding is benign without proper evaluation, even though 90% of cases have benign causes—the 10% cancer rate mandates thorough workup. 2, 3
• Do not rely on endometrial thickness alone if bleeding persists or recurs; repeat ultrasound at 3 months or proceed to sampling. 2, 4
• Dilation and curettage has false-negative rates as high as 10% and should not be performed as a standalone procedure without hysteroscopy. 1
• Estrogen therapy is usually contraindicated in the setting of unexplained postmenopausal bleeding until malignancy is excluded. 6

Follow-Up Protocol

• If initial endometrial thickness is ≤4 mm and bleeding stops, recheck with transvaginal ultrasound at 3 months. 4
• Any recurrent bleeding or endometrial thickness >4 mm on follow-up mandates endometrial sampling. 4