What is the appropriate workup for vaginal bleeding in a 78‑year‑old postmenopausal woman?

Workup for Vaginal Bleeding in a 78-Year-Old Female

Any postmenopausal vaginal bleeding in a 78-year-old woman must be presumed malignant until proven otherwise and requires immediate endometrial sampling or transvaginal ultrasound to exclude endometrial cancer, which occurs in approximately 10% of these cases. 1

Immediate Initial Assessment

• Assess hemodynamic stability first by checking vital signs, as this determines whether urgent resuscitation is needed before diagnostic workup 1, 2
• Obtain complete blood count to assess degree of anemia and guide transfusion decisions 1
• Check coagulation studies (PT/INR, aPTT), especially if the patient takes anticoagulants or antiplatelet agents, as these medications can precipitate or exacerbate bleeding 1
• Obtain complete medication history specifically asking about anticoagulants, antiplatelet agents, and hormone replacement therapy 1

Physical Examination

• Perform speculum examination to identify the bleeding source, looking specifically for cervical lesions, polyps, inflammation, vaginal atrophy, or lacerations 1
• Avoid digital bimanual examination initially if the source is unclear until imaging excludes structural pathology 1

Diagnostic Imaging

Transvaginal ultrasound is the primary imaging modality for evaluating postmenopausal bleeding and assessing endometrial thickness 3. The ACR Appropriateness Criteria designate transvaginal ultrasound as "usually appropriate" for abnormal uterine bleeding evaluation 3.

• Transvaginal ultrasound provides superior resolution compared to transabdominal ultrasound for evaluating the endometrium and identifying structural abnormalities such as polyps, masses, or endometrial thickening 3, 2
• MRI pelvis may be considered if ultrasound cannot completely visualize the endometrium due to patient body habitus, uterine position, or presence of leiomyomas or adenomyosis, as MRI has excellent soft-tissue contrast resolution and multiplanar capability 3

Mandatory Tissue Diagnosis

Endometrial biopsy is mandatory for any postmenopausal bleeding to exclude endometrial carcinoma 1. This is the most critical step in the workup, as approximately 10% of postmenopausal bleeding cases are due to endometrial cancer 1.

• Office endometrial biopsy should be performed as the initial tissue sampling method 1
• If office biopsy is negative but bleeding persists, proceed to fractional dilation and curettage under anesthesia, as office endometrial biopsy has a 10% false-negative rate 1
• Never accept a negative office endometrial biopsy as definitive if bleeding continues 1

Additional Diagnostic Procedures

• Hysteroscopy may be helpful if persistent bleeding remains undiagnosed after initial workup, particularly to identify polyps or focal lesions that may have been missed on blind sampling 1

Management Based on Findings

If Malignancy is Identified

• Immediate referral to gynecologic oncology for staging and treatment planning is necessary 1
• Do not delay referral, as survival is significantly better with early-stage disease and appropriate specialist involvement 1

If Bleeding is Anticoagulation-Related

• Do not routinely discontinue anticoagulation unless bleeding is life-threatening or uncontrolled 1
• For life-threatening bleeding on warfarin, administer 4-factor prothrombin complex concentrate plus 5 mg IV vitamin K, targeting INR <1.5 1
• For DOAC-related bleeding, consider specific reversal agents only if bleeding is uncontrolled and DOAC levels are measurable 1

Critical Pitfalls to Avoid

• Never assume postmenopausal bleeding is benign (such as atrophic vaginitis) without tissue diagnosis, as 10% of cases are endometrial cancer 1
• Do not stop the workup after a single negative office endometrial biopsy if bleeding persists—proceed to D&C under anesthesia 1
• Do not delay endometrial sampling while waiting for imaging results if tissue diagnosis can be obtained immediately 1