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12/1/2015

Evaluation and Management of Postmenopausal Bleeding in a Woman with a Stenotic Cervix

Postmenopausal bleeding (PMB), defined as any bleeding which occurs greater than 12 months after the final menstrual period, requires evaluation because of the 1-14% risk of endometrial cancer. More than 90% of women with endometrial cancer initially present with PMB. The evaluation becomes more challenging in women with cervical stenosis. Cervical stenosis typically occurs at the level of the internal os and prevents entry into the uterine cavity.  Cervical stenosis may also occur at the external os, which can prevent either identification of the os or passage of instruments. Cervical stenosis increases the risk of cervical laceration and uterine perforation.

The initial evaluation of postmenopausal bleeding may be either by transvaginal ultrasound (TVUS) or by endometrial biopsy. In a woman with known or suspected cervical stenosis, TVUS is preferred. An endometrial thickness less than or equal to 4 mm has a 99% negative predictive value for endometrial cancer. If TVUS demonstrates an endometrial thickness > /= 4 mm, or if bleeding continues after a normal ultrasound, histologic diagnosis is necessary. This can be accomplished with an office biopsy or with a hysteroscopy and dilation and curettage (D&C). Sonohysterography can be helpful in identifying focal lesions. All of these modalities require passing an instrument through the cervix.

• Cervical ripening agents have been evaluated as agents to facilitate access into the uterine cavity. Misoprostol has also been shown to be effective in assisting with uterine entry. In menopausal women, misoprostol appears to be more effective if given 12-24 hours prior to the procedure. Mechanical dilation can be achieved with small flexible dilators (“os finders”) or more rigid instruments such as a lacrimal duct probe or a 1-4 mm Hegar dilator. Intravaginal misoprostol administration of 400 micrograms has been shown to decrease pain during and after office hysteroscopy when administered at least 4 hours before the procedure, likely because of the decreased need for dilation. Data support that with the addition of 25 micrograms vaginal estrogen 14 days before the procedure, along with 400–1000 micrograms vaginal misoprostol 12 hours before the procedure, ease of cervical dilation and reduction in pain was substantial in postmenopausal patients.

Transabdominal ultrasound, performed with a full bladder can be used intra-operatively to guide instruments into the uterus and to decrease the chances of uterine perforation or creation of a false passage. Intracervical injection of a dilute vasopressin solution has also been reported to facilitate entry into the uterine cavity as it appears to soften the cervix and make it more receptive to mechanical dilation.

If these methods fail, further surgical methods can be attempted, such as incising the stenotic cervical dimple, or performing a cervical conization to resect the stenotic area.

There have been reports of the endometrium being sampled without traversing the cervix. An 18 or 20-gauge spinal needle attached to a syringe can be inserted though the vagina, through the anterior uterine wall, and into the endometrial cavity.

If all these attempts fail and the bleeding persists, a discussion about the risks and benefits of hysterectomy should be undertaken with the patient.

Further Reading:

[No Authors Listed], ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding.  Obstet Gynecol. 2018 May;131(5):e124-e129. doi: 10.1097/AOG.0000000000002631.

Al-Fozan H, Firwana B, Al Kadri H, et al, Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev. 2015 Apr 23;(4):CD005998. doi: 10.1002/14651858.CD005998.pub2.

Initial Approval: August 2015, Revised September 2018. Reaffirmed March 2020, Minor Revision September 2023

 

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