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Evaluation of Postmenopausal Vaginal Bleeding

Author: A. Savage, MD

Mentor: Rebecca McAlister, MD
Editor: Peter F. Schnatz, DO

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Postmenopausal bleeding (PMB) is defined as any staining, spotting, or bleeding that occurs more than 12 months after a woman’s last menstrual period. PMB most commonly results from vaginal or endometrial atrophy. Polyps, fibroids, and endometrial intra-epithelial neoplasia (EIN) must also be considered. Depending on the age and risk factors, 1 to 14% (less than 10% on average) of postmenopausal women with vaginal bleeding will be diagnosed with endometrial cancer, so evaluation is imperative. 

Initial evaluation of PMB should include transvaginal ultrasound (TVUS) or office endometrial biopsy, most commonly collected with a disposable device. Initial evaluation should include one test or the other, but not both.

If TVUS reveals a homogenous and thin endometrial echo of ≤ 4mm, the woman can be reassured that there is < 1% risk that the cause of the bleeding is endometrial cancer and endometrial sampling is not required. If the endometrium cannot be adequately visualized, the measurement is > 4 mm, or bleeding/concerns are ongoing, sampling is indicated. 

Office endometrial biopsy detects 83-98% of endometrial cancers. Its ability to detect cancer is improved in the setting of global endometrial pathology, and less effective in the setting of focal endometrial disease. If an adequate sample is obtained and no EIN or malignancy is identified, no further testing should be performed. Although office sampling is a valuable office tool, sampling failure may occur in as many as 50% of postmenopausal patients. The most frequent causes of failure are the inability to access the endometrial cavity and recovery of insufficient tissue for evaluation. Endocervical tissue alone does not indicate adequate endometrial sampling. Further evaluation is necessary if the endometrium cannot be adequately sampled. In this setting, TVUS for measurement of endometrial thickness is appropriate, and a normal study would complete the evaluation.

If bleeding persists after a normal TVUS study or endometrial sampling, further study is warranted, as there is a significant risk of occult disease.

In cases where further evaluation for PMB is indicated, it may include sonohysterography or hysteroscopy with directed biopsy.   Sonohysterography or hysteroscopy should be considered if PMB persists, even if endometrial measurements by TVUS were ≤ 4 mm or endometrial biopsy was sufficient and did not demonstrate abnormal pathology.


Further Reading:

American College of Obstetricians & Gynecologists; 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.

American College of Obstetricians & Gynecologists; Practice Bulletin No. 149: Endometrial cancer. Obstet Gynecol. 2015 Apr;125(4):1006-26. doi: 10.1097/

The American College of Obstetricians and Gynecologists Committee Opinion no. 631. Endometrial intraepithelial neoplasia. Obstet Gynecol. 2015 May;125(5):1272-1278. doi: 10.1097/01.AOG.0000465189.50026.20. PMID: 25932867.

Initial Approval:  August 2014; Reaffirmed:  May 2016, May 2017; Revised March 2019.  Revised November 2020; Revised May 2022; Minor Revision March 2024.


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