Evaluation of Postmenopausal Vaginal Bleeding
Mentor: Rebecca McAlister, MD
Editor: Daniel Breitkopf, MD
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. One to fourteen percent 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, 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.
Further evaluation of women with PMB is also indicated if the initial evaluation fails or indicates the possibility of significant disease. The evaluation may include sonohysterography, hysteroscopy, or additional tissue sampling. If the endometrial thickness measured by TVUS is > 4 mm, further evaluation is indicated. Sonohysterography or hysteroscopy may be useful as they can identify focal intracavitary disease, which may allow targeted sampling of the endometrium. 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.
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: 10.1097/01.AOG.0000462977.61229.de.
Dijkhuizen FP1, Mol BW, Brölmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer. 2000 Oct 15;89(8):1765-72.
Initial Approval: August 2014; Reaffirmed: May 2016, May 2017; Revised March 2019.
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