REFERENCES
- EVIDENCE based
- TOG – Management of women with postmenopausal bleeding: evidence-based review
- STARTOG
POSTMENOPAUSAL BLEEDING
DEFINITION:
Genital tract bleeding occurring after at least 1 year of amenorrhoea who are at menopausal age.(age)
INCIDENCE:
- 10% immediately after menopause.
| Causes of vaginal bleeding in postmenopausal women | |
| Polyps | 30% |
| Submucosal fibroids | 20% |
| Endometrial atrophy | 30% |
| Hyperplasia | 8–15% |
| Endometrial carcinoma | 8–10% |
| Ovarian, tubal, cervical malignancy | 2% |
- May originate from extragenital sites such as the urethra, bladder, rectum or bowel.
- Clinical approach to PMB requires prompt and effective evaluation to exclude cancer in the genital tract or precancerous lesions of the endometrium.
- Endometrial cancer often presents at an early stage when there is a possibility of curative treatment by hysterectomy; early, accurate and timely diagnosis is therefore important.
- 90% of women with endometrial carcinoma present with vaginal bleeding.
Diagnosing endometrial cancer
Imaging:
TVS
- non-invasive , more acceptable, especially to older women.
- assess thickness and morphology of the endometrium
- >=5 mm – sensitivity for detecting endometrial cancer – 96%, false-positive rate – 39%
- a pre- test probability of 10% for endometrial cancer to a post-test probability of 1%.
- >5 mm – risk of carcinoma from 14% to 31.3% (95% CI 26.1–36.3)
- <5 mm -the risk to 2.5%.
- endometrial thickness of <4 mm – none of the women with the expectant management developed cancer over 1 year of follow-up.
- TVS screening for endometrial cancer has high sensitivity in postmenopausal women.
- If the endometrial thickness is <4 mm, the presence of fluid is a indication for further investigation if the endometrium is irregular.
Role of three-dimensional ultrasound
diagnostic performance of three- dimensional (3D) ultrasound imaging for discrimination between benign and malignant endometrium is superior to 2D ultrasound examination
Saline infusion sonography (SIS)
- saline into the uterine cavity during ultrasound to separate the two walls of the endometrium
- allows the evaluation of intracavitary lesions such as fibroids or polyps.
- significantly better in premenopausal women compared with postmenopausal women.
Endometrial sampling methods
- Patients with an increased endometrial thickness should undergo further invasive testing.
- both the Pipelle device and the Vabra device were very sensitive techniques for the detection of endometrial carcinoma, with detection rates of 99.6% and 97.1%, respectively.
Insufficient sampling
it is reasonable to reassure and discharge women with an insufficient endometrial sample with negative scan ( 4 mm) without the need to expose them to hysteroscopy and curettage.
Dilatation and curettage (D&C)
- no longer recommended for the investigation of PMB.
Hysteroscopy
- visualising macroscopically focal abnormalities and taking directed biopsies.
- useful for excluding endometrial polyps or fibroids.
- detect 95% of intrauterine abnormalities
- performed in an outpatient setting without anaesthesia. à vaginoscopic’ approach , smaller diameter hysteroscopic systems
- the first line of investigation in women taking tamoxifen who has post-menopausal bleeding.
| Predictive values for endometrial cancer in postmenopausal women | ||||
| Sensitivity | Specificity | PPV | NPV | |
| Transvaginal ultrasound (TVU) | 67% | 56% | 7% | 97% |
| Endometrial biopsy (EMB) (blind)* | 87% | 98.5% | 82% | 99.1% |
| SIS | 89% | 46% | 16% | 97% |
| Hysteroscopy and biopsy | 86% | 99.2% | 100% | 99.5% |
Tamoxifen and PMB
- a three- to six-fold greater incidence of endometrial cancer due to its weak estrogenic effect on the endometrium.
- > 5 years increases risk by at least four-fold.
- PMB therefore requires urgent investigation
- women on tamoxifen should be monitored :
- periodic investigations are unlikely to be cost-effective.
- PMB should remain the primary trigger for investigation of women on tamoxifen.
- Tamoxifen can cause subendometrial cyst development, which makes the endometrium appear thickened in transvaginal sonograms. However, the subendometrial cystic tissue can be differentiated from the endometrium itself in SIS.
Unscheduled bleeding on HRT
breakthrough bleeding occurring in women on cyclical HRT or any bleeding in women on continuous combined HRT, although it can take up to 6 months for amenorrhoea to develop in the latter treatments.
For sequential regimens, abnormal bleeding may:
- heavy or prolonged at the end of, or after, the progestogen phase
- occur at any time (breakthrough bleeding).
Bleeding on continuous combined regimens should be considered abnormal (requiring endometrial assessment) if it occurs:
- after the first 6 months of treatment, or
- after amenorrhoea has been established.
Diagnosis
History & Examination
US – TVS
Hysteroscopy – predictive ability of the addition of both ultrasonography and hysteroscopy increased the receiver operating characteristic (ROC) area to 0.84. ROC is a graphical plot of the true-positive rate versus false-positive rate
TVS limits the need for endometrial biopsy to women with an endometrial thickness of ≤5 mm, an irregular endometrial outline or fluid within the uterine cavity.
The majority of women have a thin, regular endometrium and can be reassured at a first visit without further investigation.
Recommendations from standard guidelines
RCOG
While RCOG’s Green‑top guidelines (e.g., GTG 67, 34) don’t explicitly specify a numeric ET threshold, their patient information emphasizes that any bleeding after menopause warrants investigation, typically starting with transvaginal ultrasound .
Subsequent guidance from the British Gynaecological Cancer Society—endorsed by RCOG—sets the cut-off at 4 mm.
“Women with PMB with an endometrial thickness of ≥ 4 mm should undergo endometrial sampling” .
TOG / Ireland (HSE)
The Irish National Clinical Practice Guidelines mirror this, recommending endometrial sampling when ET ≥ 4 mm and diagnostic hysteroscopy for focal lesions or ET > 4 mm.
ACOG / ACOG Committee Opinion No. 734 (2018)
“Transvaginal ultrasonography is appropriate … if the ultrasound reveals a thin endometrial echo (≤ 4 mm), given … >99% negative predictive value for endometrial cancer.”
ACOG advises endometrial sampling if ET > 4 mm, or if there’s persistent/recurrent bleeding regardless of thickness.
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