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ESSENTIALS OF DIAGNOSIS

  • Any uterine bleeding in a postmenopausal woman (12 months or more following cessation of menstrual cycles).

  • Postmenopausal bleeding of any amount always should be evaluated.

  • Transvaginal ultrasound measurement of the endometrium is an important tool in evaluating the cause of postmenopausal bleeding.

GENERAL CONSIDERATIONS

The most common causes are endometrial atrophy, endometrial proliferation or hyperplasia, endometrial or cervical cancer, and administration of estrogens without or with added progestin. Other causes include atrophic vaginitis, trauma, endometrial polyps, abrasion of the cervix associated with prolapse of the uterus, and blood dyscrasias.

DIAGNOSIS

The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms. Cervical cytology should be obtained, if indicated. Transvaginal sonography should be used to measure endometrial thickness. An endometrial stripe measurement of 4 mm or less indicates a low likelihood of hyperplasia or endometrial cancer. If the endometrial thickness is greater than 4 mm or there is a heterogeneous appearance to the endometrium, endometrial sampling is indicated. Sonohysterography may be helpful in determining if the endometrial thickening is diffuse or focal. If the thickening is global, endometrial biopsy or D&C is appropriate. If focal, guided sampling with hysteroscopy should be done.

TREATMENT

Management options for simple endometrial hyperplasia without atypia include surveillance, oral contraceptives, or progestin therapy. Surveillance may be used if the risk of occult cancer or progression to cancer is low and the inciting factor (eg, anovulation) has been eliminated. Progestin therapy may include cyclic or continuous therapy (medroxyprogesterone acetate, 10 mg/day orally, or norethindrone acetate, 5 mg/day orally) for 21 or 30 days of each month for 3 months or the use of a levonorgestrel-releasing IUD. Repeat sampling should be performed if symptoms recur. For complex hyperplasia without atypia, options include progestin therapy with scheduled repeat endometrial sampling or hysterectomy. Hysterectomy is indicated for endometrial hyperplasia with atypia (also called endometrial intraepithelial neoplasia) or carcinoma of the endometrium.

WHEN TO REFER

  • Expertise in performing ultrasonography is required.

  • Endometrial hyperplasia with atypia is present.

  • Hysteroscopy is indicated.

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Bar-On  S  et al. Is outpatient hysteroscopy accurate for the diagnosis of endometrial pathology among perimenopausal and postmenopausal women? Menopause. 2018 Feb;25(2):160–4.
[PubMed: 28763396]
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Schramm  A  et al. Value of endometrial thickness assessed by transvaginal ultrasound for the prediction of endometrial cancer in patients with postmenopausal bleeding. Arch Gynecol Obstet. 2017 Aug;296(2):319–26.
[PubMed: 28634754]
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Turnbull  HL  et al. Investigating vaginal bleeding in postmenopausal women found to have an endometrial thickness of equal to or greater than 10 mm on ultrasonography. Arch Gynecol Obstet. 2017 Feb;295(2):445–50.
[PubMed: 27909879]

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