Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 18-02: Postmenopausal Vaginal Bleeding + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Any uterine bleeding that occurs 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 ++ Most common causes Atrophic endometrium Endometrial proliferation or hyperplasia Endometrial or cervical cancer Administration of estrogens without added progestin Other causes include Atrophic vaginitis Trauma Endometrial polyps Abrasions of the cervix associated with prolapse of the uterus Blood dyscrasias + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Bleeding of any amount in a postmenopausal woman should always be investigated The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms +++ Differential Diagnosis ++ Atrophic endometrium Endometrial hyperplasia or proliferation Endometrial cancer Atrophic vaginitis Perimenopausal bleeding Endometrial polyp Unopposed exogenous estrogen Cervical cancer Uterine leiomyomas (fibroids) Trauma Bleeding disorder Cervical polyp Cervical ulcer Vaginal cancer Vulvar cancer + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Cervical cytology should be obtained, if indicated +++ Imaging Studies ++ Transvaginal sonography should be used to measure endometrial thickness A measurement of 4 mm or less indicates a low likelihood of hyperplasia or endometrial cancer, although up to 4% of endometrial cancers may be missed with sonography +++ Diagnostic Procedures ++ If the endometrial thickness is > 4 mm and/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 thickening is diffuse, endometrial biopsy or D&C is appropriate If thickening is focal, guided sampling with hysteroscopy should be done + Treatment Download Section PDF Listen +++ ++ Management options for simple endometrial hyperplasia without atypia include Surveillance Oral contraceptives Progestin therapy Surveillance may be used if the Risk of occult cancer or progression to cancer is low 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 Use of a levonorgestrel intrauterine (LNG-IUD) system Repeat sampling should be performed if symptoms recur For complex hyperplasia without atypia, options include Progestin therapy with scheduled repeat endometrial sampling Hysterectomy Hysterectomy is indicated for Endometrial hyperplasia with atypia (also called endometrial intraepithelial neoplasia) Carcinoma of the endometrium + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Annual visit for pelvic examination and transvaginal sonography +++ Complications ++ Endometrial cancer Hyperplasia with atypia has a high risk of becoming adenocarcinoma of the endometrium and requires hysterectomy +++ Prevention ++ Avoidance of unopposed estrogen therapy Weight reduction Simple endometrial hyperplasia responds well to medical therapy +++ When to Refer ++ Expertise in performing ultrasonography is required Complex endometrial hyperplasia with atypia is found Hysteroscopy is indicated + References Download Section PDF Listen +++ + +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] + +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] + +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]