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For further information, see CMDT Part 18-02: Postmenopausal Vaginal Bleeding

Key Features

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

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

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

  • 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

Follow-Up

  • Annual visit for pelvic examination and transvaginal sonography

Complications

  • Endometrial cancer

  • Hyperplasia ...

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