Uterine Bleeding, Postmenopausal

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 ...