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Essentials of Diagnosis
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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
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General Considerations
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Most common causes
Atrophic endometrium
Endometrial proliferation or hyperplasia
Endometrial or cervical cancer
Administration of estrogens without added progestin
Other causes include
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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
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Differential Diagnosis
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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
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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
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Diagnostic Procedures
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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
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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
Hysterectomy is indicated for
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Endometrial cancer
Hyperplasia ...