Uterine Bleeding, Postmenopausal

Key Features

Essentials of Diagnosis

• Any uterine bleeding in a postmenopausal woman (12 months or more following cessation of menstrual cycles) is abnormal and should be evaluated

• Transvaginal ultrasound measurement of the endometrium is an important tool in evaluating the etiology 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

  • Friction ulcers 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

• Endometrial sampling is indicated

  • If the endometrial thickness is > 4 mm

  • If there is a heterogeneous appearance to the endometrium

• Guided sampling with hysteroscopy is appropriate if there is

  • Focal thickening of the endometrium on ultrasound

  • Persistent bleeding despite negative results on endometrial biopsy

Treatment

Medications

• Treat simple endometrial hyperplasia with cyclic or continuous progestin therapy

  • Medroxyprogesterone acetate, 10–20 mg once daily orally

  • Norethindrone acetate, 15 mg once daily orally

• Levonorgestrel intrauterine system (LNG-IUS) is also a treatment option

Surgery

• Endometrial biopsy or D&C may be curative

• Repeat sampling should be performed if symptoms recur

• Hysterectomy is indicated if endometrial hyperplasia with atypia or endometrial carcinoma is found

Outcome

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