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

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


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



  • 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


  • 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



  • Annual visit for pelvic examination and transvaginal sonography


  • Endometrial cancer

  • Hyperplasia with atypia has a high risk of becoming adenocarcinoma of the endometrium and requires hysterectomy


  • Avoidance of unopposed estrogen therapy

  • Weight reduction

  • Simple endometrial hyperplasia responds well to medical therapy

When to Refer


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