18-02: Postmenopausal Uterine Bleeding

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Menopause is defined as 1 year without menstrual bleeding. The most common causes of postmenopausal bleeding are endometrial atrophy, endometrial proliferation or hyperplasia, endometrial or cervical cancer, and administration of estrogens without or with added progestin. Other causes include atrophic vaginitis, trauma, endometrial polyps, abrasion of the cervix associated with prolapse of the uterus, and blood dyscrasias.

DIAGNOSIS

The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms. Cervical cytology should be obtained, if indicated. Transvaginal sonography should be used to measure endometrial thickness. An endometrial stripe measurement of 4 mm or less indicates a low likelihood of hyperplasia or endometrial cancer. If the endometrial thickness is greater than 4 mm, endometrial sampling is indicated. If there is focal thickening of the endometrium on ultrasound or persistent bleeding despite negative results on endometrial biopsy, guided sampling with hysteroscopy is more appropriate than random endometrial sampling.

TREATMENT

Management options for endometrial hyperplasia without atypia include surveillance, oral contraceptives, or progestin therapy. Surveillance may be used if the risk of occult cancer or progression to cancer is low and the inciting factor (eg, anovulation) has been eliminated. Therapy may include taking cyclic or continuous progestin therapy (medroxyprogesterone acetate, 10–20 mg/day orally, or norethindrone acetate, 15 mg/day orally) or using a hormonal IUD. Repeat sampling should be performed if symptoms recur. Hysterectomy is the preferred treatment for endometrial hyperplasia with atypia (also called endometrial intraepithelial neoplasia) or carcinoma of the endometrium. In some patients with endometrial hyperplasia with atypia, progestin therapy with scheduled repeat endometrial sampling may be an alternative to hysterectomy. Patients who elect this approach include those who desire future childbearing or those who are not candidates for surgery.

WHEN TO REFER

• Expertise in performing ultrasonography is required.

• Endometrial hyperplasia with atypia is present.

• Hysteroscopy is indicated.