Postmenopausal vaginal bleeding

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Chapter 29 POSTMENOPAUSAL VAGINAL BLEEDING

Theodore O’Connell

Postmenopausal bleeding may be defined as vaginal bleeding starting 12 months or more after the cessation of menses or unscheduled bleeding in a postmenopausal woman who has been taking hormone replacement therapy for 12 months or more. All women with postmenopausal bleeding should be evaluated for potential malignancy, including endometrial cancer, premalignant atypical endometrial hyperplasia, and cervical cancer.

No universal algorithm exists for proceeding with an evaluation of a woman with postmenopausal bleeding. Tissue sampling is the most definitive diagnostic procedure. However, because up to 90% of postmenopausal bleeding has a benign cause, questions have arisen regarding the appropriateness of biopsy in all patients with postmenopausal bleeding. Imaging techniques, particularly transvaginal ultrasonography, have been explored to help determine which patients are at higher risk of malignancy and would benefit from tissue sampling and which patients are more likely to have a benign cause for the bleeding.

The use of transvaginal ultrasonography has been studied most extensively in postmenopausal women. In the absence of visible anomalies such as fibroids, endometrial thickness has been used as a marker for endometrial disease. In postmenopausal women, 5 mm of endometrial thickness is the most commonly used threshold; this marker has been shown to be 96% sensitive for endometrial carcinoma and 92% for other endometrial disease. The sensitivities are not significantly different in women taking hormone replacement therapy. An abnormal ultrasound result must be followed by either tissue sampling or saline-infusion sonography.

Many studies have shown that a threshold of 5 mm for pursuing endometrial sampling reasonably excludes patients with endometrial carcinoma. Some authors have suggested a thicker threshold for ruling out endometrial adenocarcinoma. However, cases of endometrial carcinoma have been detected in women with an endometrial thickness of as little as 3 mm. Therefore, a threshold of 5 mm is most commonly used.

Other techniques have been proposed to add accuracy to the imaging of the endometrium. Saline-infusion sonohysterography has been used in the evaluation of postmenopausal bleeding because the infusion of saline into the endometrial cavity may improve the differentiation of intraluminal masses and shape of the endometrium.

Hysteroscopy is the “gold standard” for the evaluation of postmenopausal bleeding because of the ability to perform directed biopsy. The limitations of hysteroscopy are the invasive nature of the procedure, the requirement for expensive equipment, and the risks associated with general anesthesia.

Three-dimensional ultrasonography is a technique with emerging applications that has been used for evaluation of postmenopausal bleeding. The actual benefit of three-dimensional imaging in most patients is probably limited.

Key Physical Findings

✓ Vital signs

✓ Pelvic examination to evaluate for vulvar or vaginal lesions, signs of trauma, cervical polyps or dysplasia, uterine enlargement, or adnexal masses

Suggested Work-Up

Pap smear is necessary to evaluate for cervical disease. Endometrial evaluation may include one or more of the following:

Transvaginal ultrasonography (with biopsy if the endometrial thickness is greater than 5 mm)

Saline-infusion sonohysterography with endometrial biopsy

Hysteroscopy with biopsy

Dilatation and curettage

No universal algorithm exists for proceeding with an evaluation of a woman with postmenopausal bleeding. Tissue sampling is the most definitive diagnostic procedure, but the techniques have variable sensitivity and specificity. Further research is necessary to determine the best method for evaluating the endometrium in patients with abnormal uterine bleeding.

Additional Work-Up

Cultures for Neisseria gonorrhoeae and Chlamydia organisms	If infection is suspected or if the patient is at risk for sexually transmitted disease
Complete blood cell count (CBC)	If anemia is suspected
Liver function tests and prothrombin time measurement	If liver disease is suspected
CBC with platelet count, prothrombin time measurement, and partial thromboplastin time measurement	If coagulopathy is suspected
von Willebrand factor assay	If von Willebrand disease is suspected

FURTHER READING

Albers JR, Hull SH, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004;69:1915-1926.

Chen BH, Giudice LC. Dysfunctional uterine bleeding. West J Med. 1998;169:280-284.

Davidson KG, Dubinsky TJ. Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin North Am. 2003;41:769-780.

Goldstein SR. Abnormal uterine bleeding: the role of ultrasound. Radiol Clin North Am. 2005;44:901-910.

Kilbourn C, Richards C. Abnormal uterine bleeding. Postgrad Med. 2001;109(1):137-140.

Lethaby A, Farquhar C, Sarkis A, et al. Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev. (4):2003. CD000402

Schrager S. Abnormal uterine bleeding associated with hormonal contraception. Am Fam Physician. 2002;65:2073-2080.

Smith-Bindman R, Kerlikowske K, Feldstein VA. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280:1510-1517.

Tabor A, Watt HC, Wald NJ. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol. 2002;99:663-670.

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