Postmenopausal Bleeding

Background

• Postmenopausal bleeding (PMB) refers to any vaginal bleeding occurring at least 12 months after the last menstrual period in a patient not on hormone replacement therapy or any bleeding outside of expected cyclic bleeding in postmenopausal patients who are taking cyclic combined hormone replacement therapy.
• PMB is common and most often due to a benign uterine, cervical, or vaginal cause.
• PMB is one of the most common presenting symptoms of endometrial cancer and is a common presenting symptom of cervical cancer. All patients who present with postmenopausal bleeding require an assessment of the endometrium to exclude hyperplasia and cancer and an assessment of the cervix to exclude premalignancy and malignancy.

Evaluation

• Perform a pelvic exam, including speculum and bimanual exams to assess for possible causative abnormalities, such as endocervical polyps, vaginal or cervical lesions, pelvic masses, as well as cervical cytology sampling.
• Perform either transvaginal ultrasound (TVUS) or endometrial biopsy (EMB) to assess the endometrium to exclude the diagnosis of an endometrial malignancy.
• There is no consensus regarding the optimal testing sequence in patients with PMB.
• Consider additional diagnostic testing based upon the results of the initial assessment and the clinical situation (for example, in patients with persistent bleeding despite a negative initial endometrial assessment).
  • Consider saline infusion sonography (SIS) only if the diagnosis is uncertain after biopsy or for continued bleeding despite initial workup. This may be performed for the following:
    • to assess the uterine cavity to determine structural cause(s) of refractory abnormal uterine bleeding in postmenopausal patients
    • to evaluate the endometrium to plan further workup in patients with suspected endometrial hyperplasia and endometrial cancer, but biopsy is required to confirm the diagnosis
  • Consider hysteroscopy in postmenopausal patients with abnormal uterine bleeding when TVUS (first-line test to identify structural abnormalities of the endometrial cavity in adults, including polyps, adenomyosis, and leiomyomas) is inconclusive.
• It is uncertain whether stopping hormone replacement therapy is necessary during evaluation of postmenopausal bleeding.
• Consider reinvestigation of postmenopausal bleeding if symptoms recur after 6 months.

Management

• The management of postmenopausal bleeding is dependent upon the underlying specific diagnosis.