Pocket ObGyn – Postmenopausal Bleeding
See Abbreviations
- PMB: Vaginal bleeding occurring after ³12 mo of amenorrhea
- PMB “is endometrial cancer until proven ” Malig w/ PMB = 1–14%. Predictive value depends on age & risks: Obesity, HTN, diabetes, low parity.
- Caused by cancer (10%), atrophy (60–80%), endometrial hyperplasia (2–12%), HRT (15–25%). Tamoxifen increases endometrial cancer TVUS less useful d/t subepithelial stromal hypertrophy. Therefore any bleeding w/ tamoxifen ® w/u.
Diagnostic Workup (Obstet Gynecol 2010;116:168)
- Comprehensive H&P: Pelvic exam to evaluate rectal, vulvar, vaginal, or cervical
- Goal of endometrial eval: (1) exclude malig, (2) rx based on proper etiology (anatomic vs. nonatomic pathology)
• Endometrial eval:
Transvaginal US allows initial screening in some protocols. An EMS on TVUS
<5 mm, has a risk of malig of 1:917. PPV 9% & NPV 99%. Sens 90%, spec 48% for endometrial cancer. About 50% of pts w/ initial TVUS ® further eval (Obstet Gynecol 2009;113:462). Limitations: EMS not always visible, particularly w/ prior Surg, fibroids, obesity, adenomyosis. Incidental thick EMS in an asx pt does NOT require intervention. Often d/t polyps (82%) ® no intervention b/c negligible risk that an asx polyp (ie, no bleeding) will harbor cancer (1:1000).
EMB: Accurate for excluding cancer, but only samples small focus of endometri- um. Sens 99%, spec 98%. False negative ~10%. High rate of insuff or failed sam- pling (0–54%) ® further eval (Maturitas 2011;68:155).
Sonohysterography: Imaging w/ saline infusion (SIS) overcomes some TVUS limi- tations.
3D US & Doppler adds no additional information at this time.
D&C: Useful when unable to obtain EMB (cervical stenosis, pt intolerance, etc.). Invasive: 1–2% complication rate. May miss 10% of endometrial lesions, & of these up to 80% are polyps.
Figure 5.3 Management of postmenopausal bleeding
Modified from Hoffman BL, Schorge JO, Schaffer JI, et al., eds. Williams Gynecology. 2nd ed. New York, NY: McGraw-Hill; 2012.