Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations

Abstract

Postmenopausal uterine bleeding is defined as uterine bleeding after permanent cessation of menstruation resulting from loss of ovarian follicular activity. Bleeding can be spontaneous or related to ovarian hormone replacement therapy or to use of selective estrogen receptor modulators (eg, tamoxifen adjuvant therapy for breast carcinoma). Because anovulatory "cycles" with episodes of multimonth amenorrhea frequently precede menopause, no consensus exists regarding the appropriate interval of amenorrhea before an episode of bleeding that allows for the definition of postmenopausal bleeding. The clinician faces the possibility that an underlying malignancy exists, knowing that most often the bleeding comes from a benign source. Formerly, the gold-standard clinical investigation of postmenopausal uterine bleeding was institution-based dilation and curettage, but there now exist office-based methods for the evaluation of women with this complaint. Strategies designed to implement these diagnostic methods must be applied in a balanced way considering the resource utilization issues of overinvestigation and the risk of missing a malignancy with underinvestigation. Consequently, guidelines and recommendations were developed to consider these issues and the diverse spectrum of practitioners who evaluate women with postmenopausal bleeding. The guideline development group determined that, for initial management of spontaneous postmenopausal bleeding, primary assessment may be with either endometrial sampling or transvaginal ultrasonography, allowing patients with an endometrial echo complex thickness of 4 mm or less to be managed expectantly. Guidelines are also provided for patients receiving selective estrogen receptor modulators or hormone replacement therapy, and for an endometrial echo complex with findings consistent with fluid in the endometrial cavity.�

Figure 1.

Endometrial echo complex (EEC) measurement in the sagittal plane. Study should include coronal or transverse plane as well. For demonstration purposes, the image is from a premenopausal woman.

Figure 2.

Typical measurement of normal postmenopausal endometrial echo complex (EEC) (< 4 mm) (arrowhead).

Figure 3.

Measurement of endometrial echo complex (EEC) when there is fluid in the cavity. Thickness of fluid (B) is subtracted from distance between base of opposing layers of endometrium (A). These should be in the same plane; they are separated slightly here for demonstration purposes.

Figure 4.

Inadequate measurement of endometrial echo complex (EEC) (between symbols).

Figure 5.

Investigation of postmenopausal uterine bleeding with initial investigation of endometrial echo complex (EEC). Entire EEC should be seen, allowing demonstration of a consistent 2-layer thickness in both the sagittal and transverse planes that is less than or equal to 4 mm. If there is clear (sonolucent) fluid, the bilaminar endometrial thickness should be less than or equal to 3 mm. AUB = abnormal uterine bleeding; HRT = hormone replacement therapy; TVUS = transvaginal ultrasonography; ± = with or without.

Figure 6.

Endometrial biopsy (EB) as initial investigation of post-menopausal uterine bleeding. A satisfactory EB comprises perceptible passage of the sampling device through the cervical canal into the endometrial cavity and appropriate functioning of the aspiration mechanism. Adequacy of the specimen for histologic interpretation is determined by the pathologist. AUB = abnormal uterine bleeding; EEC = endometrial echo complex; HRT = hormone replacement therapy; TVUS = transvaginal ultrasonography; ± = with or without.

Figure 7.

Investigation of postmenopausal uterine bleeding in women receiving tamoxifen. Transvaginal ultrasonography is not sufficient for the evaluation of women experiencing bleeding while receiving tamoxifen. Endometrial sampling is necessary. AUB = abnormal uterine bleeding; ± = with or without.