Postmenopausal Vaginal Bleeding

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Introduction

Essentials of Diagnosis

• Vaginal bleeding that occurs 6 months or more following cessation of menstrual function.
  
• Bleeding is usually painless.
  
• Bleeding may be a single episode of spotting or profuse bleeding for days or months.

General Considerations

Vaginal bleeding that occurs 6 months or more following cessation of menstrual function should be investigated. The most common causes are atrophic endometrium, endometrial proliferation or hyperplasia, endometrial or cervical cancer, and administration of estrogens with or without added progestin. Other causes include atrophic vaginitis, trauma, endometrial polyps, friction ulcers of the cervix associated with prolapse of the uterus, and blood dyscrasias. Uterine bleeding is usually painless, but pain will be present if the cervix is stenotic, if bleeding is severe and rapid, or if infection or torsion or extrusion of a tumor is present. The patient may report a single episode of spotting or profuse bleeding for days or months.

Diagnosis

The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms. A cytologic smear of the cervix and vaginal pool should be taken. If available, transvaginal sonography should be used to measure endometrial thickness. A measurement of 4 mm or less indicates a very low likelihood of hyperplasia or endometrial cancer. In 20 studies of a total of 4759 women with postmenopausal bleeding and an endometrial thickness of 4 mm or less, only 0.25% were found to have endometrial cancer. If the thickness is greater than 4 mm or there is a heterogeneous appearance to the endometrium, endocervical curettage and endometrial biopsy or D&C preferably with hysteroscopy should be performed.

Treatment

Endometrial biopsy or D&C may be curative. Simple endometrial hyperplasia calls for cyclic progestin therapy (medroxyprogesterone acetate, 10 mg/d, or norethindrone acetate, 5 mg/d) for 21 days of each month for 3 months. A repeat endometrial biopsy should be performed, and if tissues are normal and estrogen replacement therapy is reinstituted, a progestin should be prescribed (as above) in a cyclic or continuous regimen. If endometrial hyperplasia with atypical cells or carcinoma of the endometrium is found, hysterectomy is necessary.

Preferences
Gull B et al: Transvaginal ultrasonography in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy? Am J Obstet Gynecol 2000;185:509. 

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