Postmenopausal Vaginal Bleeding

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.

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.

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 (TVS) should be used to measure endometrial thickness. A measurement of 5 mm or less indicates a low likelihood of hyperplasia or endometrial cancer, although up to 4% of endometrial cancers may be missed with sonography. If the thickness is greater than 5 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. If endometrial hyperplasia with atypical cells or carcinoma of the endometrium is found, hysterectomy is necessary.

Tabor A et al: Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol 2002;99:663. [PMID: 12039131]