replacement therapy. Although the most common cause of postmenopausal
bleeding is vaginal or endometrial atrophy, the most important diagnosis to rule
out is endometrial carcinoma.
The mediating factor for most endometrial carcinomas appears to be unopposed
estrogen. This results from excessive hyperstimulation of the endometrium
without the stabilizing effect of progesterone.
Risk factors include obesity, hypertension, and diabetes mellitus. Other risk
factors include tamoxifen, nulliparity, late menopause, and chronic anovulation
conditions, such as PCO disease.
Diagnostic Tests: Endometrial biopsy or transvaginal ultrasound can be used as
an initial test for evaluating the endometrium.
Endometrial sampling. This office procedure has historically been the initial
diagnostic test for postmenopausal bleeding, due to its high sensitivity, low
complication rate, and low cost. It is ideal for global lesions but not very
sensitive for diagnosing localized structural lesions such as polyps or
submucous leiomyomas.
Transvaginal sonogram. This is an acceptable alternative initial test for non-
persistent minimal bleeding in women who are not on hormone replacement.
A thin, homogenous endometrial stripe <5 mm can reasonably exclude
endometrial carcinoma. A thicker endometrial stripe warrants further
assessment with an endometrial sampling.
Hysteroscopy. This procedure allows direct visualization of the endocervical
canal and endometrial cavity. Endocervical or endometrial polyps, or
submucous leiomyomas, can be removed at the time of the hysteroscopy.