The Evaluation of Postmenopausal Bleeding

Summary of Ultrasound For Postmenopausal Bleeding YouTube video [Reference (1)]:

Postmenopausal bleeding is endometrial cancer until proven otherwise. A negative blind endometrial biopsy does not rule out endometrial cancer. The speaker recommends that a woman with postmenopausal bleeding recieve a transvaginal ultrasound which if technically adequate and normal can rule out endometrial cancer.

Vaginal bleeding is the presenting signs in almost all cases [of endometrial cancer.

Incidence of endometrial cancer in studies of women with postmenopausal bleeding ranges from 1 – 14% (most are 3 – 7%).

Newest ACOG Guidance: July 2012

  • References the fact that when cancer involves less than 50% of the endometrial cavity blind biopsy is not as reliable as previously thought.
  • “A blind endometrial biopsy that does not show cancer or complex atypical hyperplasia cannot be considered an endpoint.”

Transvaginal Ultrasound

  • Consistently, the finding of a thin distinct echo </= 4  to 5 mm was shown to effectively exclude significant tissue in postmenopausal women with bleeding.


Transvaginal U/S Validation of Early Studies

  • For an Endometrial thickness of on Transvaginal     U/S </= 4 mm incidence of malignancy 1 in 917

Is Endometrial Biopsy even still necessary?

  • False negative rate to exclude cancer of TV U/S </= signficantly less than a “negative” blind biopsy.
  • In one study of endometrial thickness < 5 mm: only 82% were successfully completed, and of those only 27% gave enough tissue to be adequate for a diagnosis.
  • ACOG Committee Opinion (2/09, reaffirmed 2011) “When transvaginal ultrasound is performed for postmenopausal bleeding and Endometrial thickness </= is found Endometrial sampling is not required.”
  • Occasionally the endometrial echo is not sufficiently visualized for technical reasons (coexisting fibroids, previous surgery, marked obesity, axial uterus, adenomyosis
  • In such cases saline infusion sonohysterography (the installation of 10 – 20 cc) will distinguish:
    1. No pathology (was unable to appreciate for technical reasons)
    2. Global Process (Blind Biopsy Reliable)
    3. Focal Process (Requires Direct Vision Biopsy under Hysteroscopy)


So [above] we put some fluid into the uterine cavity and it distends the back and front wall and we can see that this woman has absolutely  no abnormality. [No. 1 – No pathology. No further evaluation needed].


[Above] This woman has a polyp and so if you did a blind biopsy and you got a piece of the back wall and you would be misled

[So this, above, is No. 3 – Focal Process (Requires Direct Vision Biopsy under Hysteroscopy)]

Fig26[Above] This woman has an advanced tumor along the front wall but nothing along the back wall.

[So this, above, is also No. 3 – Focal Process (Requires Direct Vision Biopsy under Hysteroscopy)]

If the transvaginal ultrasound scan is nondiagnostic, then the next step is hysterosonography with endometrial sampling YouTube video [See Reference (2) for instructions on how to perform the procedure].

Causes of Postmenopausal Bleeding [Reference (3)]:


Treatment of Postmenopausal Bleeding [Reference (4)]:


Ultrasound For Postmenopausal Bleeding:


(1) Ultrasound First and Postmenopausal Bleeding – Steven Goldstein, MD

(2) AIUM Webinar: Sonohysterography & Sonosalpingography

(3) Postmenopausal Bleeding [Full Text PDF]. Office Gynaecology, Vol 16 No 3 Spring 2014.

(4) An Overview of Postmenopausal Bleeding
By Marinelle Platon-Jones, DO, Gigi Kwok, MD, and Jennifer Keehbauch, MD

This entry was posted in Medical News, Obstetrics and Gynecology, Ultrasound Imaging. Bookmark the permalink.