Abstract
The clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia and to find out the real source. Postmenopausal bleeding is ‘endometrial cancer until proven otherwise’, although only 1-14% of such patients will actually have cancer. Clinical risk factors of endometrial carcinoma such as obesity, unopposed estrogen use, polycystic ovary syndrome, diabetes mellitus and family history of gynaecologic malignancy also should be considered during evaluation. Postmenopausal bleeding usually attributed to an intrauterine source, but it may arise from the cervix, vagina, vulva or fallopian tubes & ovaries. The origin of bleeding can also involve non-gynaecologic sites, such as the urethra, bladder, anus/rectum/bowel, or perineum.
 Meticulous history and thorough physical examination are must. Initial evaluation is by TVS, if endometrial thickness (ET) is <4mm no further evaluation is required but follow up consultation must. If ET is> 4mm, hysteroscopic evaluation and endometrial sampling is recommended
 Blind endometrial sampling is not accurate as only reveals when endometrial cancer exceeds more than 50% of the endometrial surface area so may be done if hysteroscopic evaluation is not possible. Higher dose of progesterone may be required for endometrial protection when higher doses of estradiol as hormone replacement therapy are used, or in women with high BMI. Unopposed estrogen therapy is associated with a duration and dose-related increase in risk of endometrial hyperplasia and cancer. Endometrial protection requires an adequate dose and duration of progestogen. Endometrial hyperplasia with atypia has much malignant potential but endometrial hyperplasia without atypia may be managed medically with 3 monthly endometrial sampling, if no regression or further progression hysterectomy is the choice of treatment. Finally, patient counseling with discussion of risks /benefits of different options of treatment modalities is the cornerstone of success of addressing postmenopausal bleeding.
Highlights
Postmenopausal bleeding (PMB) is considered at least 12 months after the last normal period
All postmenopausal women with unexpected vaginal bleeding should be evaluated for endometrial carcinoma since this potentially lethal disease will be the cause of bleeding in approximately 10 percent range (1 to 25 percent), depending upon risk factors [2]
transvaginal ultrasound (TVS) can be useful in the triage of patients in whom endometrial sampling was performed but tissue was insufficient for diagnosis
Summary
Postmenopausal bleeding (PMB) is considered at least 12 months after the last normal period. Unscheduled bleeding is defined as noncyclical bleeding in menopause women taking hormone replacement therapy. PMB usually has benign causes, the priority is to exclude malignancy. All postmenopausal women with unexpected vaginal bleeding should be evaluated for endometrial carcinoma since this potentially lethal disease will be the cause of bleeding in approximately 10 percent range (1 to 25 percent), depending upon risk factors [2]. Management of PMB is aimed at excluding cervical carcinoma, endometrial carcinoma precancerous endometrial changes and to treat the real cause. The differential diagnosis of bleeding in postmenopausal women is less broad than that for abnormal uterine bleeding in premenopausal women since the various causes of anovulation are not relevant here
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