|October 2002 · Vol. 14, No. 10
Postmenopausal AUB: Rule out endometrial cancer first
When a postmenopausal woman presents with abnormal uterine bleeding, endometrial cancer is the biggest concern. But a host of other etiologies also are possible. The author reviews them and outlines a systematic approach to diagnosis.
Dr. Eisenberg is the division director of reproductive endocrinology and infertility in the department of OBG at Vanderbilt University Medical Center in Nashville, Tenn.
Uterine bleeding or spotting after the initiation of hormone replacement therapy (HRT) is not unusual.
Endometrial evaluation is called for in women not taking HRT who develop uterine bleeding after more than 1 year of amenorrhea. It also is indicated in postmenopausal women on HRT for more than 6 months with persistent uterine bleeding, and previously amenorrheic women on HRT who begin bleeding without apparent cause.
Screening asymptomatic women for endometrial cancer through transvaginal ultrasound or endometrial biopsy is not recommended.
If endometrial thickness is greater than 4 mm, sonohysterography should be performed.
Approximately 1 of every 8 post-menopausal women who present with abnormal uterine bleeding (AUB) will be diagnosed with endometrial cancer, making this one of the most troubling symptoms clinicians encounter in gynecologic practice. Because a wide variety of pathophysiologic problems can cause AUB in post-menopausal women, these patients require prompt evaluation. At a minimum, this should include a clinical history and physical examination, as well as endometrial sampling or evaluation by ultrasound—especially for women not taking hormone replacement therapy (HRT). This process enables clinicians to detect endometrial cancer at an early stage, before it has spread beyond the uterus. Early detection is associated with an expected survival rate of 90%.1
Over the past decade, the evaluation and treatment of postmenopausal bleeding has evolved significantly, thanks to the availability of office-based transvaginal ultrasound (TVUS) and saline-infusion sonohysterography, as well as the advent of endometrial ablation (TABLE 1). Here, I discuss diagnostic testing and review conditions that can lead to postmenopausal bleeding. Once the etiology is identified, the choice of therapeutic intervention usually is self-evident.