Postmenopausal uterine bleeding
- Annekathryn Goodman, MD
Annekathryn Goodman, MD
- Obstetrics, Gynecology, Reproductive Biology
- Harvard Medical School
- Division of Gynecologic Oncology
- Massachusetts General Hospital
- MGH Global Disaster Response
Postmenopausal bleeding (PMB) refers to any uterine bleeding in a menopausal woman (other than the expected cyclic bleeding that occurs in women taking cyclic postmenopausal hormone therapy). It accounts for about 5 percent of office gynecology visits .
All postmenopausal women with unexpected uterine bleeding patients 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) . However, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium . In the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies .
The evaluation of postmenopausal women with vaginal bleeding will be reviewed here. Evaluation and management of premenopausal women with vaginal bleeding is discussed separately. (See "Differential diagnosis of genital tract bleeding in women" and "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)
Vaginal bleeding occurs in approximately 4 to 11 percent of postmenopausal women [5-8]. The incidence of bleeding appears to correlate with time since menopause, with the likelihood of bleeding decreasing over time. As an example in a study that asked 271 postmenopausal women to complete a daily record, the estimated incidence of bleeding fell from 409/1000 person-years immediately after the first 12 months of amenorrhea following menopause to 42/1000 person-years more than three years after menopause .
Abnormal bleeding noted in the genital area is usually attributed to an intrauterine source, but may actually arise from the cervix, vagina, vulva, or fallopian tubes, or be related to ovarian pathology. The origin of bleeding can also involve nongynecologic sites, such as the urethra, bladder, anus/rectum/bowel, or perineum. Cervical stenosis may inhibit egress of blood from the uterine cavity; hematometra may result.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol 2004; 24:736.
- Prendergast EN, Misch E, Chou YA, et al. Insufficient endometrial biopsy results in women with abnormal uterine bleeding. Obstet Gynecol 2014; 123 Suppl 1:180S.
- Smith PP, O'Connor S, Gupta J, Clark TJ. Recurrent postmenopausal bleeding: a prospective cohort study. J Minim Invasive Gynecol 2014; 21:799.
- APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, 2006.
- Astrup K, Olivarius Nde F. Frequency of spontaneously occurring postmenopausal bleeding in the general population. Acta Obstet Gynecol Scand 2004; 83:203.
- Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321.
- Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol 2004; 24:558.
- Mirkin S, Archer DF, Taylor HS, et al. Differential effects of menopausal therapies on the endometrium. Menopause 2014; 21:899.
- Van den Bosch T, Ameye L, Van Schoubroeck D, et al. Intra-cavitary uterine pathology in women with abnormal uterine bleeding: a prospective study of 1220 women. Facts Views Vis Obgyn 2015; 7:17.
- Duffy S, Jackson TL, Lansdown M, et al. The ATAC adjuvant breast cancer trial in postmenopausal women: baseline endometrial subprotocol data. BJOG 2003; 110:1099.
- Berlière M, Radikov G, Galant C, et al. Identification of women at high risk of developing endometrial cancer on tamoxifen. Eur J Cancer 2000; 36 Suppl 4:S35.
- Ferenczy A. Pathophysiology of endometrial bleeding. Maturitas 2003; 45:1.
- Burbos N, Musonda P, Giarenis I, et al. Age-related differential diagnosis of vaginal bleeding in postmenopausal women: a series of 3047 symptomatic postmenopausal women. Menopause Int 2010; 16:5.
- Bani-Irshaid I, Al-Sumadi A. Histological findings in women with postmenopausal bleeding: Jordanian figures. East Mediterr Health J 2011; 17:582.
- Ronghe R, Gaudoin M. Women with recurrent postmenopausal bleeding should be re-investigated but are not more likely to have endometrial cancer. Menopause Int 2010; 16:9.
- van Hanegem N, Breijer MC, Khan KS, et al. Diagnostic evaluation of the endometrium in postmenopausal bleeding: an evidence-based approach. Maturitas 2011; 68:155.
- Cote ML, Ruterbusch JJ, Ahmed Q, et al. Endometrial cancer in morbidly obese women: do racial disparities affect surgical or survival outcomes? Gynecol Oncol 2014; 133:38.
- Munro MG, Southern California Permanente Medical Group’s Abnormal Uterine Bleeding Working Group. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. Perm J 2014; 18:55.
- Marcu M, Chefani A, Sajin M. Postmenopausal choriocarcinoma: a case report. Rom J Morphol Embryol 2005; 46:145.
- Doherty L, Mutlu L, Sinclair D, Taylor H. Uterine fibroids: clinical manifestations and contemporary management. Reprod Sci 2014; 21:1067.
- Paramsothy P, Harlow SD, Greendale GA, et al. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women's Health Across the Nation (SWAN): a prospective cohort study. BJOG 2014; 121:1564.
- Reinhold C, McCarthy S, Bret PM, et al. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology 1996; 199:151.
- Shoff SM, Newcomb PA. Diabetes, body size, and risk of endometrial cancer. Am J Epidemiol 1998; 148:234.
- van Hunsel FP, Kampschöer P. [Postmenopausal bleeding and dietary supplements: a possible causal relationship with hop- and soy-containing preparations]. Ned Tijdschr Geneeskd 2012; 156:A5095.
- Chandrareddy A, Muneyyirci-Delale O, McFarlane SI, Murad OM. Adverse effects of phytoestrogens on reproductive health: a report of three cases. Complement Ther Clin Pract 2008; 14:132.
- Unfer V, Casini ML, Costabile L, et al. Endometrial effects of long-term treatment with phytoestrogens: a randomized, double-blind, placebo-controlled study. Fertil Steril 2004; 82:145.
- Sabadell J, Castellví J, Baró F. Tuberculous endometritis presenting as postmenopausal bleeding. Int J Gynaecol Obstet 2007; 96:203.
- Mengistu Z, Engh V, Melby KK, et al. Postmenopausal vaginal bleeding caused by endometrial tuberculosis. Acta Obstet Gynecol Scand 2007; 86:631.
- Güngördük K, Ulker V, Sahbaz A, et al. Postmenopausal tuberculosis endometritis. Infect Dis Obstet Gynecol 2007; 2007:27028.
- Sladkevicius P, Opolskiene G, Valentin L. Prospective temporal validation of mathematical models to calculate risk of endometrial malignancy in patients with postmenopausal bleeding. Ultrasound Obstet Gynecol 2017; 49:649.
- Moschos E, Bailey AA, Twickler DM. Comparison of saline infusion sonography (SIS) versus SIS-guided endometrial sampling in the diagnosis of endometrial pathology. J Clin Ultrasound 2016; 44:416.
- Capmas P, Pourcelot AG, Giral E, et al. Office hysteroscopy: A report of 2402 cases. J Gynecol Obstet Biol Reprod (Paris) 2016; 45:445.
- Wang J, Wieslander C, Hansen G, et al. Thin endometrial echo complex on ultrasound does not reliably exclude type 2 endometrial cancers. Gynecol Oncol 2006; 101:120.
- Chandavarkar U, Kuperman J, Muderspach L, et al. Postmenopausal endometrial cancer: Reevaluating the role of endometrial echo complex. Gynecol Oncol 2011; 120:S11.
- http://seer.cancer.gov/csr/1975_2007/browse_csr.php?section=5&page=sect_05_table.07.html (Accessed on March 14, 2011).
- Postmenopausal hormone therapy
- Endometrial hyperplasia
- Leiomyomata uteri
- Disease in adjacent organs
- Post radiation therapy
- Anticoagulant therapy
- Herbal and dietary supplements
- DIAGNOSTIC EVALUATION
- History and physical examination
- Endometrial evaluation
- Cervical cytology
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- INFORMATION FOR PATIENTS
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