Postmenopausal Vaginal Bleeding

Postmenopausal vaginal bleeding is due to endometrial cancer or atypical adenomatous endometrial hyperplasia in about 20 to 30% of cases (see Table 118-1). It may also be caused by estrogen or progesterone use or by genital atrophy secondary to low estrogen levels.

The history should evaluate past and present illnesses, drug use (especially exogenous estrogens), and previous gynecologic problems. Pelvic examination, including a Pap test and bimanual examination, should be performed to rule out trauma, bleeding from atrophic sites, and vulvar, vaginal, or cervical tumors.

Most patients are referred to a gynecologist for endometrial biopsy or full fractional dilatation and curettage (D & C). Diagnostic testing can be performed in the physician's office rather than the operating room. For the majority of women at risk of developing endometrial cancer, an attempt at in-office biopsy with a small-caliber (3.1-mm diameter) suction curette is warranted; this procedure has a high sensitivity for detecting endometrial cancer. If cervical stenosis precludes performance of a biopsy, if an inadequate tissue sample is obtained, or if bleeding continues and cannot be explained by biopsy findings, D & C with hysteroscopy is likely to be needed.

Transvaginal ultrasonography is also useful for evaluating postmenopausal vaginal bleeding. If the endometrial thickness is < 4 mm, cancer is unlikely.

Treatment for cancer is discussed in Ch. 72. For women without cancer who are not taking estrogen, estrogen is often started, because the bleeding may be secondary to genital atrophy. For women taking exogenous hormones, the dose of estrogen may need to be lowered or the dose of progesterone increased. Treatment must be individualized, and continued bleeding, if persistent, should be aggressively investigated.