Master the board step 3

Gynecology
Postmenopausal Bleeding
A 65-year-old obese patient complains of vaginal bleeding for 3 months. Her last
menstrual period was at age 52. She has no children. She has type 2 diabetes and
chronic hypertension. Physical examination is normal with a normal-sized uterus and
with no vulvar, vaginal, or cervical lesions. What is the next step in management?
a. Begin progestin therapy
b. Begin estrogen and progestin therapy
c. Perform an endometrial biopsy
d. Perform a Pap smear and endocervical sampling
e. Prescribe topical estrogen cream
Answer: C. The most common cause of postmenopausal bleeding is vaginal or endometrial
atrophy, but the most important diagnosis to rule out is endometrial carcinoma
(the most common gynecologic malignancy). Endometrial biopsy is the first step in
management of any patient with postmenopausal bleeding.
The most important risk factors for endometrial carcinoma are unopposed
estrogen states (obesity, nulliparity, late menopause/early menarche, chronic
anovulation) and a history of tamoxifen use.
All postmenopausal bleeding is suspected endometrial carcinoma until proven
otherwise.
Never give estrogen alone
to a woman with a uterus.
Always combine with
progestins to prevent
unopposed endometrial
stimulation.
All reproductive age
women with chronic
anovulation (e.g.,
PCOS) are at high risk of
endometrial carcinoma.
Give progestins to prevent
endometrial hyperplasia
and cancer.
Diagnosis
Management
1. Pelvic Exam If the endometrial biopsy reveals atrophy and no cancer, no further workup
is needed
If the endometrial biopsy reveals adenocarcinoma → perform surgery staging:
(TAH and BSO, pelvic and para-aortic lymphadenectomy, and peritoneal washings)
+ Radiation therapy if: lymph node metastasis, > 50% myometrial invasion, positive
surgical margins, or poorly differentiated
+ Chemotherapy if: metastasis
2. Hysteroscopy Identifies endometrial or cervical polyps as source of bleeding
3. Ultrasonography Measures thickness of endometrial lining
In postmenopausal patients the endometrial lining stripe should < 5 mm thick
TAH: total abdominal hysterectomy; BSO: bilateral salpingo-oophorectomy; HRT: hormone replacement therapy
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