Intern Ready: Ob/Gyn

Before Your First: Postmenopausal Bleeding Evaluation

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Join this episode to learn about postmenopausal bleeding (PMB) — the incidence, the etiologies, and the diagnostic approach to a patient presenting with uterine bleeding after menopause. A special focus is placed on endometrial hyperplasia and endometrial malignancy, including associated risk factors and the use of transvaginal ultrasound and endometrial sampling in the evaluation. Critical evaluation of PMB is important as the leading concern is cancer until proven otherwise in this patient population.

Keywords: Postmenopausal bleeding, Transvaginal ultrasound, Endometrial hyperplasia, Endometrial malignancy/cancer, Endometrial sampling

Topics Covered:

  • Overview of PMB – Definition, incidence (5% of office GYN visits, 4–11% of menopausal patients), and why the leading concern is endometrial cancer until proven otherwise.
  • Etiologies
    • Polyp (~35%) – Localized overgrowths stimulated by estrogen; mostly benign but higher concern for malignancy/hyperplasia in PMB patients.
    • Atrophy (~30%) – Low estrogen leads to endometrial/vaginal atrophy, micro-erosions, and spotting.
    • Uterine Fibroid (~5%) – Less common postmenopausally; if a PMB patient has fibroids, still assume endometrial pathology.
    • Endometrial Carcinoma (6–14%) – Most common gynecologic cancer in the U.S. Type I (estrogen-driven, favorable prognosis) vs. Type II (high-grade, aggressive).
    • Endometrial Hyperplasia (with and without atypia) – May coexist with or progress to carcinoma in 30–50% of cases.
    • Other causes – Proliferative/secretory endometrium, medications (HRT, anticoagulants, tamoxifen, SSRIs), post-radiation, infection, and non-uterine sources.
    • Risk Factors for Malignancy – Increasing age, obesity, unopposed estrogen, tamoxifen, early menarche, late menopause, nulliparity, PCOS, Type 2 DM, Lynch syndrome, Cowden syndrome, and family history.
    • Diagnostic Approach
      • History and physical exam
      • Transvaginal ultrasound (TVUS) – Endometrial thickness measurement; normal <4 mm in postmenopausal women; sensitivity 94–97%.
      • Endometrial sampling – In-office EMB vs. OR-based hysteroscopy with D&C, including benefits, risks, and how to choose.
      • Follow-Up and When to Refer – Management by pathology result, when to proceed to HSC D&C, and indications for Gyn Oncology referral.

        • Resources:

        • UpToDate: Approach to the Patient with Postmenopausal Uterine Bleeding
        • ACOG Committee Opinion: The Role of Transvaginal Ultrasound in Evaluating the Endometrium of Women with Postmenopausal Bleeding
        • ACOG Clinical Consensus: Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia
        • APGO Topic #54: Endometrial Hyperplasia and Carcinoma
        • ASCCP Cervical Cancer Screening Guidelines

          • About the Speakers:

          Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

          Guest Speaker: Emily Stock, MD – Chief resident in the Department of Gynecology & Obstetrics at Johns Hopkins Medicine. She is currently applying for GYN Oncology Fellowship.

          Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

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          Intern Ready: Ob/GynBy Lucy Brown, M.D.