Uterine cancer is the most common gynecologic malignancy in the United
States. It commonly presents as postmenopausal bleeding (vaginal bleeding/spotting
that occurs after menstrual periods had previously stopped for over one year).
The clinical approach to postmenopausal bleeding requires a prompt and
efficient evaluation to diagnose or exclude cancer. The American College
of Obstetrics & Gynecology recently updated their triage recommendations
for postmenopausal bleeding. While the initial evaluation may include
either endometrial biopsy (a small tissue sample from the inside lining
of the uterus) or transvaginal ultrasound, the later has the advantage
of being non invasive and consequently painless. If the transvaginal (not
abdominal) ultrasound clearly demonstrates the endometrium is ≤ 4mm
thick then it excludes uterine cancer with an accuracy of 99%—superior
to endometrial biopsy. If it is thicker than this or cannot be clearly
seen then further evaluation is warranted. For instance, we can enhance
the ultrasound by performing a saline infused sonogram that more accurately
reveals small polyps projecting into the uterine cavity, which may be
the source of bleeding. Finally, if endometrial thickening is present
and cannot be explained by these imaging studies, then an endometrial
biopsy is performed in the office.
For most women we perform this entire work up conveniently during a single
office consultation. This efficient process alleviates anxiety and saves time.
Should
postmenopausal bleeding persist in spite of an initial negative evaluation then further testing
is indicated, which usually includes the gold standard of hysteroscopic
directed biopsy (placing a thin scope inside the uterine cavity to look
for abnormal growths).
Even if uterine cancer is detected, it frequently has a favorable outcome.
More good news… the majority of women presenting with postmenopausal
bleeding do so because of changes to the vagina or uterus from estrogen
deficiency. Consequently, an efficient evaluation usually yields reassurance.