Assessment of Postmenopausal Bleeding

Menopause, the end of ovulation and menstrual periods, naturally occurs for most women at the age of 40–55 years. The process of ending ovulation and menstruation is gradual, spanning 1 to 2 years. Postmenopausal bleeding (PMB) is bleeding that occurs 12 or more months after the last menstrual period and accounts for 5% of all gynecologic office visits1. Moreover, a reported 25% of gynecologic surgeries involve abnormal uterine bleeding2. The response for the postmenopausal individual will depend on her own specific endometrial sensitivity, as well as the magnitude of the dose of the hormone supplement. Approximately one in 10 women will experience some bleeding after the menopause3. Postmenopausal bleeding should always be taken seriously and be investigated, no matter how minimal or nonpersistent. Causes may be nongenital, genital extrauterine or uterine4. Possible uterine conditions associated with PMB include endometrial atrophy, polyps, estrogen therapy, foreign bodies, trauma, infection, endometrial hyperplasia, and carcinoma (Table)4,5. Uterine myoma should never be accepted as a cause of PMB. Endometrial atrophy is the most common endometrial finding in women with PMB, accounting for 60–80% of such bleeding. Women with endometrial atrophy have usually been menopausal for 10 years. Hormonal replacement therapy accounts for 15–25% of PMB. The uterine lining responds to supplemental hormone stimulation just as it did earlier in the woman’s ASSESSMENT OF POSTMENOPAUSAL BLEEDING