Evaluation of Recurrent Postmenopausal Bleeding

Abstract

Objectives: This study was undertaken to examine the prevalence and predictors of endometrial cancer or endometrial hyperplasia in women with recurrent postmenopausal bleeding after an initial negative assessment.
Methods: This was a retrospective study of 1931 women who had investigations in our Postmenopausal Bleeding Clinic for single or recurrent postmenopausal bleeding from 1 September 2007 to 30 June 2011. Their basic characteristics, the causes of bleeding, and time of recurrence were analysed.

Results: In women with postmenopausal bleeding for the first time, the prevalence of endometrial cancer and endometrial hyperplasia were 3.1% and 1.2%, respectively. After initial negative assessment, 262 (10.6%) women had recurrent postmenopausal bleeding. Among them, 5 (1.9%) turned out to have endometrial cancer, 4 (1.5%) had endometrial hyperplasia, and 1 (0.4%) had cervical cancer. The time interval between the initial negative assessment and the final diagnosis of endometrial cancer or hyperplasia ranged from 6 to 73 months with a median of 17 months. Women with endometrial thickness of more than 4 mm at the initial assessment were more likely to have endometrial cancer or hyperplasia if they experienced recurrent postmenopausal bleeding (odds ratio=10.1; 95% confidence interval, 2.0-51.8; p=0.003) when compared to those with less endometrial thickness. The greater the endometrial thickness (>5 mm) at the initial assessment, the higher was the risk (odds ratio=13.6; 95% confidence interval, 3.0-60.7; p=0.001). Women with initial histopathology showing proliferative or secretory endometrium were also more likely to have endometrial cancer or hyperplasia when they experienced recurrent postmenopausal bleeding (odds ratio=7.4; 95% confidence interval, 1.7-32.4; p=0.021) than those with other histopathology (including insufficient sample, atrophic endometrium, endometrial polyp and pyometra). A case of suboptimal hysteroscopic examination with insufficient tissue from endometrial biopsy for histopathological diagnosis with increased endometrial thickness
had endometrial cancer diagnosed 6 months after the initial ‘negative’ assessment.
Conclusion: Women with recurrent postmenopausal bleeding after initial negative assessment should be reinvestigated because they still have the risk of significant genital tract malignancy. Those with endometrial thickness of more than 4 mm or a proliferative or secretory endometrium at the initial assessment are especially at risk. Whenever a woman presents with postmenopausal bleeding and increased endometrial thickness but the hysteroscopic assessment is suboptimal and there is insufficient tissue for diagnosis from the endometrial biopsy, a more thorough examination and specific management should be considered.