Postmenopausal bleeding: Role of imaging in the diagnosis and management

Abstract

Menopause is defined as no bleeding for 12 months and results from the depletion of ovarian follicles. Bleeding is a significant complaint among postmenopausal women and is reported in about 10% of women in this group. A small but significant number of such women will be diagnosed with endometrial cancer. Endometrial cancer is the most common gynecological cancer with vaginal bleeding being the most common presenting sign and is so in 90% of postmenopausal patients with endometrial carcinoma. In 2020, the American Cancer Society estimates that there will be about 65,620 new cases of the cancer of the body of the uterus and that about 12,590 women will die from cancers of the uterine body. The average of diagnosis of endometrial cancer is 60 years. A much better prognosis is seen for women diagnosed with endometrial cancer than those with ovarian cancer due to diagnosis at an earlier stage; this is attributed to the presentation with postmenopausal bleeding. Endometrial thickness measured during an endovaginal pelvic ultrasound is the established initial assessment to triage patients to receive endometrial biopsy. Common causes of postmenopausal bleeding include endometrial atrophy, endometrial polyps, and endometrial hyperplasia. Some of these causes are readily diagnosed on ultrasound evaluation. The supplemental use of Saline infused sonohysterography adds to the diagnostic value of ultrasound assessment of the endometrium. Hysteroscopy allows direct visualization and guided biopsy and/or resection of endometrial lesions causing abnormal bleeding in selected cases. Magnetic resonance imaging is useful for the assessment of the endometrium for narrowing the differential diagnosis of endometrial abnormalities and for staging of endometrial cancers. Majority of the patients with vaginal bleeding actually bleed secondary to atrophic changes in the vagina or the endometrium.