tog BASED

1. An Assessment of women
with post menopausal
bleeding
Dr.KG Hewawitharana

2. What is PMB ?
• Uterine bleeding occurring at least 1 year after amenorrhea
• Common condition with incidence of 10% just after menopause
• PMB pts have 10-15% risk of endometrial CA
• It is vital to exclude CA or precancerous lesion of endometrium

3. Possible Causes
𝒏𝒂𝒐𝒈
• Prevalence of endometrial
hyperplasia & endometrial polyp
is about 40%
• PMB may related to Vulva-
Vagina-Cervix , tubes or Ovarian
Pathology

4. Endometrial CA
• Most common gynecological cancer
• Pretest probability is 10%
• Risk factors includes Obesity , Unopposed Estrogens , PCOD ,
Nulliparity , DM , Endometrial Hyperplasia , HTN , NHPCC , Post
menopause , Tamoxifen + Breast CA
• 90% present with Vaginal bleeding
• ECA risk is 1% if Age <50 yrs
• ECA risk is 25% if age reaches 80 yrs

5. TVS in PMB
assessment

6. • Non invasive & acceptable
• Likelihood of malignancy
high if ET increases
• Cutoff ET is 4mm when
further investigations for
PMB is considered
• If ET<4mm , endometrial
sampling is not
recommended

7. Evidence on TVS assessment
Test sensitivity specificity PPV NPV Pres test
probability
Post test
probability
Smith-
Bindman
metanalysis
96% with 40%
false positive
value
10% 1%
Gupta
systematic RV
2.5%
Tabor
metanalysis
96% 50% with
false negative
rate 4%
Timmerman
metanalysis
Previous
studies have
over
estimated

8. Summery
• Sensitivity 96%
• Specificity 75%
• False positive 40%
• False negative 04%
• Pre test probability 10%
• Post test probability 1-2.5%

9. Cont.
• Metanalysis were based on ET 5mm
• Only one study has considered ET 4mm cutoff with evidence of no CA
progression after 1 year follow up for that cutoff (Gull B et al 2000)
• ET<5mm pts can be mx without endometrial sampling with high
degree of certainty for absence of malignancy
• Since meaningful assessment is not always possible if bleeding
persists pts may need further investigation methods

10. 2018 ACOG committee opinion
If ET less than 4mm – NPV for CA is > 99%

12. Endometrial sampling when ET is > 4mm or
<4mm with Risk factors of Endometrial CA exists
D&C Pipelle Hysteroscopy &
biopsy
sensitivity 65-92% 99.6% postMP
91% preMP
81% for Hpp
96%
specificity ????? >98% 100%

13. D & C
• Outdated as primary investigation form
• 60% cases less than 50% endometrial cavity
subjected for sampling
• 10% false positive results (Gunner et al,1996)

15. Pipelle biopsy
• failure rate is 8%-10%
• Farrell et al showed 20% of pipelle insufficient pts had some
sort of Ut pathology in subsequent Ix
• 3% of pipelle insufficient pts had endometrial CA
• Insufficient sampling is a reason for further investigation & it is
slightly higher than D&C
• But there is no difference between D&C and Pipelle when
compare hysterectomy specimens

17. Hysteroscopy
• Current gold standard
• In patient or out patient basis
• Can do target biopsy

18. Positive peritoneal cytology
after Hysteroscopy
• General Prevalence of PPC = 12-15%
• More with normal saline distention
medium than CO2
• But working with Saline is easy than CO2
• More with high intrauterine pressure thus
it should be less than 80 mmHg
• Time duration of procedure has a role

19. Work-up Plan

20. How to mx asymptomatic High ET pts?
• Routine invasive tests not required as CA incidence is less in this type
of pts
• Hysteroscopy if ET>6mm - commonest (75%) pathology Polyp
• For atypical hyperplasia or carcinoma
TVS cut-off sensitivity specificity
5mm 77 85.5
5.2mm 80.5 86.2
6.75mm 84.3 89.9

21. Malignancy risk with Endometrial polyps
• When asymptomatic , prevalence for malignancy is 10 times less than
symptomatic patients
• Polyp diameter is important as it’s the only variable associated with
abnormal histology in asymptomatic patients

22. Fluid in Endometrial cavity
• Good marker for endometrial pathology in post menopausal female
with ET >4mm
• If <4mm ET, endometrial fluid presence is not an indication for further
invasive investigations
• Fluid levels should not incorporate to ET

23. Tamoxifen & PMB
• Weak estrogenic action on endometrium increase endometrial CA
incidence by 3-6 fold
• PMB should be the primary trigger for further investigation in this
group

24. Unscheduled bleeding on HRT
• Breakthrough bleeding when on cyclical HRT or any bleeding while on
continuous combined HRT
• It may take about 6 months for amenorrhea with continuous
combined HRT
• If bleeding present on Continuous combined regimens after first 6
months or once amenorrhea is established , consider as abnormal &
investigate

25. Reference TOG 2012/2015
ACOG 724