Published: 2020-06-25

Evaluation of endometrial causes of postmenopausal bleeding with it's correlation with endometrial thickness and hysteroscopy findings and endometrial tissue histopathology

Saurabh V. Bhangale, Shailja Sharma, Asmita Patil, Beena Kumari


Background: Postmenopausal bleeding (PMB)accounts for 5% of gynecology visit. All with unexpected uterine bleeding should be evaluated for endometrial carcinoma since this potentially lethal disease is the cause of bleeding in approximately 10 percent patients (range 1 to 25 percent, depending upon risk factors). The aim of the study was to evaluate endometrial causes of postmenopausal bleeding (PMB) with it's correlation with endometrial thickness (ET)and hysteroscopy findings and endometrial tissue histopathology.

Methods: A total 50 consecutive cases of PMB fulfilling the inclusion and exclusion criteria and giving informed consent were selected. Each patient was subjected to transvaginal sonography (TVS) in which uterus, adnexa and endometrial thickness (ET) was assessed. Then hysteroscopy and/or dilation and curettage was scheduled at subsequent visit. Endometrial sample was sent for histopathological examination. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy was calculated for ET by TVS and hysteroscopy findings, considering histopathological diagnosis as the gold standard.

Results: Most common endometrial cause of PMB was atrophic endometrium (44%). The other causes were endometrial carcinoma (18%), endometrial hyperplasia (18%), endometrial polyp (12%), endometritis (4%), and leiomyoma (4%). The diagnostic accuracy of ET by TVS at a cut-off point of 5 mm was 94% with sensitivity 89.3%, specificity 100%, PPV 100% and NPV 88%. The diagnostic accuracy of hysteroscopy was 98% with sensitivity 96.4%, specificity 100%, PPV 100% and NPV 95.7%.

Conclusions: Being relatively cheap, easily accessible, non-invasive, TVS with ET measurement should first line investigation in the evaluation of women with postmenopausal bleeding with suspected endometrial pathology. Although hysteroscopy is more specific and sensitive, in poor resource settings it should be limited to cases with ill-defined endometrial lining, recurrent/ persistent bleeding and cases with endometrial thickness greater than 5 mm irrespective of endometrial echotexture.


Endometrial thickness, Hysteroscopy, Postmenopausal bleeding, Transvaginal sonography

Full Text:



Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol. 2004;24:736.

Prendergast EN, Misch E, Chou YA, Roston A, Patel A. Insufficient endometrial biopsy results in women with abnormal uterine bleeding. Obstet Gynecol. 2014;123:180S-S.

Smith PP, O'Connor S, Gupta J, Clark TJ. Recurrent postmenopausal bleeding: a prospective cohort study. J Minim Invasive Gynecol 2014; 21:799.

Laddad MM, Kshirsagar N, Patil S, Shinde G, Bhosale R. Study of adolescent abnormal uterine bleeding (AUB) and its outcome-in tertiary centre KIMS Karad. J Evolut Med Dent Sci. 2015;4(69):12043-51.

Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol. 1990;163:119-23.

Varner RE, Sparks JM, Cameron CD, Roberts LL, Soong SJ. Transvaginal sonography of the endometrium in postmenopausal women. Obstet Gynecol. 1991;78:195-9.

Granberg S, Wikland M, Karlsson B, Norstrom A, Friberg LG. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol. 1991;164:47-52.

Refaie A, Anderson T, Cheah SS. Out-patient Hysteroscopy: findings and decision making for treatment of abnormal uterine bleeding in pre- and post-menopausal women. Middle East Fertil Soci J. 2005;10(1):43-8.

Elewa AM, El Karim MA, Saad SA, Ramadan MA, El Hai MA. Correlation of vaginal ultrasound and hysteroscopy with endometrial histopathology in postmenopausal women. Middle East Fertil Soci J. 2001;6:26-33.

ParkK.Park’s Textbook of Preventive Medicine; Screening for Disease. 23rd edition. Jabalpur: m/s Banarsidas Bhanot; 2015:140-7.

Sousa R, Silvestre M, Almeida e Sousa L, Falcao F, Dias I, Silva T, et al. Transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding: a prospective. Acta Obstet Gynecol Scand. 2001;80:5.

Yela AD. Comparative study of transvaginal ultrasound and outpatient hysteroscopy for diagnosing pathologic endometrial lesions in postmenopausal women. Rev Assoc Med Bras. 2009;55(5):553-6.

Kaul I, Kalsi M, Anand AK, Jad R, Menia V. Transvaginal sonography versus histopathology in postmenopausal bleeding: a prospective study. JK Sci. 2012;14(3):129-33.

Verma R. A study on abnormal uterine bleeding in perimenopausal age in rural Bihar. JMSCR. 2016;4(2):9262-74.

Naik VS, Rege JD, Kusum DJ. Pathology of genital tract in postmenopausal bleeding. Bombay Hospital J. 2005;47:14-7.

Sengupta A. A study of 50 cases of post-menopausal bleeding. J Obstet Gynecol India. 1989:577-81.

Gao X. A study on 234 postmenopausal women at WCUMS, Chengdu. Brit J Obstet Gynecol. 2002.

Ahmed JA. Clinico pathological evaluation of postmenopausal uterine bleeding in Mosul City. Tikrit Med J. 2007;13:73-8.

Karlson B, Granberg S, Ridell B, Wikland M. Endometrial thickness as measured by transvaginal sonography: interobserver variation. Ultrasound Obstet Gynecol. 1994;4(4):320-5.

Bakour SH, Dwarakanath LS, Kahn KS, Newton JR, Gupta JK. The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding. Acta Obstet Gynecol Scand. 1999;78:447-51.

Grandberg S, Wickland M, Karlsson B. Endometrial thickness as measured by endovaginal ultrasound for identifying endometrial abnormalties. Am J Obstet Gynecol. 1991;164:47-52.

Cacciatore B, Ramsoy T, Lehtoirta P, Ylostalo P. Transvaginal sonography and hysteroscopy in postmenopausal bleeding. Acta Obstet Gynecol Scand. 1994;73:413-6.

Nasri MN, Shepherd JH, Setchell ME, Lowc DG, Chard T. The role of vaginal scan in measurement of endometrial thickness in postmenopausal women. Br J Obstet Gynecol. 1991;98:470.

Mathlouthi N, Slimani O, Ferchichi A, Ben Temime R, Makhlouf T, Attia L, et al. Postmenopausal bleeding. Comparison between ultrasonography, hysteroscopy and histology results. Tunis Med. 2013;91(2):99-103.