Postmenopausal Bleeding

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Postmenopausal bleeding (PMB) refers to any bleeding other than the expected bleeding that occurs with sequential hormones in postmenopausal women. It is a common problem that affects 1 in 10 postmenopausal women older than 55 years. Although most abnormal vaginal bleedings are caused by hormone imbalance, they can be indicative of diseases such as polyps, myomas, endometrial hyperplasia, and cancers of the cervix and endometrium. Cancer of the endometrium is the most common type of gynecologic cancer in the United States. In 2008, an estimated 40,100 cases of cancer of the endometrium and an estimated 7,470 deaths were expected. Vaginal bleeding is the presenting sign in more than 90% of postmenopausal patients with endometrial carcinoma . The majority of patients with postmenopausal vaginal bleeding experience bleeding secondary to atrophic changes of the vagina or endometrium. However, depending on age and risk factors, 114% will have endometrial cancer. Thus, the clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose carcinoma. In post-menopausal women, the greatest concern is endometrial cancer, which is now the most common gynecological cancer. More than 90% of the cases of endometrial cancer occur in women over 50 and this disease accounts for approximately 10% of the cases of vaginal bleeding in post-menopausal women. Radiologists are relatively new in their involvement in evaluation of patients with postmenopausal bleeding. Various investigations available for evaluation of the endometrium are TVUS, saline infusion sonohysterography (SIS), D&C, hysteroscopy, and endometrial biopsy. So the question is, which test is to be done first? That depends on the accuracy, safety, comfort, efficiency, and availability of each modality. We will discuss these methods.