Are we spending unnecessarily on postmenopausal women who present with bleeding?

Abstract

Bleeding in a postmenopausal woman is an alarming symptom. The major etiologic factor to be addressed is malignancy of the genital tract. Transvaginal ultrasound scan has played a tremendous role in the initial management of this condition in which it is considered that no further evaluation is necessary if the double thickness endometrial stripe is less than 5 mm (1) . The trend is to manage them expectantly without proceeding to a complete diagnostic workup. The procedure is minimally invasive, painless, and produces few or no complications. However, there is 1% risk of endometrial cancer in women who present with postmenopausal bleeding (PMB) with an endometrial thickness of less than 5 mm. Are the postmenopausal women going to accept this 1% risk of missing an endometrial cancer?In a recent article by Timmermans et al.(2) on patients' preferences in the evaluation of PMB made an interesting read, and according to it most women wanted to be 100% certain that carcinoma could be ruled out, and they were prepared to undergo hysteroscopy to rule out any risk of cancer. However, facilities and the skills to go for a complete diagnostic workup are lacking.The most common cause for PMB is atrophic vaginitis, and these atrophic changes are quite clearly seen in routine speculum examination of the cervix and vagina as thinned out smooth vaginal mucosa with light pink to white appearance (3) and do not necessarily need a histologic diagnosis. We can easily assess the prevalence of endometrial cancer in patients with PMB, with an endometrial thickness of less than 5 mm and with clearly demonstrable atrophic changes in the cervix and vagina. This figure might be far less than 1% and possibly be almost close to 0%. If that is so, can we reassure this specific subset of women that their risk of malignancy is virtually 0%? Debby et al. (4) in a recent study have found that all patients in their study population who presented with intrauterine fluid collection, with an endometrial thickness less than 3 mm, had atrophic endometrium. Perhaps, the 5-mm cutoff value for the postmenopausal women might need a little adjustment. So, it seems that we are spending a lot of money, time, and effort on unnecessary investigations in postmenopausal women who present with bleeding with atrophic changes in the genital tract and with an endometrial thickness of less than 5 mm. This new concept will have a tremendous effect on the workload of outpatient gynecologists, unnecessary interventions, and psychologic burden of women undergoing these procedures.