The grades of evidence (I-1 – IV) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
- Postmenopausal bleeding (PMB) shall be defined to be spontaneous vaginal bleeding that occurs more than one year after the date of the last menstrual period. (Grade C)
- Breakthrough bleeding is unscheduled uterine bleeding encountered in any woman using hormone replacement therapy (HRT). (Grade C)
- Women with spontaneous PMB should be primarily evaluated with either endometrial biopsy (EB), or transvaginal sonography (TVS) to measure the thickness of the endometrial echo complex (EEC). (Grade A)
- When TVS or saline infusion sonography (SIS) is used as a technique for assessing the endometrium of women with PMB, photographs of the sagittal and transverse images should be placed in the chart with a suitable note describing the findings. (Grade C)
- Practitioners without adequate training in either office-based EB or TVS should refer patients with PMB or breakthrough bleeding to an individual, usually a gynecologist, appropriately trained in these techniques. (Grade C)
- Women with spontaneous PMB and an EEC of >5 mm should be further evaluated with endometrial sampling. (Grade B)
- A satisfactory endometrial biopsy comprises perceptible passage of the sampling device through the cervical canal into the endometrial cavity and appropriate functioning of the aspiration mechanism. Adequacy of the specimen for histological interpretation is determined by the pathologist. (Grade C)
- Women with persistent spontaneous PMB require further evaluation of the endometrial cavity for focal lesions with one or a combination of office-based SIS and hysteroscopy. Such an approach is necessary even if there is a satisfactory/adequate endometrial biopsy without evidence of hyperplasia, and regardless of the EEC thickness. (Grade B)
- Operating room-based dilation and curettage (D&C) of women with PMB should be performed only when office based endometrial biopsy is indicated and cannot be performed for technical reasons, or when it is inconclusive and sonographic techniques (TVS, SIS) are non reassuring. (Grade B)
- Women taken to the operating room for D&C should have concomitant hysteroscopy with ancillary instruments that allow for the removal of focal lesions such as endometrial polyps. (Grade C)
- Only selected women with bleeding associated with estrogen and progestin containing HRT require assessment of the endometrium. Uterine bleeding or spotting may be expected depending in part on the dose of HRT administered, in part on the schedule of progestin administration, and in part on the duration of therapy. (Grade A)
- It is not necessary to routinely evaluate the endometrium of women with uterine spotting or light uterine bleeding in the first six months of continuous estrogen and progestin therapy. Endometrial assessment of such women is recommended if spotting or bleeding persists beyond six months, although there is a very low incidence of endometrial hyperplasia or neoplasia. (Grade A)
- Women on doses of unopposed estrogen will have a much higher incidence of endometrial hyperplasia and neoplasia and require appropriate investigation of the endometrium. (Grade A)
- Women on estrogen and cyclical progestins can be expected to have indefinite progestin withdrawal bleeding provided the dose and duration of cyclic progestins is adequate. (Grade A)
- For women using cyclic progestins, bleeding outside the time of progestin withdrawal is considered abnormal and requires appropriate investigation. (Grade B)
- It is apparent that EEC thresholds used for spontaneous bleeding can be applied to patients with HRT-related bleeding, but with a higher incidence of false positive evaluations. (Grade A)
- Women experiencing uterine bleeding on tamoxifen (usually used as an adjuvant for breast cancer) should be assessed primarily with endometrial sampling as, in such patients, TVS is neither sensitive nor specific for neoplasia. (Grade A)
- Women with persisting bleeding on tamoxifen, and who have already undergone endometrial sampling, should be assessed with one or a combination of SIS and hysteroscopy with appropriate sampling or excision of polyps if found. (Grade B)
- Women with repeated bleeding on tamoxifen, and who have been demonstrated to have normal histology and a structurally normal endometrial cavity, should have EB repeated annually. (Grade C)
- Postmenopausal bleeding can be a presenting symptom of cancer in the cervical canal. Consequently, if there is no endometrial explanation for PMB, appropriate steps to evaluate patients for cervical cancer should be undertaken considering Pap smear, colposcopy, and curettage of the endocervical canal. (Grade C)
Definitions:
Support for Recommendations
Based on the American College of Obstetricians and Gynecologists Strength of Recommendation Classification:
Level A. Recommendations are based on good and consistent scientific evidence
Level B. Recommendations are based on limited or inconsistent scientific evidence
Level C. Recommendations are based primarily on consensus and expert opinion
Classification of Evidence
Modified US Preventive Services Task Force Hierarchy of Research Design
I-1: Evidence obtained from at least one meta-analysis or systematic review of randomized clinical trials.
I-2: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III: Descriptive studies and case reports.
IV: Opinions of respected authorities, consensus committees, clinical experience
