Role of imaging in a postmenopausal woman with vaginal bleeding
Endometrial polyps, endometrial hyperplasia, submucosal fibroids, and endometrial cancer can all present with vaginal bleeding. Although vaginal bleeding is most often due to a benign etiology, imaging can be performed to exclude an underlying anatomic cause and potentially guide tissue sampling if needed. Transvaginal US is the first line of imaging because it can visualize the endometrium and assess endometrial thickness. Endometrial thickness greater than 4 mm on US has a sensitivity of 98% for detection of endometrial cancer and requires further workup, whereas endometrial thickness of 4 mm or less has a negative predictive value of 99%. Sonohysterography and MRI may be performed for further evaluation as needed. Tissue sampling of the endometrium may be warranted using dilation and curettage (D&C) or hysteroscopy to enable visualization of the endometrium and directed biopsies. A diagnostic feature favoring endometrial cancer rather than endometrial hyperplasia or polyp is the presence of myometrial invasion or metastatic disease.