Question:
“I am 45 years old recently menopausal based on no periods for 18 months and confirmation by labs. I recently was having pelvic pressure and went to my ob/gyn. He ordered a transvaginal ultrasound that showed thickened endometrium (15) which he said needed to be biopsied. After the ultrasound, I began to have heavy bleeding which lasted several weeks. He placed me on progesterone to stop the bleeding. When I went back for the biopsy (4 weeks later), he said there was not much to biopsy because of the shedding of the lining from the bleeding. The biopsy returned negative. I am still taking the progesterone daily with no more bleeding. I have a follow up in 4 more weeks. The biopsy was negative. Should I still be concerned about this? I have no personal or family history of any type of cancer except my maternal grandmother with colon cancer in her very late 70’s.”
Answer:
I think you and your doctor are paying attention to this episode of postmenopausal bleeding so there is no cause for alarm. Concern is appropriate, but what I mean by “concern” is having a care plan and following it – which is exactly what you are doing.
I think you are also asking whether your current treatment plan is sufficient to rule out endometrial cancer. Below are my thoughts.
You mentioned no personal family history. The other risk factors for endometrial cancer are increasing age, nulliparity (never having given birth), diabetes, more estrogen than progesterone in the body, obesity, and family history—so these should be taken into account when weighing the pros and cons of any additional work-up at this point.
There is a greater incidence of postmenopausal bleeding in the first years since menopause, like what you had. There are many causes including: benign endometrial growth (proliferative endometrium), polyp, hyperplasia without atypia (a type of overgrowth), hyperplasia with atypia (overgrowth that is precancer) or cancer – which has an overall incidence of ~ 6-10%
In one analysis, the risk of cancer in someone with bleeding who is not on hormone therapy and has a thickened endometrium was found to be as high as 19%. (Clarke et al. Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis, JAMA Intern Med. 2018;178(9):1210)
In your case, the spontaneous bleeding and the progesterone probably thinned the endometrium such that there wasn’t much tissue to biopsy. The question is whether this scant biopsy sufficiently excludes cancer. The result is reassuring because your tissue was negative. On your follow up visit, your doctor may want to do an ultrasound to check if, indeed, your lining thinned (as opposed to missing thickened tissue on biopsy) and is in the normal postmenopausal range of ≤4mm. If your uterine lining is still thickened, your doctor may want to do another biopsy or schedule you for a D & C with hysteroscopy. He might also want to do one of these tests if he deems that the first biopsy was “nondiagnostic” meaning the scant tissue was not enough for adequate assessment.
With no more bleeding, and if the uterine lining is normal on ultrasound, the approach is typically to do nothing unless you have another bleeding episode. Some doctors may want to repeat an ultrasound in a few months.
If you have any more bleeding episodes, then diagnostic options include a hysteroscopy with D & C or a saline-infusion ultrasound as an alternative procedure to assess the cavity, along with a biopsy.
If you have additional risk factors for endometrial cancer (such as mentioned above), one of these procedures may also be considered now.
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