The First-Line Investigation of Postmenopausal Bleeding

Abstract

Postmenopausal bleeding is a common problem in clinical practice with significant implications; however, the diagnostic strategies often vary among different centers. In the recent years, there was a trend to adopt less invasive procedures without compromising efficacy and safety. There is continuous debate about the different available modalities for investigation, and a large number of studies were conducted to define their roles. Some authors recommended that hysteroscopy should be the standard investigation procedure for women with postmenopausal bleeding. Nonetheless, there is a strong evidence to suggest that transvaginal ultrasound scanning, with or without endometrial biopsy, is a safe and more cost-effective initial tool in investigating these women. This commentary highlights this important issue and discusses the role of these different modalities.

Saline infusion sonohysterography versus hysteroscopy for uterine cavity evaluation

“…3D SIS is also recommended in patients with normal TVS who are unresponsive to medical management 8. Evaluation of AUB is of special importance in postmenopausal women, because of the high prevalence of endometrial cancer in these women 9. Ninety-five percent of women with endometrial cancer present with postmenopausal bleeding.…”

“…It allows for direct visualization of the endometrial cavity, with accurate assessment of intracavitary lesions,13 and thus, accurate removal of lesions such as polyps and submucosal fibroids 913. However, it provides limited assessment with regard to the myometrial extension of the fibroid 13.…”

“…The gold standard for diagnosis of intrauterine abnormalities is diagnostic hysteroscopy combined with a histological examination of endometrial aspiration or biopsy 1569–12. Hysteroscopy is invasive, reasonably expensive, time consuming, and involves general anesthesia 9–11. Hysteroscopy is also associated with risks like uterine perforation and ascending genitourinary infection 1013…”

“…Three-dimensional saline infusion sonography (3D SIS) in comparison to hysteroscopy is less invasive, cheaper, and does not require general anesthesia 910. 3D SIS reliably evaluates uterine contour, adhesions, and focal pathologies 8.…”

“…Furthermore, in 3D SIS, after distending the cavity with saline, there is clear visualization of the inner surface of both sides of the endometrium 813. Focal and diffuse abnormalities can be distinguished, and in most cases an endometrial polyp can be differentiated from the submucous fibroid based on the imaging characteristics 89. The polyps are typically round in shape, smooth in outline, and are generally echogenic, compared to the endometrium or are isoechoic to it.…”