Obstetrics/Gynecology

PCP submission

59 y/o F with postmenopausal bleeding after starting estrogen/progesterone supplementation for bones, vaginal atrophy and sleep. Recent US showed 6 mm endometrial cyst vs. fluid collection in the fundal endometrium. Endometrial strip 0.2 cm thickness. No solid endometrial lesions visualized. Uterine myometrium heterogenous but otherwise negative with no focal myometrial lesions seen. 

Does this patient need a uterine bx based on US results? Does she have to stop estrogen? Or could we try a smaller dose of estrogen? Any thoughts are welcome!

Specialist response

Thanks for this consult. An endometrial biopsy can be appropriately deferred for now. Postmenopausal bleeding bleeding is not uncommon among patients starting combined (ie estrogen-progestin) hormone therapy. It is particularly common if taking cyclic progesterone and in the early months of therapy. If PMB continues beyond 6 months in patients using a continuous progesterone regimen, endometrial evaluation is warranted. This can be with TVUS or endometrial biopsy. An endometrial stripe measuring <5mm has 98-99% sensitivity in excluding endometrial cancer. In other words if the endometrial stripe is homogeneous and less than or equal to 4mm you can be reassured that there is < 1% risk that the cause of the bleeding is endometrial cancer and endometrial sampling is not required. So to summarize since the patient is early in her initiation of HRT and her EE is <5mm EMB can be deferred. You can continue HRT at this dose for now and if bleeding persists after 6mo reevaluate with either TVUS or biopsy.