What Is the Recurrence Rate of Postmenopausal Bleeding in Women Who Have a Thin Endometrium During a First Episode of Postmenopausal Bleeding

The risk of recurrent postmenopausal bleeding in women whose endometrial thickness after a first episode was 4 mm or less could have major implications for management. If the recurrence rate is low, follow-up by transvaginal ultrasonography (TVU) would suffice. In contrast, a high recurrence rate (or the diagnosis of malignancy at follow-up) would call for immediate endometrial sampling. The investigators, from 7 university-affiliated teaching hospitals in The Netherlands, practiced expectant management for consecutive patients not on hormone replacement therapy who presented with a first episode of postmenopausal bleeding and were found to have a thin endometrium. Of 607 women with a first episode of postmenopausal bleeding, 249 had an endometrial thickness of 4 mm or less. During a median follow-up of approximately 3.25 years, 25 of these 249 women (10%) had recurrent bleeding. The median interval before bleeding recurred was 49 weeks. Two patients with recurrent bleeding proved to have endometrial carcinoma and another had malignant melanoma. Recurrent bleeding appeared not to correlate with age, time since menopause, body mass index, hypertension, diabetes, or anticoagulant therapy. Whether or not endometrial sampling was carried out in the office at initial presentation did not influence the findings. There was, however, a significant difference in recurrent bleeding between patients who underwent hysteroscopy and/or dilatation and curettage at initial workup (5/21) and those who did not (20/208). The hazard rate ratio was 2.8, with a 95% confidence interval of 1.05 to 7.5. These findings endorse the use of TVU as an initial measure in women with postmenopausal bleeding. It is, however, vital that patients who are managed expectantly be reevaluated and have endometrial sampling should bleeding recur.