A patient presents with postmenopausal bleed. Endometrial biopsy will be done if endometrial thickness is:
Ans: (b) 5 mmRef: DC Dutta's Textbook of Gynecology, Page 561; Berek and Novak's Gynecology, Page 1978Causes of postmenopausal bleedingBenign conditionsMalignant conditions*. Senile endometritis*. Atrophic endometrium*. Dysfunctional uterine bleeding*. Uterine polyp*. Tubercular endometritis*. Cervical erosion and polyp*. Senile vaginitis*. Decubitus ulcer*. Retained and forgotten pessary or IUCD*. HRT*. Urethral caruncle, polypEndometrial hyperplasiaGenital malignancy-Carcinoma of the cervix, endometrium, vagina, vulva and Fallopian tube Granulosa cell tumor of the ovarySarcoma uterusOne-third of the cases of PMB are due malignancy, commonly due to endometrial and cervical carcinoma.Abnormal perimenopausal and postmenopausal bleeding should always be taken seriously and be properly investigated.Invasive tumors of the cervix, vagina and vulva are usually evident on local and Speculum examination and any lesion identified should be biopsied.If any visible cervical growth - biopsy is taken for histology.If cervix apparently looks normal - cervical and endocervical smear to exclude dysplasia or CIN.The possibility of uterine source of bleeding must always be eliminated.Uterine Causes of Postmenopausal BleedingCause of BleedingPercentage %Endometrial atrophy (Most common)60-80Estrogen replacement therapy15-25Endometrial polyps2-12Endometrial hyperplasia5-10Endometrial cancer10DIAGNOSIS OF UTERINE PATHOLOGYOffice endometrial aspiration biopsy is the accepted first step in evaluation of perimenopausalAUB or PMBDiagnostic accuracy is 90 - 98%.Endocervical curettage is performed at the time of endometrial biopsy if cervical pathology is suspected.Hysteroscopy and D&CReserved for cases of cervical stenosis, patient intolerance for OPD aspiration biopsy, bleeding recurs after a negative endometrial biopsy or if the specimen obtained is inadequate.Hysteroscopy is more accurate in identifying polyps and submucous myomas.Transvaginal sonography (TVS) is a useful adjunct to endometrial biopsy for selecting patients for further evaluationTVS +/-SIS (saline infusion sonography) - helps to distinguish between patients with postmenopausal atrophic endometrium and those with significant amount of endometrial tissue or polyps who need further evaluation.The finding of ET>4mm, a polypoid endometrial mass, or collection of fluid within the uterus requires further evaluation.Pap smear-Only 30% to 50% of patients with endometrial cancer have abnormal Pap test results.
3 mm
5 mm
7 mm
8 mm
Physiology & Histology