By Rebecca Bowers

EXECUTIVE SUMMARY

To inform clinical decision-making, investigators performed an analysis looking at the frequency of postmenopausal bleeding in endometrial cancers and the risk of endometrial cancer among women who have postmenopausal bleeding.

  • Postmenopausal bleeding can be a symptom of endometrial cancer. However, it also is associated with many benign conditions. Fewer than one in 10 women with postmenopausal bleeding will be diagnosed with endometrial cancer.
  • Transvaginal ultrasonography is indicated for an initial evaluation of postmenopausal bleeding if ultrasound images indicate a thin endometrial echo of 4 mm or less.

Is targeting women who have postmenopausal bleeding for early detection of endometrial cancer a useful strategy? To inform clinical decision-making, investigators performed an analysis looking at the frequency of postmenopausal bleeding in endometrial cancers and the risk of endometrial cancer among women who have postmenopausal bleeding.1

Unlike most cancers, endometrial cancer incidence and mortality rates in the United States have increased during the past several years.2 Fortunately, if detected early, endometrial cancer can be highly curable, says Megan Clarke, PhD, MHS, a postdoctoral fellow at the National Cancer Institute’s Division of Cancer Epidemiology and Genetics and lead author of the analysis.

In the current paper, Clarke says researchers set out to answer two important questions:

  • How common is postmenopausal bleeding among women with endometrial cancer, particularly in early-stage cancers that have a high likelihood of being cured?
  • How common is endometrial cancer in women with postmenopausal bleeding?

“Our study is the first to systematically evaluate these questions and provides precise estimates for the relationship between postmenopausal bleeding and endometrial cancer,” notes Clarke. “These estimates can be used to support risk-informed decision making in clinical management of women with postmenopausal bleeding.”

Review the Findings

For the systematic review and meta-analysis, researchers looked at 41,000 women from 129 studies. The review identified 34,000 women with postmenopausal bleeding and more than 6,000 women with endometrial cancer. Outcomes were pooled for the frequency of postmenopausal bleeding among women with endometrial cancer and the risk of endometrial cancer in women with postmenopausal bleeding.

The findings suggest that nine of 10 women diagnosed with endometrial cancer will present with postmenopausal bleeding, notes Clarke. “Importantly, this includes cancers at early stages that have a high chance of cure,” she states. “However, less than 10% of women with postmenopausal bleeding will be diagnosed with cancer.”

Talk With Patients

What are the ramifications for clinical practice? Providers should inform their female patients that postmenopausal bleeding can be a symptom of endometrial cancer and that they should seek medical attention if they experience this symptom, notes Clarke. However, clinicians also need to emphasize that postmenopausal bleeding is associated with many benign conditions and fewer than one in 10 women with postmenopausal bleeding will be diagnosed with endometrial cancer, she states.

Vaginal bleeding is the leading symptom in more than 90% of postmenopausal women who have endometrial carcinoma.3 The risk factors include age, obesity, unopposed estrogen use, and comorbidities such as polycystic ovary syndrome, type 2 diabetes mellitus, or the presence of atypical glandular cells in screening cervical cytology. Clinicians should consider a family history of gynecologic malignancy when evaluating postmenopausal bleeding.

The American College of Obstetricians and Gynecologists issued a committee opinion in early 2018 on the use of transvaginal ultrasonography to evaluate the endometrium in women who have postmenopausal bleeding.4 The opinion advises that transvaginal ultrasonography is indicated for an initial evaluation of postmenopausal bleeding if the ultrasound images indicate a thin endometrial echo of 4 mm or less. Transvaginal ultrasonography can be used as an alternative to endometrial sampling as an initial approach for postmenopausal women who have a first bleeding episode. If blind sampling does not detect endometrial hyperplasia or malignancy, then additional evaluation using hysteroscopy with dilation and curettage may be the most effective approach in evaluating women with bleeding that is persistent or recurrent. Use of transvaginal ultrasonography is not appropriate for screening postmenopausal women without bleeding for endometrial cancer, the opinion states.4

How can women lower their risk of endometrial cancer? Achieving and maintaining a healthy weight is one approach. According to the American Cancer Society, women who are overweight or obese have up to three and half times the risk for the disease, compared with women who are at a healthy weight. Research also indicates that increasing physical activity may help lower endometrial cancer risk.5

REFERENCES

  1. Clarke MA, Long BJ, Del Mar Morillo A, et al. Association of endometrial cancer risk with postmenopausal bleeding in women. A systematic review and meta-analysis. JAMA Intern Med 2018; doi:10.1001/jamainternmed.2018.2820. [Epub ahead of print].
  2. Gaber C, Meza R, Ruterbusch JJ, Cote ML. Endometrial cancer trends by race and histology in the USA: Projecting the number of new cases from 2015 to 2040. J Racial Ethn Health Disparities 2016; doi:10.1007/s40615-016-0292-2. [Epub ahead of print].
  3. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med 2001;20:1025-1036.
  4. ACOG committee opinion no. 734 summary: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol 2018;131:945-946.
  5. Schmid D, Behrens G, Keimling M, et al. A systematic review and meta-analysis of physical activity and endometrial cancer risk. Eur J Epidemiol 2015;30:397-412.