#obgyn

Diagnostic Evaluation
Though most women with PMB will have atrophic vulvovaginitis or some other benign underlying cause, all women with PMB should be evaluated to rule out endometrial cancer, since 15-20% of women with this symptom will have the disease. The risk of harbouring endometrial cancer increases with age from a low of 15% in the immediately postmenopausal cohort to [...]% in patients 80 years or older.

Initial evaluation should include a relevant history and physical examination, which must include a pelvic examination. An endometrial biopsy should be performed and any obvious lesion of the cervix or vagina should be biopsied directly. Endocervical curettage (ECC) should be considered if there is clinical concern regarding the possibility of cancer within the endocervical canal.

Endometrial sampling should be routinely considered for patients with PMB to rule out endometrial cancer.

Pelvic ultrasound can occasionally be useful as an adjunct to pelvic examination and endometrial sampling in the evaluation of women with PMB. This test is most useful in women where adequate endometrial sampling is not feasible without invasive methods (ie D+C +/- hysteroscopy). Ultrasound performed using an endovaginal probe can serve two purposes: to rule out the presence of other pelvic pathology not detected on pelvic examination (e.g. ovarian neoplasms) and to directly measure the endometrial thickness as a surrogate for the likelihood of an underlying endometrial carcinoma. An endometrial thickness of 5mm or more is considered abnormal. Although women with a thin endometrium rarely have an underlying type I endometrial cancer, women with type II endometrial cancer may have an endometrial thickness less than 5mm. A thickened endometrium is not always indicative of an underlying endometrial cancer, as large endometrial polyps, submucous fibroids, characteristic tamoxifen effects (subendothelial cystic hyperplasia), or adenomyosis may result in an apparent thickened endometrium on ultrasound. As a result of this lack of diagnostic sensitivity and specificity, ultrasound is not acceptable as an alternative to pelvic examination or endometrial sampling for ruling out endometrial cancer in patients with PMB.

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