Abstract
We evaluated the interpretation of atrophic endometrium (AE) histology as the most common cause for postmenopausal bleeding (PMB). This theory has been accepted for several generations by gynecologists and gynecologic oncologists and has been published in past and current major gynecology textbooks. In our review of the literature, we did not find sufficient histological or clinical proof for this concept. In our view, AE is not a cause of PMB and we back this up with a review of old and current medical literature. The old studies are based on information which was obtained prior to the existence of transvaginal sonogram, sonohysterogram and hysteroscopy. Focal lesions are notorious for being missed by endometrial sampling and curettage. Recent studies show that focal endometrial lesions are a crucial cause for PMB and some of those lesions can harbor cancer. In our opinion, AE is the most common histology found because it is physiologic and a ubiquitous finding in postmenopausal women, but it is not a cause of PMB. Referring to AE as a cause of PMB may result in misdiagnosis of cancer, management delay and unnecessary intervention. To avoid misdiagnosis of cancer, transvaginal sonogram should be considered in all women with PMB and AE on pathology. If endometrial thickness is found, AE is unlikely to be the cause of the PMB and further workup is warranted to reveal the true etiology for the bleeding.
References
Astrup K, Olivarius NDF (2004) Frequency of spontaneously occurring postmenopausal bleeding in the general population. Acta Obstet Gynaecol Scand 83:203–207
Moodley M, Roberts C (2004) Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol 24:736
The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. ACOG Committee Opinion No 734. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131(5): e124–e129
Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R et al (2001) Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med 20:1025–1036
Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, Brand R, Grady D (1998) Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 280(17):1510–1517
Gredmark T, Kvint S, Havel G, Mattsson LA (1995) Histopathological findings in women with postmenopausal bleeding. Br J Obstet Gynaecol 102(2):133–136
Van den Bosch T, Ameye L, Van Schoubroeck D et al (2015) Intra-cavitary uterine pathology in women with abnormal uterine bleeding: a prospective study of 1220 women. Facts Views Vis Obgyn 7:17
Kurman RJ, Lora HE, Ronnett BM (Eds) (2011) Blaustein’s pathology of the female genital tract, 6th edn, p 382
Buckley CH, Fox H (2002) The normal endometrium, as seen in biopsy material. In: Buckley CH, Fox H (eds) Biopsy pathology of the endometrium, 2nd edn. Arnold, London, pp 27–42
Te Linde RW (1940) Causes of postmenopausal bleeding. Am J Surg 48:289
Novak EB (1964) Postmenopausal bleeding. Clin Obstet Gynecol 7(2):64–475
Dreisler E, Stampe Sorensen S, Ibsen PH, Lose G (2009) Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20–74 years. Ultrasound Obstet Gynecol 33(1):102–108
Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL (2016) Trends in obesity among adults in the United States, 2005–2014. JAMA 315(21):2284–2291
Marczak L, O’Rourke K, Shepard D (2016) When and why people die in the United States, 1990–2013. JAMA 315(3):241
Paloucek FP, Graham JB, Randall CL (1967) Benign postmenopausal vaginal bleeding. JAMA 199(10):701–703
Schumamm E, Hyatt R (1952) Postmenopausal vaginal bleeding. Obstet Gynecol Surv 7(4):544–546
Kanter AE, Klawand AH (1950) Postmenopausal bleeding. Urg Clin N Am 30(1):287–297
Brzezinsky A, Bromberg YM (1953) Significance of postmenopausal genital bleeding in Jewish women. Obstet Gynecol 1(3):359–363
Evans TN (1958) Postmenopausal bleeding. Clin Obstet Gynecol 1(3):809–818
Meyer WC, Malkasian GD, Dockerty MB, Decker DG (1971) Postmenopausal bleeding from atrophic endometrium. Obstet Gynecol 38(5):731–738
Rahn DD, Carberry C, Sanses TV, Mamik MM, Ward RM, Meriwether KV, Olivera CK, Abed H, Balk EM, Murphy M (2014) Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol 124(6):1147–1156
Ferenczy pathophysiology of endometrial bleeding Maturitas 2003;45(1):1–14
Berek & Novak's gynecology (14th ed Berek, Jonathan S. Lippincott Williams & Wilkins, 2007. p 1349. Table 33.3: Causes of Postmenopausal Bleeding
http://www.uptodate.com/contents/postmenopausal-uterine-bleeding#H19
http://www.webmd.com/menopause/guide/postmenopausal-bleeding
JB Halter, JG Ouslander et al. Hazzard's geriatric medicine and gerontology, 7e gynecologic disorders table 42–4: differential diagnosis of vaginal bleeding in older women
https://www.health.harvard.edu/womens-health/abnormal-uterine-bleeding-in-peri-and-postmenopausal-womenPublished: January, 2011
Ortiz ME, Croxatto HB (2007) Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception 75(6 Suppl):S16-30 (Epub 2007 Mar 29)
American College of Obstetricians and Gynecologists (2011) ACOG Practice Bulletin No 121: long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 118(1):184–196
M Sinha, R Rani, R Gupta, K Chand, G Kaur, L Loop (2015) Inserted 45 years back: the dilemma to remove it or leave it in situ. A case report with review of literature. Clin Diagn Res. 9(430)
Cicinelli E, De Ziegler D, Nicoletti R, Colafiglio G, Saliani N, Resta L, Rizzi D, De Vito D (2008) Chronic endometritis: correlation among hysteroscopic, histologic, and bacteriologic findings in a prospective trial with 2190 consecutive office hysteroscopies. Fertil Steril 89:677–684
Garuti G, Sambruni I, Colonnelli M, Luerti M (2001) Accuracy of hysteroscopy in predicting histopathology of endometrium in 1500 women. J Am Assoc Gynecol Laparosc 8(2):207–213
Rotenberg O, Renz M, Reimers L, Doulaveris G, Gebb J, Goldberg GL, Dar P (2015) Simultaneous endometrial aspiration and sonohysterography for the evaluation of endometrial pathology in women aged 50 years and older. Obstet Gynecol 125:414
Astrup K, Olivariusnde F, Møller S, Gottschau A, Karlslund W (2004) Menstrual bleeding patterns in pre- and perimenopausal women: a population-based prospective diary study. Acta Obstet Gynecol Scand 83(2):197–202
Astrup K, Olivariusnde F (2004) Frequency of spontaneously occurring postmenopausal bleeding in the general population. Acta Obstet Gynecol Scand 83(2):203–207
Burbos N, Musonda P, Giarenis I, Shiner AM, Giamougiannis P, Morris E, Nieto JJ (2010) Age related differential diagnosis of vaginal bleeding in postmenopausal women: a series of 3047symptomatic postmenopausal women. Menopause Int 16(1):5–8
Manson JE (2012) Overview on menopause. Chapter 1 page 4. http://www.menopause.org/docs/2012/cg_a.pdf.
Magos AL, Brincat M, Studd JW, Wardle P, Schlesinger P, O’Dowd T (1985) Amenorrhea and endometrial atrophy with continuous oral estrogen and progestogen therapy in postmenopausal women. Obstet Gynecol 65(4):496–499
Epstein E, Ramirez A, Skoog L, Valentin L (2001) Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. Acta Obstet Gynecol Scand 80(12):1131–1136
Ferrazzi E, Torri V, Trio D, Zannoni E, Filiberto S, Dordoni D (1996) Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal bleeding. An Italian multicenter study. Ultrasound Obstet Gynecol 7:315–321
Geels YP, Pijnenborg JM, van den Berg-van-Erp SH, Bulten J, Visscher DW, Dowdy SC, Massuger LF (2012) Endometrioid endometrial carcinoma with atrophic endometrium and poor prognosis. Obstet Gynecol 120(5):1124–1131
van Hanegem N, Breijer MC, Slockers SA, Zafarmand MH, Geomini PMAJ, Catshoek R, Pijnenborg JMA, van der Voet LF, Dijkhuizen FPHLJ, van Hoecke GCR, Reesink-Peters N, Veersema S, van Hooff MHA, van Kesteren PJM, Huirne JA, Opmeer BC, Bongers MY, Mol BWJ, Timmermans A (2017) Diagnostic workup for postmenopausal bleeding: a randomised controlled trial. BJOG 124(2):231–240. https://doi.org/10.1111/1471-0528.14126
Bansal N, Herzog TJ, Burke W, Cohen CJ, Wright JD (2008) The utility of preoperative endometrial sampling for the detection of uterine sarcomas. Gynecol Oncol 110(1):43–48
Obstetrics and Gynaecology: an evidence-based guide 2nd Edition Chapter 19, p 257
ACOG: Frequently asked questions. Perimenopausal bleeding and bleeding after Menopause.https://www.acog.org/~/media/For%20Patients/faq162.pdf. November 2018
RACGP: The women with postmenopausal women bleeding. Reprinted from Australian Family Physician Vol. 36, No. 3, March 2007
Otify M, Fuller J, Ross J, Shaikh H, Johns J (2015) Endometrial pathology in the postmenopausal woman—an evidence based approach to management. Obstet Gynaecol 17:29–38
Funding
The authors declare they did not receive any funding for this manuscript.
Author information
Authors and Affiliations
Contributions
The authors whose names are listed immediately above certify that they both contributed to the creation of this manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare they do not have any conflict of interest. The authors whose names are listed immediately above certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Ethical approval
This article does not contain any studies with human participants performed by any of the authors.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Rotenberg, O., Goldberg, G.L. The significance of “atrophic endometrium” in women with postmenopausal bleeding. Arch Gynecol Obstet 306, 579–583 (2022). https://doi.org/10.1007/s00404-022-06540-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00404-022-06540-1