Post Menopausal Bleeding Workup

[anonperson]

I wanted to get some input and get a general consensus on post menopausal bleeding work up.

Hypothetical case:

65 year old- one episode of post menopausal bleeding/spotting a month ago. Normal BMI (<30), No DM or tamoxifen use. Otherwise healthy

TVUS shows a small uterus with an endometrial stripe of 8mm. Pelvic exam normal. Pap smear neg for malignancy. In office endometrial biopsy path report comments on benign endometrium with no evidence of hyperplasia, atypia, or malignancy.

Does this end the work up or does this patient require a D+C with hysteroscopy? I've heard some conflicting things from attendings, some of whom comment that the in office biopsy's value is to rule in cancer and a negative result doesn't mean much. Others say with only one episode of bleeding, they would reassess only if the bleeding persisted.

I guess my confusion lies in the fact that the stripe is thickened and although a using a pipelle to biopsy is a useful test, I was under the impression that it sampled a very small portion of the cavity and would miss any focal lesions.

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[THP]

Really good question and a scenario you will continue to encounter the rest of your career. Was she on HRT? Does she take a lot of soy products? I once had a patient who was having abnormal bleeding and would self treat with massive amounts of soy supplements because she noticed the bleeding would slow when she took and ended up having a very thickened stripe and needed a D&C. Only simple hyperplasia . . . but I digress.

Supposedly the endometrial biopsy has 95% concordance with D&C. At 8mm you can definitely make an argument for doing the D&C and I typically use the endometrial biopsy to "rule in" cancer. However, given that the path was completely normal I think it would be entirely reasonable to treat her with progestins for 3-6 months with a follow up US. She either needs a D&C or medical treatment in my opinion.