Hysteroscopy in the assessment of postmenopausal bleeding

Although postmenopausal bleeding (PMPB) is a frequent problem in clinical practice and as such has major clinical relevance, the management strategies are often quite different. This review, after an introduction describing the various causes of PMPB, analyses in which order diagnostic procedures are indicated. There is much concern in decreasing the rate of invasive procedures; this is possible with the aid of transvaginal ultrasound (TVS) which is very reliable in excluding endometrial cancer at a thickness of < or = 4 mm. The vast majority of benign and malignant endometrial changes have an endometrial thickness of > 4 mm. Since the specificity of TVS for a pathological finding at a thickness of > 4 mm is low, other investigations are needed. Saline infusion sonohysterography (SIS), an easy complementary tool to TVS, and office hysteroscopy seem to give the same results, the first one being better accepted by the patients, the latter permitting biopsies and resections to be performed at the same time. Anyway, in all these cases a histological diagnosis is mandatory (endometrial biopsy/D&C/hysteroscopic resection). In cases of persisting or recurrent PMPB, independent of the TVS result, a hysteroscopy (with biopsy and/or resection) is mandatory.