Analysis of Timely Follow-Up in the Evaluation of Postmenopausal Bleeding

To characterize guideline-adherent follow-up in patients evaluated with transvaginal ultrasonography (TVUS) for postmenopausal bleeding.

We conducted a retrospective study of patients with an intact uterus and postmenopausal bleeding who presented to a single academic institution and underwent TVUS between January 2013 and December 2022. Primary outcome measures were prompt follow-up, defined as receipt of endometrial sampling within 3 months of a finding of thickened or inadequately visualized endometrium, diagnosis of endometrial cancer, cancer stage at diagnosis, and rates of tissue sampling. Associations between sociodemographic variables and prompt follow-up were assessed. A Pareto analysis was performed to describe reasons for lack of prompt follow-up.

Of 1,671 patients with thickened endometrium, 307 (18.4%) did not receive prompt follow-up; of 389 patients with inadequately visualized endometrium, 128 (33.0%) did not receive prompt follow-up. Sociodemographic variables were not associated with prompt follow-up. Clinician-related factors, including misinterpretation of ultrasound results, accounted for 46.1% of delayed or absent follow-up for thickened endometrium and 58.4% of inadequately visualized endometrium. The rates of diagnosing endometrial cancer within 1 year were similar after findings of thickened endometrium (8.8%; 95% CI, 7.5-10.3%) compared with inadequately visualized (7.7%; 95% CI, 5.3-10.9%) endometrium.

Clinician misinterpretation of TVUS performed for postmenopausal bleeding was the most common reason for delayed or absent follow-up. Given observed suboptimal rates of prompt follow-up after findings of thickened or inadequately visualized endometrium on ultrasonography and similar rates of an eventual cancer diagnosis in these cohorts, efforts should be focused on clinician understanding of ultrasonographic endometrial evaluation. To simplify the diagnostic process and reduce the risk of missing a cancer diagnosis, universal endometrial sampling for patients with postmenopausal bleeding could be considered.