One more thing: When a postmenopausal patient bleeds, make sure you don't skip this step

Is your postmenopausal patient bleeding? Make sure you include endometrial sampling in your workup to rule out endometrial cancer.

That was the message issued recently by the College of Physicians and Surgeons of Manitoba, which gleaned the recommendation as a “lesson learned” from a discipline case.

“The most common initial presentation for endometrial cancer is abnormal vaginal bleeding and any postmenopausal bleeding should be promptly investigated to rule out endometrial cancer,” the CPSM posted on its website. 

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The case that yielded this lesson involved a postmenopausal patient who reported vaginal bleeding along with bloating and occasional loss of bladder control. The physician found on examination that the patient had a small cervical ostium and referred for an ultrasound. The patient’s chart showed no comments about the role of an endometrial biopsy.

The ultrasound—which took four months to book because the referral was made during the pandemic—revealed a thin, two-millimetre endometrial lining and a cavity “distorted by fibroids,” according to the CPSM post.

“At follow-up, the provider noted that blood was visible at the cervix, but because the cervical os appeared small and atrophic, an endometrial sample could not be obtained,” wrote the college. “The patient was therefore referred for endometrial sampling.”

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The pathology report from the subsequent endometrial aspiration indicated a high-grade endometrial cancer. This finding came four-and-a-half months after the patient had initially presented with postmenopausal bleeding.

This case should remind physicians about the importance of investigating postmenopausal bleeding in a timely manner, and of being aware that ultrasounds are not reliable for high-grade endometrial cancers.

“Timely endometrial sampling (or referral for such) should be prioritized, particularly if there is a delay in accessing diagnostic imaging and when symptoms persist despite a double wall endometrial thickness of ≤ 5mm,” wrote the college. 

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