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Endometrial cancer and postmenopausal bleeding
Every postmenopausal bleed is endometrial cancer until proven otherwise; transvaginal ultrasound with an endometrium of 4 mm or less is reassuring, while a thicker endometrium or recurrent bleeding requires a biopsy.
Why it matters in the exam
This is the most common gynaecological cancer in the Western world, and in the exam it appears mainly through the question "a 60-year-old woman with vaginal bleeding — what is the next step". The answer is transvaginal ultrasound or an endometrial biopsy (Pipelle), and if the biopsy is non-diagnostic or bleeding continues — hysteroscopy. Further questions deal with the risk factors, all linked to oestrogen unopposed by progesterone: obesity, nulliparity, early menarche and late menopause, polycystic ovary syndrome, tamoxifen, and oestrogen-secreting ovarian tumours (granulosa cell).
Know the difference between the endometrioid type (hormonal, common, good prognosis) and the serous type (older women, unrelated to oestrogen, aggressive), and the newer molecular classification (POLE, mismatch-repair deficiency, abnormal p53) that changes treatment. Lynch syndrome is the main hereditary cause, so mismatch-repair proteins are tested in every tumour. The basic treatment is surgery: hysterectomy and removal of the ovaries with sentinel node sampling. Hyperplasia without atypia is treated with a progestin, and atypical hyperplasia with hysterectomy, unless the woman wishes to preserve fertility.
Key points
- Postmenopausal bleeding = exclude endometrial cancer.
- Endometrium 4 mm or less is reassuring; above that or recurrent bleeding → biopsy.
- Risk factors: unopposed oestrogen, Lynch, tamoxifen.
- Atypical hyperplasia → hysterectomy (or progestin to preserve fertility).
- Treatment: hysterectomy, removal of the ovaries and sentinel node; molecular class guides further treatment.
Summary table
| Situation | Finding | Treatment | Exam notes |
|---|---|---|---|
| Postmenopausal bleeding | Endometrium 4 mm or less on transvaginal ultrasound | Surveillance; biopsy if bleeding recurs | Very high negative predictive value |
| Thick endometrium | Above 4 mm | Biopsy (Pipelle); non-diagnostic → hysteroscopy and curettage | On tamoxifen the endometrium is thick anyway — decide by bleeding |
| Hyperplasia without atypia | Low cancer risk | Progestin, preferably a hormonal IUD (LNG-IUD) | Follow-up biopsies |
| Atypical hyperplasia (EIN) | Up to about 40% with coexisting cancer | Hysterectomy; for fertility preservation — high-dose progestin and close follow-up | A precancerous lesion |
| Stage I-II | Confined to the uterine body (I) or the cervical stroma (II) | Hysterectomy, removal of the ovaries and sentinel node; radiotherapy by risk | IA: less than 50% myometrial invasion |
| Stage III-IV | Serosa, ovaries, vagina or nodes (III); bladder, bowel or distant spread (IV) | Surgery and debulking, chemotherapy and radiotherapy | The serous type spreads early to the peritoneum |
A free exam question
מה מאפיין את התקלה הגנטית ב- SYNDROME LYNCH? (the question as examined, in Hebrew)
- א. AR מוטאציה אוטוזומאלית רצסיבית
- ב. MMR GENES DNA -מקבץ של מוטאציות ב
- ג. מוטאציה הגורמת לחוסר יציבות בגנים מקבוצת ה- .CHECK
- ד. MSH3 MSH5. -מוטאציות ב
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Sources
- ESGO/ESTRO/ESP Guidelines for the management of patients with endometrial carcinoma, 2021 — Diagnosis, molecular classification and treatment
- FIGO staging of endometrial cancer, 2023 — Endometrial cancer staging
- ACOG Committee Opinion No. 734, 2018 — The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding
- Berek and Novak's Gynecology, 16th edition (2019) — Uterine Cancer
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.