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Transvaginal Ultrasound in the Evaluation of Postmenopausal Bleeding


Postmenopausal uterine bleeding needs to be evaluated quickly and transvaginal ultrasound can play an important role in the initial work-up.

Endometrial Thickness  

  • Measure the maximum anterior-posterior thickness on a long-axis transvaginal view 
  • Transvaginal ultrasound is appropriate for the initial evaluation  
  • Thin endometrial echo  
    • Defined as ≤4mm   
    • Endometrial fluid should not be included in measuring endometrial thickness
    • >99% NPV for endometrial cancer 
    • Cannot exclude all pathology, including endometrial cancers such as uterine papillary serous, mucinous, clear cell  
  • Thickened endometrium is not diagnostic of a particular pathology  

Recommended Management 

  • Transvaginal ultrasound  
    • Should only be used as an initial evaluation if there is low prior probability for cancer or hyperplasia   
    • Additional evaluation is required if persistent/recurrent bleeding  
    • Either transvaginal ultrasound or endometrial sampling are ‘reasonable’ alternatives as first line – both not required if low risk
    • Proceed to endometrial sampling if abnormal endometrium is seen on transvaginal ultrasound  
  • Endometrial sampling  
    • First-line test if clinical risk factors are present (see ‘Endometrial Cancer: The Basics’ in ‘Related ObG Topics’ below) or clinical presentation is suspicious  
    • Outpatient endometrial sampling using disposable device is method of choice  
    • NOTE: Proceed to hysteroscopy with D&C if persistent or recurring bleeding and blind sampling is negative for endometrial hyperplasia or malignancy 


  • If transvaginal ultrasound image inadequate proceed to following options  
    • Sonohysterography | Office hysteroscopy | Endometrial sampling   
  • If insufficient tissue on endometrial sampling 
    • Transvaginal ultrasound can be used to further evaluate and if a thin echo is seen and bleeding has stopped, no further work-up is necessary  
    • Persistent/recurrent bleeding needs a histologic evaluation even in the presence of a thin echo 
  • Postmenopausal women who are not bleeding 
    • Transvaginal ultrasound should not be used as a screening tool for endometrial cancer in this population  
    • If an endometrial echo >4mm is found incidentally, this is not an automatic ‘trigger’ for further evaluation but rather should be placed in context and “individualized … based on patient characteristics and risk factors”  

Learn More – Primary Sources:  

ACOG Committee Opinion 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding