According to ACOG, approximately 90% of patients diagnosed with endometrial cancer have postmenopausal bleeding. Read more on the College's updated recommendations below.
Since approximately 90% of patients diagnosed with endometrial cancer have postmenopausal bleeding, and because of a steady increase in endometrial cancer incidence in recent decades, the American College of Obstetricians & Gynecologists (ACOG) has released updated guidance for evaluating postmenopausal bleeding.1
The medical society recommends a combination of transvaginal ultrasonography and endometrial tissue sampling be used as part of the initial evaluation in most patients with postmenopausal bleeding. “This guidance is designed to support clinicians to perform earlier and more comprehensive screenings,” said ACOG President Steven J. Fleischman, MD, MBA, FACOG, in a statement. “It gives clinicians a more robust framework for evaluating patients with postmenopausal bleeding—one that prioritizes prompt diagnosis and reduces the risk that a cancer is missed.”
The following updated clinical guidance was published in Obstetrics & Gynecology.
“The combination of both transvaginal ultrasonography and endometrial tissue sampling is recommended as part of the initial evaluation in most patients with postmenopausal bleeding. Transvaginal ultrasonography without endometrial biopsy may be used during initial evaluation of select patients with a single episode of postmenopausal bleeding and a sonographically fully visualized endometrium not thicker than 4 mm, without factors strongly associated with increased risk of endometrial cancer, who are counseled that continued or recurrent bleeding requires immediate re-evaluation, and for whom there are no significant barriers to prompt gynecologic evaluation.”2
For some patients with postmenopausal bleeding—defined as bleeding presumed to be from the uterus 12 or more months after the final menstrual period—relying on ultrasound alone can impose a greater risk of missing a cancer diagnosis. ACOG references recent data that suggested that 5% to 12% of cancers may not be diagnosed on initial presentation.1
According to the College, the updated and dual approach is meant to help clinicians promptly diagnose and treat endometrial cancer in patients who could be falsely reassured by ultrasound results, with the potential to reduce care-associated burdens for patients with limited access to easily-accessible gynecologic, radiologic, and oncologic care.
“ACOG’s updated guidance reflects a meaningful shift in how clinicians approach postmenopausal bleeding,” said David Shalowitz, MD, MSHP, FACOG, author of the guidance and a gynecologic oncologist, in a news release. “Current recommendations for using endometrial thickness by ultrasonography as a triage tool are associated with an unacceptably low sensitivity for malignant and premalignant endometrial pathology. By recommending tissue sampling as part of the initial evaluation for most patients, we are giving clinicians a more reliable path to detecting and treating uterine cancer.”
Additionally, the updated guidance acknowledges and addresses disproportionate incidence and mortality rates for endometrial cancer among Black women, noting that the incidence of endometrial cancer rose 2.7% per year through 2022 in Black women compared with 0.7% for White women. Further, the risk of death because of endometrial cancer from 2019 to 2023 for non-Hispanic Black women was 9.8 per 100,000 women per year, which is more than twice the risk for non-Hispanic White women (4.8 per 100,000 women per year), according to the guidance authors.2
ACOG stated early data is encouraging, as “patients are more likely to undergo endometrial sampling at their initial evaluation when clinicians engage in patient-centered counseling and share educational materials on the topic. As with any procedure, the decision to proceed with endometrial sampling should result from shared decision making and reflect patients’ values and preferences.”
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