The most important role of the gynecologist–when it comes to the evaluation of post-menopausal bleeding–is to perform accurate testing so that you can be assured that the bleeding does not come from a pre-malignant or malignant lesion.
Tests that are frequently performed include a transvaginal ultrasound, the sonohysterogram and the diagnostic hysteroscopy. Generally, the diagnostic hysteroscopy is accompanied by an endometrial biopsy. The biopsy of a suspicious lesion is a critical step in ruling-out any cancerous or precancerous lesion.
Transvaginal ultrasound (TVUS): The TVUS is generally performed at the initial visit in evaluating a woman with PMB. The TVUS is an inexpensive examination that is typically done along with a Pap smear and a speculum examination.
During the TVUS the endometrial thickness can be measured. If the endometrial thickness is less than 4 mm it is considered to be quite reassuring –often no further testing is required.
Sonohysterogram (SHG): A sonohysterogram is a transvaginal ultrasound examination but with one addition—water. When water or saline is injected into the uterine cavity it highlights any abnormalities within the uterus—such as polyps or fibroids.
The reason is that water appears jet black on ultrasound and provides contrast to the various shades of grey that are typical of fibroids or polyps.
Diagnostic hysteroscopy: During a diagnostic hysteroscopy a lit telescope attached to a digital camera is passed into the uterus—yes, we give intravenous pain medication—so that the inside of the uterus can be visualized.
This allows the physician to actually see fibroids, polyps and endometrium and provides the most accurate assessment of the inside of the uterus (endometrial cavity).
Endometrial biopsy: An endometrial is generally combined with a diagnostic hysteroscopy. Some physicians do not perform a hysteroscopy at the time of a biopsy.
The problem with this approach is that a “blind biopsy” won’t necessarily detect the worst area of the uterine lining tissue. This may cause a precancerous or cancerous lesion to be missed. For that reason we are strong advocates of combining hysteroscopy with endometrial biopsy.