Practice Rational imaging

Imaging the endometrium in postmenopausal bleeding

BMJ 2007; 334 doi: (Published 22 March 2007) Cite this as: BMJ 2007;334:635
  1. A Sahdev, consultant radiologist
  1. Department of Radiology, St Bartholomew's Hospital, London EC1A 7BE
  1. Correspondence to: anju.Sahdev{at}
  • Accepted 23 January 2007

The patient

A 72 year old multiparous woman presented with intermittent postmenopausal bleeding. The patient's relevant medical history included insulin dependent diabetes, hypertension, and recent breast cancer. She had been treated with tamoxifen for three years. On examination, the patient was obese (body mass index 32) and no cause for the bleeding was found in the introitus, vulva, vagina, cervix, uterus, or adnexa. She was referred to the cancer unit for gynaecological assessment in accordance with “improving outcomes in gynaecological cancers” 1999 guidelines.1

Learning points

  • Risk factors for endometrial cancer are prolonged (more than five years) use of unopposed oestrogen hormone replacement therapy, tamoxifen use, hereditary non-polyposis colorectal carcinoma, obesity combined with diabetes, hypertension, and endogenous or exogenous increase in oestrogens

  • Transvaginal ultrasound should be the primary imaging investigation for assessing the endometrium in postmenopausal women with vaginal bleeding

  • Endometrial thickness of 5 mm or more requires endometrial biopsy; thickness less than 5 mm has a negative predictive value for endometrial cancer of 98%

  • Magnetic resonance imaging is reserved …

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