Diagnostic Imaging Pathways - Bleeding (Post-Menopausal)

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Population Covered By The Guidance

This pathway provides guidance on the imaging of adult female patients with unexplained postmenopausal bleeding.

Date reviewed: October 2013

Date of next review: 2017/2018

Published: November 2013

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No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv


Pathway Diagram


Image Gallery

Note: These images open in a new page
1 Click to view full size image Endometrial Polyp

Image 1 (Saline Infusion Sonohysterography): There is a soft tissue structure connected to the endometrium via a thin stalk and supplied by a single blood vessel (arrow). The features are consistent with an endometrial polyp.

2 Click to view full size image Endometrial Polyp

Image 2 : Hysterectomy specimen showing a polyp arising from the fundus of the endometrial cavity. Histological examination confirmed this to be an adenomyoma.

3a Click to view full size image

Endometrial Cancer

Image 3a, 3b (Transabdominal Ultrasound) and 2c (Transvaginal Ultrasound): The uterus is anteverted and measures 77 x 31 x 49mm. There are no signs of fibroids. The endometrium is 17mm thick at the fundus and has a number of cystic spaces within it. No free fluid is seen in the pelvis. Biopsy confirmed endometrial cancer.

3b Click to view full size image
3c Click to view full size image
4a Click to view full size image Endometrial Cancer

Image 4a: Hysterectomy showing an extensive endometrioid adenocarcinoma filling the endometrial cavity down to the isthmus.

4b Click to view full size image Image 4b (H&E, x2.5) and 4c (H&E, x10): Uterine curettings showing an endometrioid adenocarcinoma composed of closely packed glands with complex architecture. At high power, the malignant cells are columnar and demonstrate irregular nuclei with prominent nucleoli and occasional mitotic figures.
4c Click to view full size image

{tab=Teaching Points}

Teaching Points


Post-Menopausal Bleeding


Transvaginal Ultrasound (TVUS)


Saline Infusion Sonohysterography (SIS)


Hysteroscopy and Endometrial Sampling



References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol. 1996;87(3):345-9. (Level II evidence)
  2. Güner H, Tiras MB, Karabacak O, Sarikaya H, Erdem M, Yildirim M. Endometrial assessment by vaginal ultrasonography might reduce endometrial sampling in patients with postmenopausal bleeding: a prospective study. Aust N Z J Obstet Gynaecol. 1996;36(2):175-8. (Level II evidence)
  3. Garuti G, Sambruni I, Cellani F, Garzia D, Alleva P, Luerti M. Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding. Int J Gynaecol Obstet. 1999;65(1):25-33. (Level III evidence)
  4. Wolman I, Sagi J, Ginat S, Jaffa AJ, Hartoov J, Jedwab G. The sensitivity and specificity of vaginal sonography in detecting endometrial abnormalities in women with postmenopausal bleeding. J Clin Ultrasound. 1996;24(2):79-82. (Level II evidence)
  5. Gupta JK, Chien PFW, Voit D, Clark TJ, Khan KS. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81(9):799-816. (Level II evidence)
  6. Bree RL, Bowerman RA, Bohm-Velez M, Benson CB, Doubilet PM, DeDreu S, et al. US evaluation of the uterus in patients with postmenopausal bleeding: A positive effect on diagnostic decision making. Radiology. 2000;216(1):260-4. (Level II evidence)
  7. Gredmark T, Kvint S, Havel G, Mattsson LA. Histopathological findings in women with postmenopausal bleeding. Br J Obstet Gynaecol. 1995;102(2):133-6. (Level II evidence)
  8. Weiderpass E, Adami HO, Baron JA, Magnusson C, Bergstrom R, Lindgren A, et al. Risk of endometrial cancer following estrogen replacement with and without progestins. J Natl Cancer Inst. 1999;91(13):1131-7. (Level III evidence)
  9. Curtis RE, Boice JD, Shriner DA, Hankey BF, Fraumeni JF. Second cancers after adjuvant tamoxifen therapy for breast cancer. J Natl Cancer Inst. 1996;88(12):832-4. (Level IV evidence)
  10. Davidson KG, Dubinsky TJ. Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin North Am. 2003;41(4):769-80. (Review article)
  11. Scottish Intercollegiate Guidelines Network. Investigation of post- menopausal bleeding: a national clinical guideline. September 2002. (Evidence based guideline). View the reference
  12. Wolman I, Amster R, Hartoov J, Gull I, Kupfermintz M, Lessing JB, et al. Reproducibility of transvaginal ultrasonographic measurements of endometrial thickness in patients with postmenopausal bleeding. Gynecol Obstet Invest. 1998;46(3):191-4. (Level III evidence)
  13. Alcázar JL, Zornoza A. Transvaginal ultrasonographic measurement of endometrial thickness: an intra-observer and interobserver reproducibility study. Radiography. 2001;7(2):101-4. (Level II evidence)
  14. Smith Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280(17):1510-7. (Level I-II evidence)
  15. Granberg S, Ylostalo P, Wikland M, Karlsson B. Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding. Maturitas. 1997;27(1):35-40. (Level III evidence)
  16. Mendelson EB, Bohmvelez M, Joseph N, Neiman HL. Gynecologic imaging - comparison of trans-abdominal and trans-vaginal sonography. Radiology. 1988;166(2):321-4. (Level IV evidence)
  17. Epstein E, Ramirez A, Skoog L, Valentin L. Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm. Ultrasound Obstet Gynecol. 2001;18(2):157-62. (Level III evidence)
  18. Epstein E, Valentin L. Gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and vascularity as assessed by color Doppler for discrimination between benign and malignant endometrium in women with postmenopausal bleeding. Ultrasound Obstet Gynecol. 2006;28(1):89-95. (Level II evidence)
  19. Timmerman D, Deprest J, Bourne T, Van den Berghe I, Collins WP, Vergote I. A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen. Am J Obstet Gynecol. 1998;179(1):62-70. (Level II evidence)
  20. Clark TJ, Voit D, Gupta J, Hyde C, Song F, Khan K. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA. 2002;288(13):1610-21. (Level I-II evidence)

{tab=Information for Consumers}

Information for Consumers

Information from this website

Information from the Royal Australian and New Zealand College of Radiologists’ website

Consent to Procedure or Treatment

Radiation Risks of X-rays and Scans


Ultrasound (Doppler)

Radiation Risk of Medical Imaging During Pregnancy

Radiation Risk of Medical Imaging for Adults and Children


Saline Infusion Sonohysterography

Transvaginal Ultrasound



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