Postmenopausal bleeding (PMB) is a significant clinical concern, defined as abnormal uterine bleeding occurring at least one year after the permanent cessation of menstruation(1). Although PMB may result from benign conditions such as endometrial atrophy, it is a critical warning sign, as approximately 10% of symptomatic postmenopausal women are diagnosed with intrauterine malignancies(1). The association between PMB and endometrial pathology necessitates a thorough clinical and histopathological evaluation to differentiate benign from malignant causes (2). Endometrial cancer is the most common gynecological malignancy in postmenopausal women, with the majority of cases exhibiting abnormal vaginal bleeding as the primary symptom (3). Endometrial atrophy remains the most frequent cause of PMB, followed by endometrial polyps and hyperplasia. The differentiation between these etiologies is crucial for appropriate clinical management and early intervention in high-risk cases (3).

The initial evaluation of PMB relies on transvaginal sonography (TVS), which is a widely accepted non-invasive screening tool (2). An endometrial thickness (ET) threshold of 5 mm has been established as a critical marker, with a sensitivity of 92% for detecting any endometrial pathology and 96% for endometrial malignancies (1,2). However, controversy persists regarding whether TVS alone is sufficient for diagnosing endometrial pathology or whether an endometrial biopsy should be the primary diagnostic modality (1,2).

Given the high prevalence of endometrial pathology among postmenopausal women with bleeding, a systematic assessment integrating clinical history, sonographic findings, and histopathological evaluation is necessary (3–5). Identifying risk factors associated with endometrial neoplasia can facilitate targeted screening and timely interventions, ultimately reducing the morbidity and mortality associated with endometrial malignancies (3–5).

Thus, the present study was undertaken to evaluate the clinical presentation and endometrial pathology in postmenopausal women with bleeding. By correlating clinical findings with histopathological outcomes, this research aims to enhance risk stratification, guide appropriate diagnostic strategies, and optimize patient management. The study will also help establish the prevalence of various endometrial pathologies in women with PMB and identify significant predictors of malignancy.

Study Design: A single centre, hospital-based cross-sectional observational study conducted to investigate the clinical and histopathological correlation of postmenopausal bleeding (PMB) in women undergoing endometrial biopsy or dilatation and curettage (D&C).

Study Setting: The study was conducted in the Department of Obstetrics and Gynecology at SAMC & PGI, Indore, Madhya Pradesh, a tertiary care hospital providing specialized gynecological services.

Ethical Clearance: The study received ethical approval from the Institutional Ethics Committee (IEC) following ethical guidelines for research involving human subjects. Written informed consent was obtained from all participants before their inclusion in the study.

Study Duration: The study was conducted over a period of 12 months.

Primary Outcome: To determine the histopathological diagnosis of endometrial samples obtained from women with PMB.

Secondary Outcomes: To identify the clinical risk factors associated with endometrial hyperplasia and endometrial cancer in postmenopausal women presenting with vaginal bleeding.

Measurement of the Outcome: Histopathological examination of endometrial biopsy/D&C samples was performed using standard pathological staining and microscopic evaluation to classify endometrial pathology into atrophy, proliferative endometrium, endometrial polyps, endometrial hyperplasia, and endometrial carcinoma.

Independent Variables: Age, duration of menopause, BMI, parity, history of diabetes, hypertension, previous hormone therapy, tamoxifen use, and transvaginal ultrasound findings (endometrial thickness).

Definition of the Exposure/Intervention: The exposure in this study was postmenopausal bleeding (PMB). The intervention included transvaginal ultrasound (TVS) measurement of endometrial thickness and endometrial biopsy/D&C for histopathological analysis.

Study Participants: Postmenopausal women presenting with abnormal uterine bleeding at the Obstetrics and Gynecology Department during the study period were considered eligible for screening. Women meeting the eligibility criteria and willing to participate in the study were recruited.

Inclusion Criteria

1. Postmenopausal women (≥12 months of amenorrhea).
2. Patients with postmenopausal bleeding (PMB) and an endometrial thickness (ET) >5 mm on transvaginal ultrasound.
3. Women who provided informed consent for biopsy/D&C and participation in the study.

Exclusion Criteria

1. Patients with non-endometrial causes of postmenopausal bleeding (e.g., cervical or vaginal pathology, hematological disorders).
2. Women with known gynecological malignancy or previous endometrial cancer diagnosis.
3. Patients on anticoagulants or hormonal therapy affecting endometrial thickness.
4. Patients with severe comorbid conditions making endometrial sampling unsafe.

Sample Size: A total of 30 eligible and consenting women with PMB and ET >5 mm were included in the study.

Sampling Methodology: A purposive sampling technique was used to recruit postmenopausal women meeting the inclusion criteria within the study period.

Participant’s Recruitment: Participants were recruited from the Outpatient Department (OPD) and inpatient wards of the Obstetrics and Gynecology Department, following initial clinical evaluation and TVS.

Obtaining Informed Consent: Before enrolling in the study, participants were provided with detailed information regarding the study’s objectives, procedures, risks, and benefits. Written informed consent was obtained in the participant’s preferred language.

Data Sources

1. Clinical Data: Patient history, physical examination findings, and risk factor assessment.
2. Imaging Data: Transvaginal ultrasound (TVS) measurements.
3. Histopathological Data: Endometrial biopsy/D&C specimen analysis.

• Data Collection Procedure

1. Baseline assessment – Demographic and clinical history were recorded.
2. Ultrasonography – TVS was performed to measure endometrial thickness.
3. Endometrial sampling – Biopsy/D&C was performed in all eligible patients.
4. Histopathology – Tissue samples were analysed by a pathologist.
5. Data entry – Collected data were documented in a structured format.

Statistical Analysis Plan: Descriptive statistics, including mean, standard deviation, and proportions, were used to summarize the demographic and clinical characteristics of the study population. Inferential statistical analysis was conducted using the Chi-square test for categorical variables and either the independent t-test or Mann-Whitney U test for continuous variables, depending on data distribution. Additionally, logistic regression analysis was performed to identify predictors of endometrial pathology. All statistical analyses were carried out using Stata version [17.0], with a significance level set at p < 0.05.

Funding: This study was an institutionally funded study.

Conflict of Interest: The authors declare no conflict of interest related to this study.

Endometrial Thickness Distribution

The mean endometrial thickness (ET) among study participants was 11.13 ± 6.37 mm. The ET was further categorized as follows:

• 5–10 mm: 46.7% (14/30)
• 10–15 mm: 33.3% (10/30)
• >15 mm: 20% (6/30)

Table 2: Histopathology of Endometrium

Histopathological Findings

Histopathological examination of endometrial biopsy/D&C specimens revealed a spectrum of endometrial pathologies. The most common histological diagnosis was endometrial atrophy (30%), followed by proliferative endometrium (26.6%). Notably, 16.6% (5/30) of cases were diagnosed with endometrial cancer (EC).

Association of Endometrial Pathology with Clinical Risk Factors

• Diabetes mellitus: Among diabetic women, 21.4% (3/14) had endometrial cancer, compared to 12.5% (2/16) in non-diabetic women.
• Hypertension: Among hypertensive women, 18.1% (2/11) had endometrial cancer, while 15.7% (3/19) of non-hypertensive women had endometrial malignancy.
• Obesity (BMI ≥25 kg/m²): 23.5% (4/17) of obese/overweight women had endometrial cancer, whereas only 7.6% (1/13) of non-obese women had malignancy.
• Endometrial thickness (ET ≥10 mm): 66.7% (10/15) of women with ET >10 mm had endometrial hyperplasia or cancer, compared to 20% (3/15) of women with ET 5–10 mm.

The histopathological finding of endometrial Ca is about 16.6% cases of postmenopausal bleeding alarms for thorough examination of postmenopausal bleeding. The timely detection and prompt treatment of endometrial Ca increases survival and life expectancy of patient.

1. Sung S, Carlson K, Abramovitz A. Postmenopausal bleeding. StatPearls [Internet]. 2023 Dec 20 [cited 2024 Dec 25]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK562188/
2. Hurtado S, Shetty MK. Post-menopausal bleeding: Role of imaging. Semin Ultrasound CT MRI. 2023 Dec 1;44(6):519–27.
3. Ferenczy A. Pathophysiology of endometrial bleeding. Maturitas. 2003 May 30;45(1):1–14.
4. Shetty MK, Hurtado S. Postmenopausal bleeding: Role of imaging in the diagnosis and management. Breast Gynecol Dis Role Imaging Manag. 2021 Jun 24;375–404.
5. Sasaki LMP, Andrade KRC, Figueiredo ACMG, Wanderley M da S, Pereira MG. Factors associated with malignancy in hysteroscopically resected endometrial polyps: A systematic review and meta-analysis. J Minim Invasive Gynecol. 2018 Jul 1;25(5):777–85.
6. Bharani B, PhatakSatish R. Feasibility and yield of endometrial biopsy using suction curette device for evaluation of abnormal pre- and postmenopausal bleeding. J Obstet Gynaecol Ind. 2008;58(4):322–6.
7. Malhotra N. Jeffcoate’s principles of gynecology. 9th ed. Jaypee Brothers Medical Publishers; 2001. p. 578–600.
8. Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol. 2004;24(7):736–41.
9. Wong SF, Luk KL, Wong AY, Tang LC. Findings in women with postmenopausal bleeding investigated with hysteroscopy. J Obstet Gynaecol. 2001;21(4):392–5.
10. Krishnamoorthy N, Fatima Shanthini N. Role of transvaginal sonography and hysteroscopy in abnormal uterine bleeding: Does the diagnostic yield increase by combining transvaginal sonography, hysteroscopy and biopsy? Int J Reprod Contracept Obstet Gynecol. 2014;3:919–23.
11. Kadakola B, Gurushankar G, Shivamurthy G, Rashmi MN. Ultrasonographic evaluation of abnormal uterine bleeding in postmenopausal women. Int J Reprod Contracept Obstet Gynecol. 2015;4:229–34.
12. Singh P, Dwivedi P, Mendiratta S. Correlation of endometrial thickness with the histopathological pattern of endometrium in postmenopausal bleeding. J Obstet Gynaecol India. 2016;66(1):42–6.
13. Babacan A, Gun I, Kizilaslan C, Ozden O, Muhcu M, Mungen E, et al. Comparison of transvaginal ultrasonography and hysteroscopy in the diagnosis of uterine pathologies. Int J Clin Exp Med. 2014;7(3):764–9.
14. Timmermans A, Opmeer BC, Khan KS, Bachmann LM, Epstein E, Clark TJ, et al. Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: A systematic review and meta-analysis. Obstet Gynecol. 2010;116(1):160–7.
15. Naik VS, Rege JD, Jashnani KD. Pathology of genital tract in postmenopausal bleeding. J Clin Pathol. 2005;03:438–42.