Washington, D.C.—Today, the American College of Obstetricians & Gynecologists (ACOG) published updated guidance recommending that a combination of transvaginal ultrasonography and endometrial tissue sampling be used as part of the initial evaluation in most patients with postmenopausal bleeding.
“Because the incidence of endometrial cancer in the United States has been rising steadily for decades, this guidance is designed to support clinicians to perform earlier and more comprehensive screenings,” said ACOG President Steven J. Fleischman, MD, MBA, FACOG. “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.”
Approximately 90% of patients diagnosed with endometrial cancer have postmenopausal bleeding, which is defined as bleeding presumed to be from the uterus 12 or more months after the final menstrual period. For some patients presenting with postmenopausal bleeding, relying on ultrasound alone may carry a greater risk of missing a cancer diagnosis, with recent studies suggesting that 5–12% of cancers may not be diagnosed on initial presentation.
“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. “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.”
This dual approach is intended to help clinicians promptly diagnose and treat endometrial cancer in patients who might otherwise be falsely reassured by ultrasound results. It may also reduce health care-associated burdens for patients who have limited access to prompt gynecologic, radiologic, and oncologic care.
The update also addresses the disproportionate incidence and mortality rates in endometrial cancer among Black women, citing that a combination of ultrasonography and biopsy is particularly important for evaluating postmenopausal bleeding in this patient population.
The update acknowledges that a shift toward combined ultrasonography and biopsy will help clinicians promptly diagnose and treat endometrial cancer in patients for whom endometrial sampling is recommended. Early data suggest that 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.
This Clinical Practice Update is a focused update of related content in Committee Opinion 734: “The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding.” Read the full guidance.