The Symptom That Should Never Be Ignored
Postmenopausal bleeding — any vaginal bleeding that occurs 12 or more months after the last menstrual period — is the presenting symptom in approximately 90% of uterine (endometrial) cancer cases. This means most uterine cancers are diagnosed early, when cure rates are highest. The challenge is that many women delay seeking assessment, reassured by the fact that most causes of postmenopausal bleeding are benign.
While the majority of cases (approximately 70–90%) will turn out to be due to atrophic vaginitis, endometrial atrophy, polyps, or fibroids, the clinical rule is clear: all postmenopausal bleeding requires investigation until endometrial malignancy has been excluded.
Risk Factors for Endometrial Cancer
- Obesity — adipose tissue converts androgens to oestrogen; excess oestrogen unopposed by progesterone is the primary driver of most endometrial cancers
- Diabetes and insulin resistance
- Nulliparity (never having been pregnant)
- Late menopause (after age 55)
- Oestrogen-only hormone replacement therapy in women with an intact uterus
- Tamoxifen use for breast cancer (weakly oestrogenic effect on the endometrium)
- Lynch syndrome (hereditary non-polyposis colorectal cancer) — the highest-risk hereditary syndrome for endometrial cancer
How Is It Investigated?
Investigation begins with a transvaginal ultrasound (TVUS), which measures the endometrial thickness. An endometrial stripe of 4 mm or less in a postmenopausal woman is reassuring; values above this threshold warrant further investigation with an endometrial biopsy — a 5-minute outpatient procedure. In some cases a hysteroscopy (direct visualisation of the uterine cavity) is needed to obtain a targeted biopsy.
If endometrial cancer is confirmed on biopsy, an MRI of the pelvis and a CT of the thorax/abdomen/pelvis is arranged to assess depth of myometrial invasion and any lymph node spread before surgical planning.
Premenopausal Women Are Not Immune
Although endometrial cancer is primarily a postmenopausal disease (median age 63 at diagnosis), premenopausal women — particularly those who are obese, have polycystic ovarian syndrome, or have Lynch syndrome — can also develop it. Persistent abnormal uterine bleeding in a premenopausal woman over 40 should also be investigated.
The key message: do not normalise abnormal uterine bleeding. It deserves evaluation.
Dr. Nishtha Tripathi Patel is a gynaecological oncologist in Ahmedabad specialising in uterine, ovarian, and cervical cancers. Contact: +91 76988 00333.