 ultrasound of postmenopausal bleeding. We often time get such cases where a patient has presented with bleeding postmenopause and they are concerned about postmenopausal bleeding. So what do we really mean by menopause? WHO defines it as a permanent cessation of the menstrual cycles which occurs due to a loss of the ovarian follicular activity. But from our perspective if you look at it we define or we accept postmenopausal bleeding as a vaginal bleeding which has occurred in a woman whose last menstrual cycle was more than 12 months prior to this event. That means more than one year back she had her previous cycle or cessation of periods for more than a year is considered as menopausal state. So why do patients get so concerned? Why do ladies get so concerned when they get vaginal bleeding postmenopause? That's because endometrial cancer is a leading gynecological malignancy. So a post menopausal bleeding ends up being a matter of concern for the lady and when she presents to the clinician to the clinician too. But one thing that we have to realize is that just like endometrial thickness can vary we or oftentimes the first line of investigation ends up being imaging. In imaging what we look for is the first thing we see is the endometrial thickness. Just like endometrial thickness varies a lot during her reproductive age group it varies according to the hormonal cycles. In the same way in a postmenopausal lady if the lady is on a hormone replacement therapy then a withdrawal bleeding is accepted or is expected and just because you have withdrawal bleeding is not something we need to be worried or concerned about. So a patient needs to be primed about it right when the hormone replacement therapy started that they can develop a withdrawal bleeding and the timing of this should be explained based on the regime and any bleeding that is occurring during the withdrawal bleeding is not accepted as an omnias sign and a reason for evaluation. But a bleeding that occurs at a time when you're not expecting this withdrawal bleeding is called as the unscheduled bleeding and in a postmenopausal lady which we defined just before in our postmenopausal lady when you have this unscheduled bleeding is and this patient is on a hormone replacement therapy that is when this patient needs to be evaluated further. There have been a lot of studies about a postmenopausal endometrial thickness and though there is no strict consensus about what it should be the optimal cutoff that is accepted by most of the people is that it should be less than or equal to four or five millimeters it should be homogeneous and there should be no lumpy bumpy areas it should be homogeneous and there should be no focal thickening and it is basically understood by all these studies that when you have a thickness which is less than or equal to four or five millimeters there is a very high probability that this patient has endometrial atrophy and not something omnias and definitely not something like a malignancy like a endometrial carcinoma. Postmenopausal bleeding when we see end up seeing it less than five millimeters can be attributed to endometrial atrophy which is also a cause of bleeding and this is not a matter of concern. So what is to be looked for other than the endometrial thickness there have been a lot of studies on the patterns that can be seen and the Doppler and it was found that Doppler does not add significant benefit added benefit to it but when you look at the appearance wise if you see a homogenous and diffuse thickening it is most likely hyperplasia but you might also have cystic areas in hyperplasia but if you see focal echocinic areas or focal echopore vascular area with a vascular particle or cystic areas associated with these echopore or echocinic areas it is an endometrial polyp. When you see focal areas of endometrial distortion heterogeneous areas with increased vascularity poor endometrial differentiation which possibly represents infiltration that this could represent an endometrial malignancy but there's so much of overlap in these imaging features that there is no particular impact that one of these imaging features carries. These imaging features is possibly going to add on to your decision-making as to what to do further. So what are the imaging recommendations that are suggested ideally a transseptominal scan is not a good enough modality for us to evaluate a thin endometrium optimally however it has the added benefit of evaluating large lesions of pelvic collections which can be missed out in a transveginal scan so ideally you should have a transseptominal scan followed by a transveginal scan and when you do a transveginal scan you have to do a long axis and short axis evaluation of the entire endometrium. You look at the mid societal view you see a thin homogenous endometrium you don't be too happy about it look at it along the entire length and width of the uterus because you might have a focal lesion sitting somewhere so you have to scan the entire endometrium and you also have to look at the entire cervix also because you might have an endocervical or a cervical malignancy which is also common in this age group. If you see fluid in the endometrium you should be measure only layer by layer that is the anterior and the posterior layer gets measured separately and both the layers the thickness of each layer gets added up together and if you see fluid in the endometrial canal it is actually a good way for you to evaluate the inner surface of the endometrium so you can look for any subtle submucosal lesions that might be there some polyps or some kind of irregularity in the endometrium it can help you evaluate the surface in a surface of the endometrium also. If you are not seeing the endometrium you should not be staying reassured thinking that the endometrium is very thin so you're not visualizing it rather if you do not visualize the endometrium it should warrant further evaluation you should possibly go ahead with this ono histidogram to evaluate the endometrial canal because this could happen because there is a possibly a large fibroid which is obliterating the canal or it could also be because there is an endometrial malignancy which is actually infiltrating the myometrium and is not giving you a good differentiation of the endometrium so it should actually warrant a further evaluation of the endometrium. As per the SRU guidelines an endovascular ultrasound or a transvechanal ultrasound is considered abnormal if you have a thickness which is greater than 5 millimeters if you have focal abnormality or if you have incomplete visualization of the stripe or in distinct margins of the endometrium the last two reasons should warrant you to go for further evaluation which most often is either through a sonosalpincogram or by a targeted biopsy. So this is an optimal image you go for a transvechanal scan you see the entire length of the endometrium the entire length in the mid-segiatal axis take the thickness from the echogenic to echogenic area and you're not seeing any focal bumpy areas look at the cervix look at the entire endometrium in all the both the axis it should be homogeneous so this is the optimal imaging. These are the scenarios that you commonly encounter you might see a smooth homogeneous thickening which is endometrial hyperplasia you might see this heterogeneous area with increased vascularity infiltration it's not very common but this is the appearance of an endometrial carcinoma. You can see this kind of a thickening where you see the central image you can see this kind of a thickening where you see some focal echogenic area and if you look at the vascularity you might be able to demonstrate a vascular pedicle but when you put in instil some saline into the canal and you do a sonohistrogram you can see this polyps so well it gets beautifully demonstrated when you're doing a sonohistrogram so that is how and a sonohistrogram is going to help you evaluate endometrial canal or endometrial lining lesions better. So this is a flow chart that is recommended for how you should be evaluating imaging wise a postmenopausal bleeding patient. You do a trans abdominal and a trans vaginal scan. If the endometrial thickness is less than 5 millimeters then mostly the cause is an endometrial atrophy so leave this patient alone this patient does not need to be evaluated further. If you see that you're not able to measure the endometrium or maybe the endometrial thickness is more than 5 millimeters then do a sonohistrogram. When you're doing a sonohistrogram you're seeing that there is the you see both the lining separate so you measure them separately and if each lining is less than 2 millimeters then you're getting a total amount of less than 5 millimeters of thickness of the entire endometrium so it's a thin endometrium basically which means it's most likely due to endometrial atrophy. If you see diffuse thickening most likely it is because of hyperplasia and you might want to do a DNC and the sampling of the same. If you see a focal thickening or a polypoidal lesion you do a targeted biopsy. There can also be a submucous fibride which is very well demonstrated or you see an endometrial carcinoma which will look like a heterogeneous lesion which is possibly protruding into the canal and you can easily take a sample from this lesion through histroscopic guidance and targeted biopsy of this lesion can be taken. If this patient is on a hormone replacement therapy we expect the accepted thickness can go up to 8 millimeters based on which regime the regimen the patient is following supposing the patient is on a cyclical estrogen and progesterone then ultrasound should be done at the beginning or the end of the cycle. If the patient is having an unopposed estrogen being provided then the thickness if it is up to 8 millimeters it is accepted but if it is going more than 8 millimeters then a biopsy of this area of the involved area or if it is a diffuse thickening then you don't need to take a targeted biopsy but a biopsy or sampling needs to be taken. So in summary when you see that an endometrial thickness is less than or equal to 5 millimeters in a patient having vaginal bleeding postmenopause the chance is it's because of endometrial atrophy and you do not need to biopsy such a patient if it is more than 5 millimeters do a sonar historiography look if the cause is diffuse or focal and then help guide the biopsy technique but 5 millimeters is not the normal or upper limit of normal in these ladies rather it is an action threshold for these patients it helps you determine whether you should be taking an action or not and if this patient has not presented to you with bleeding and you still have a thickening of more than 5 millimeters then this patient needs to be evaluated based on the appearance of the endometrial thickness whether there is focal thickening whether it is heterogeneous what kind of vascularity it is dependent on the echo texture or the appearance on the whole and also depending on the clinical picture whether this patient is a high-risk patient or whether the patient has any other risk factors for endometrial carcinoma so imaging basically helps us a guidance tool and hopefully this says this was useful for you