ACR Appropriateness Criteria®

Clinical Condition: Abnormal Vaginal Bleeding

Variant 1: Postmenopausal vaginal bleeding. First study.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Postmenopausal vaginal bleeding, endometrium <5 mm by transvaginal ultrasound.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Postmenopausal vaginal bleeding, endometrium >5 mm by transvaginal ultrasound.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field

Variant 4: Premenopausal vaginal bleeding. First study.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field

Variant 5: Premenopausal vaginal bleeding, endometrium <16 mm by transvaginal ultrasound.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Premenopausal vaginal bleeding, endometrium >16 mm by transvaginal ultrasound.

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary of Literature Review

Virtually every woman will at some point in her lifetime experience episodes of vaginal bleeding that will be perceived as abnormal. Menses begin at puberty and extend to menopause. The average menstrual cycle is 29 days long with a range of 23 to 39 days. Overall, the length of the menstrual cycle remains relatively constant throughout the reproductive years, but as a woman approaches menopause, the cycle gradually shortens. Although blood loss is difficult to quantify, most blood loss occurs in the first few days of menses, and bleeding generally lasts from 2 to 7 days. The cycle length and the volume and duration of bleeding remain fairly constant for a woman throughout her reproductive years. After menopause, bleeding ceases completely. Any variation from this pattern is potentially abnormal.

Abnormal vaginal bleeding is most often caused by hormone imbalance. Vaginal bleeding is also caused by pregnancy, polyps, myomas, endometrial hyperplasia, adenomyosis and cancers of the cervix or endometrium. In a premenopausal or perimenopausal woman, who is not pregnant, the most likely cause of abnormal bleeding is anovulatory cycles. It may also be associated with adenomyosis in parous women. In a postmenopausal woman, the most likely cause of abnormal bleeding is atrophic endometrium. In the menstruating female, a trial of medical hormonal therapy can be instituted. In the postmenopausal female or if bleeding persists in the premenopausal female despite medical management, imaging studies are warranted. In younger women, the goal is to diagnose polyps, myomas, or other focal structural causes for bleeding. In older women the goal is the same and includes diagnosis of endometrial cancer, which is the underlying cause in 10% of postmenopausal women with abnormal bleeding. Meta-analysis has shown that an endometrial thickness <5 mm is associated with less than 1% probability of endometrial cancer.

Transvaginal Ultrasound

Transvaginal ultrasound (TVUS) depicts endometrial pathology. The upper limit of normal for endometrial thickness has been debated. For premenopausal women with bleeding, a thickness of >16 mm has a sensitivity of 67%, specificity of 75%, and positive predictive value of 14% for demonstrating relevant pathology. For postmenopausal women with bleeding, a thickness of >5 mm has a sensitivity of at least 82% for detecting endometrial abnormalities, and for detecting endometrial cancer has a sensitivity of 80%-100% and a specificity of about 60%. Few clinicians advocate mandatory uterine sampling for abnormal postmenopausal bleeding regardless of the ultrasound (US) findings. Most, however, suggest that endometrial sampling is not necessary if thickness is <5 mm. When the endometrium is thickened, the vaginal sonogram helps localize focal lesions, thereby reducing the risk of missing lesions at sampling.

Myometrial abnormalities causing menorrhagia can be diagnosed by both TVUS and magnetic resonance imaging (MRI). Although both modalities can be used effectively to diagnose adenomyosis and differentiate it from leiomyomas, TVUS is usually the first imaging study obtained in patients with abnormal bleeding. Using specific criteria to diagnose adenomyosis, sonography demonstrates a sensitivity of 80%-86% and specificity of 50%-96%.

Hysterosonography

Hysterosonography consists of introduction of sterile saline into the uterine cavity via a small catheter using transvaginal sonographic guidance. In 48 postmenopausal women with bleeding and endometrial thickness between 5 and 10 mm, the distension of the cavity with saline revealed focal cavitary masses in 19 (40%). Seven of the patients with endometrial masses had biopsy prior to hysterosonography, and the biopsy was false negative in four (57%). In both premenopausal and postmenopausal women with abnormal bleeding and endometrial thickening, the exclusion of a focal mass may help direct management to hormone treatment or blind biopsy, whereas the identification of a focal mass may direct management to hysteroscopically-guided biopsy. There is also strong evidence that hysterosonography is as accurate as office hysteroscopy in detecting intracavitary lesions and is better tolerated by the patient.

Transabdominal Ultrasound

Although transabdominal US gives an overall view of the pelvis, the depiction of the endometrium is better with TVUS.

Doppler Ultrasound

In postmenopausal women with vaginal bleeding, there is evidence to suggest that the uterine artery resistive index and the pulsatility index are lower for endometrial cancer than for benign lesions. There is, however, variability from institution to institution and overlap between benign and malignant findings. In general, duplex Doppler US does not add significant additional information to gray-scale imaging of the endometrium. However, color Doppler sonography can identify the feeding vessel of a polyp, significantly aiding their detection.

Three-Dimensional Sonography

Three-dimensional sonography and hysterosonography have been found to add information that is not available on the 2-dimensional transvaginal image, due to its multiplanar capabilities. With the ability to capture a volume of US data and image in the coronal plane, there is enhanced visualization of intracavitary abnormalities associated with vaginal bleeding.

Magnetic Resonance Imaging

MRI of the pelvis is not warranted unless bleeding is attributed to leiomyomas and myomectomy is contemplated, or unless sonography is indeterminate in differentiating adenomyosis from leiomyomas. MRI accurately depicts the size, number, and location of leiomyomas. Using specific criteria, MRI differentiates adenomyosis from leiomyomas with a sensitivity and specificity of 86%-100% and an overall accuracy of 85%-90.5%.

Computed Tomography

Computed tomography (CT) scan of the pelvis is not warranted for diagnosis of abnormal vaginal bleeding.

Anticipated Exceptions

The following are available:

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.