US guidance encourages prompt diagnosis and treatment of patients with endometrial cancer.
Updated American College of Obstetricians and Gynecologists (ACOG) guidelines recommend endometrial tissue sampling in combination with transvaginal ultrasound for the initial evaluation of most women who present with postmenopausal bleeding.[54]
Several factors have prompted the implementation of a more stringent triage strategy, including an increased prevalence of endometrial cancer among the US population, a disproportionate rise in endometrial cancer incidence and mortality among non-Hispanic black women compared with white women, and a recognition that transvaginal ultrasonography may be technically less effective than previously thought.[54]
Transvaginal ultrasonography may be used without endometrial biopsy during initial evaluation of select patients when all of the following are present:
a single episode of postmenopausal bleeding, and
an endometrial thickness of 4 mm or less, and
no risk factors strongly associated with malignancy, such as obesity, unopposed estrogen, and a family history of endometrial cancer, and
access to prompt gynecologic care and follow-up.
Summary
Differentials
Common
- Cervical cancer
- Miscarriage
- Cervical polyp
- Ectropion
- Iatrogenic
Uncommon
- Endometrial cancer
- Ovarian cancer
- Vaginal cancer
- Ectopic pregnancy
- Placental abruption
- Placenta previa
- Cervicitis
- Vaginitis
- Sexual abuse in children
- Neonatal uterine bleeding
- Precocious puberty
- Genital trauma
- Vaginal foreign body
- Condylomata acuminata
Contributors
Authors
Steven R. Goldstein, MD, MSCP, CCD, FACOG, FRCOG(H)
Professor
Obstetrics and Gynecology
New York University Grossman School of Medicine
New York, NY
Disclosures
SRG has been paid by Pfizer for consulting, Bayer for membership on a Data and Safety Monitoring Board, and Mylan for case adjudication. He has received royalties from Cook Medical Obstetrics and Gynecology. He was previously paid by Scynexis for participation on an advisory board.
Acknowledgements
Dr Goldstein wishes to gratefully acknowledge Dr Intisar Elnahhas and Dr Mohamed Mitwally, previous contributors to this topic.
Peer reviewers
Sarah Baxley, MD, PhD
Assistant Professor
University of Florida College of Medicine
Gainesville, FL
Disclosures
SB declares that she has no competing interests.
Sana Salih, MD
Assistant Professor
Department of Obstetrics and Gynecology
University of Wisconsin
Madison, WI
Disclosures
SS declares that she has no competing interests.
Austin Ugwumadu, PhD, FRCOG
Consultant/Senior Lecturer in Obstetrics and Gynaecology
St George's Hospital
London
UK
Disclosures
AU declares that he has no competing interests.
M. Jonathon Solnik, MD, FACOG, FACS
Associate Professor of Obstetrics & Gynaecology
Head of Gynaecology & Minimally Invasive Surgery
Faculty of Medicine at the University of Toronto
Mt. Sinai Hospital
Toronto
Canada
Disclosures
JS consults for Medtronic, Hologic, and Olympus. He is on the advisory board for Abbvie.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.Full text Abstract
National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication].Full text
National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Jun 2026 [internet publication].Full text
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 193: tubal ectopic pregnancy. Mar 2018 [internet publication].
American College of Radiology. ACR appropriateness criteria: first trimester vaginal bleeding. 2025 [internet publication].Full text
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