Postmenopausal Bleeding · Endometrial Imaging Assessment

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Symptomatic PMB or asymptomatic thickening
   Postmenopausal bleeding (PMB) or asymptomatic incidental endometrial thickening? (PMB = uterine bleeding ≥12 months after the last period; ~90% of endometrial cancers present with PMB, PMB raises endometrial cancer risk ~64-fold; TVUS alone misses 5–12% of cancers (including thin-endometrium high-grade/serous/clear cell). Measure endometrial thickness excluding any fluid.)
   • Symptomatic PMB (with bleeding) → TVUS endometrial assessment (2026 ACOG)
   • Asymptomatic, incidental endometrial thickening → Asymptomatic incidental thickening · individualized
2. [End] Asymptomatic incidental thickening · individualized
   Asymptomatic, no bleeding, incidental endometrial thickening: consider sampling only if >11 mm (individualized with risk factors), ≤11 mm usually follow up; individualize for high-risk (tamoxifen/hormone replacement/obesity).
3. [Decision] TVUS endometrial assessment (2026 ACOG)
   TVUS endometrial thickness and features? (2026 ACOG update: most symptomatic PMB should have TVUS + endometrial biopsy together (rising endometrial cancer incidence, ultrasound alone misses thin-endometrium cancer). Only highly selected low-risk patients may use TVUS ≤4 mm and defer biopsy.)
   • Highly selected low-risk: single bleed, endometrium fully seen ≤4 mm, no high-risk factors, close follow-up possible → Highly selected low-risk · TVUS ≤4 mm may defer biopsy
   • Endometrium >4 mm / poorly seen / fluid / persistent or recurrent bleeding / high-risk factors (most patients) → Endometrial sampling · exclude malignancy
4. [End] Highly selected low-risk · TVUS ≤4 mm may defer biopsy
   Highly selected low-risk patient (single bleed, endometrium fully seen ≤4 mm, no strong high-risk factors, prompt follow-up possible): may use TVUS alone and defer biopsy, but must counsel clearly that any persistent/recurrent bleeding needs immediate re-evaluation and sampling; most patients are still advised to have concurrent endometrial sampling. Measure thickness excluding fluid.
5. [End] Endometrial sampling · exclude malignancy
   Endometrium >4 mm / poorly seen / fluid / persistent or recurrent bleeding / high-risk factors: endometrial sampling (office sampling preferred) ± saline infusion sonography/hysteroscopy; inadequate sampling or persistent bleeding → hysteroscopy + dilation and curettage; persistent/recurrent bleeding needs pathology regardless of endometrial thickness.

Source guidelines & references

• ACOG transvaginal ultrasound assessment of the endometrium in postmenopausal bleeding, 2026 update (Obstet Gynecol 2026)
• ACOG TVUS assessment of PMB committee opinion · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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