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閉経後出血 · 内膜画像と生検

閉経後出血の多くはTVUS+内膜生検を併用。内膜厚の閾値と生検適応を整理。

根拠：ACOG 2026 update。各ノードはガイドラインの判断ロジックを要約したものであり、原文の転載ではありません。 医療従事者向けの参考情報であり、臨床判断の代替ではありません。日本の関連学会指針および施設プロトコルを優先してください。

ステップごとに回答すると、結論と対応の目安が表示されます。前の質問に戻ることもできます。

ステップ 1 · 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.

パス全体像

  1. 【判断】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. 【終点】Asymptomatic incidental thickening · individualized
    A有症状, no 出血, incidental endometrial thickening: 検討 sampling onlyの場合>11 mm (individualized 〜あり risk factors), ≤11 mm usually フォロー; individualizeに対し高リスク (tamoxifen/hormone replacement/obesity).
  3. 【判断】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. 【終点】Highly selected low-risk · TVUS ≤4 mm may defer biopsy
    Highly selected 低リスク patient (single bleed, endometrium fully seen ≤4 mm, no strong 高リスク factors, prompt フォローアップ possible): may use TVUS alone・defer 生検, but must counsel clearly that any persistent/recurrent 出血 needs 直ちに re-evaluation・sampling; most patients are still advisedへhave concurrent endometrial sampling. Measure thickness excluding fluid.
  5. 【終点】Endometrial sampling · exclude malignancy
    Endometrium >4 mm / poorly seen / fluid / persistentまたはrecurrent 出血 / 高リスク factors: endometrial sampling (office sampling 優先) ± saline infusion sonography/hysteroscopy; inadequate samplingまたはpersistent 出血 → hysteroscopy + dilation・curettage; persistent/recurrent 出血 needs 病理 regardlessのendometrial thickness.

よくある質問

閉経後出血 · 内膜画像と生検はどの臨床課題を扱う診療パスですか？
閉経後出血の多くはTVUS+内膜生検を併用。内膜厚の閾値と生検適応を整理。
閉経後出血 · 内膜画像と生検の主要な意思決定ステップは何ですか？
Symptomatic PMB or asymptomatic thickening；TVUS endometrial assessment (2026 ACOG)
閉経後出血 · 内膜画像と生検はどのような対応方針を示しますか？
Asymptomatic incidental thickening · individualized：A有症状, no 出血, incidental endometrial thickening: 検討 sampling onlyの場合>11 mm (individualized 〜あり risk factors), ≤11 mm usually フォロー; individualizeに対し高リスク (tamoxifen/hormone replacement/obesity).；Highly selected low-risk · TVUS ≤4 mm may defer biopsy：Highly selected 低リスク patient (single bleed, endometrium fully seen ≤4 mm, no strong 高リスク factors, prompt フォローアップ possible): may use TVUS alone・defer 生検, but must counsel clearly that any persistent/recurrent 出血 needs 直ちに re-evaluation・sampling; most patients are still advisedへhave concurrent endometrial sampling. Measure thickness excluding fluid.；Endometrial sampling · exclude malignancy：Endometr…
閉経後出血 · 内膜画像と生検はどのガイドラインに基づいていますか？
ACOG transvaginal ultrasound assessment of the endometrium in postmenopausal bleeding, 2026 update (Obstet Gynecol 2026)；ACOG TVUS assessment of PMB committee opinion · 準拠：ACOG 2026 update

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