Postmenopausal Bleeding Common in Women With Endometrial Cancer

Evaluation of women with postmenopausal bleeding has the potential to capture as many as 90% of endometrial cancers, according to the results of a meta-analysis published recently in JAMA Internal Medicine.

However, researchers led by Megan A. Clarke, PhD, MHS, of the National Cancer Institute, cautioned that most women with postmenopausal bleeding will not be diagnosed with endometrial cancer.

“Current practice guidelines recommend workup to rule out endometrial cancer among all women with postmenopausal bleeding,” Clarke and colleagues wrote. “Our findings support this recommendation by providing reassurance that targeting this high-risk group of women for early detection and prevention strategies will capture most endometrial cancers.”

Endometrial cancer is the most common gynecologic cancer in developed countries, and the incidence of the disease has increased in recent years. Postmenopausal bleeding is a common symptom of endometrial cancer. With this study, Clarke and colleagues wanted to evaluate the prevalence of postmenopausal bleeding in women with endometrial cancer and the risk for this cancer among women with postmenopausal bleeding.

The researchers reviewed literature on endometrial cancer and postmenopausal bleeding from English-language studies published between 1977 through 2017. The analysis included data from 129 studies that included 34,432 women with postmenopausal bleeding and 6,358 women with endometrial cancer.

Ninety-one percent of women with endometrial cancer had postmenopausal bleeding. There was no significant difference in the prevalence of postmenopausal bleeding by cancer stage. Looking at different geographic regions, the researchers found that the prevalence of postmenopausal bleeding was 94% in North America, and 90% in Western Asia and Eastern Asia.

The overall pooled risk of endometrial cancer among women with postmenopausal bleeding was 9%, according to the study. This risk increased to 12% when the data were limited to those studies that excluded women using hormone therapy.

“Use of hormone therapy affects this association at multiple levels,” the researchers explained. “Certain combined formulations of estrogen plus progestin therapy are established to have a protective effect on the endometrium. Furthermore, irregular uterine bleeding is a common adverse effect of hormone therapy, particularly within the first 6 months of use.”

Risk for cancer in women with postmenopausal bleeding was lowest in North America (5%) and highest in Western Europe (13%).

“The widespread practice of referring all women with postmenopausal bleeding for transvaginal ultrasound and/or endometrial biopsy carries a considerable burden and cost,” the researchers wrote. “Given the rise in endometrial cancer incidence and mortality, our findings raise the important question of how to best manage postmenopausal bleeding to optimize the benefit of early detection approaches while avoiding unnecessary harms.”

In an editorial published with the study, Kristen A. Matteson, MD, MPH, of Women and Infants Hospital in Providence, Rhode Island, and colleagues applauded the study authors for conducting a study that should “inform both research and clinical care delivery.”

Maurie Markman, MD, president of the Cancer Treatment Centers of America in Boca Raton, Florida, believes the results of this meta-analysis are important.

“This analysis is relevant as it provides a relatively simple summary for physicians seeing women with postmenopausal bleeding with the potential for the underlying condition to be endometrial cancer. In the diagnostic decision process it is relevant to appreciate that approximately 90% of women with endometrial cancer will experience postmenopausal bleeding, but that conversely only about 10% of women with postmenopausal bleeding are ultimately found to have endometrial cancer,” he told Cancer Network.