9 Managing women with post-menopausal bleeding Elisabeth Epstein * MD, PhD Lil Valentin MD, PhD Professor Department of Obstetrics and Gynaecology, University of Lund, Malmo ¨ University Hospital, Malmo ¨ 205 02, Sweden Transvaginal ultrasound examination can reliably distinguish women with post-menopausal bleeding (PMB) who are at low risk of endometrial pathology (endometrial thickness # 4 mm) from those who are at high risk (endometrium $ 5 mm) and can rule out focally growing lesions in the uterine cavity using saline infusion into the cavity as a negative contrast agent (hydrosonography). The 5 mm cut-off is applicable irrespective of the use of hormone replacement therapy. It is justified to refrain from endometrial sampling in women with PMB and an endometrial thickness of # 4 mm because the risk of endometrial cancer in these women is low (0.1–1.0%). However, it is not known whether these women need follow-up. About 80% of women with PMB and an endometrium of $ 5 mm have focally growing pathological lesions in the uterine cavity. These should be removed by operative hysteroscopy because dilatation and curettage (D and C) will fail to diagnose and remove a large proportion of these lesions. However, D and C is a reliable diagnostic method for women without focal lesions in the uterine cavity. It is not known whether simple outpatient sampling devices (e.g. Pipelle w ) are as reliable as D and C in women without focal lesions. A measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer. The reliability of ultrasound evaluation of endometrial morphology and/or vascularization for risk estimation of endometrial malignancy remains to be determined. Key words: endometrial cancer; endometrial pathology; endometrial polyp; malignancy; post- menopausal bleeding; ultrasonography; endometrial biopsy; curettage; saline contrast sonohys- terography; hydrosonography; hysteroscopy; power Doppler; reproducibility; observer variation; endometrium; three-dimensional ultrasonography. GUIDELINES FOR THE MANAGEMENT OF WOMEN WITH POST-MENOPAUSALBLEEDING Post-menopausal bleeding (PMB) is the most common symptom of endometrial cancer. Therefore all women presenting with PMB should undergo further evaluation. Having undergone both a clinical examination and a cervical smear, all women with PMB should undergo transvaginal ultrasound examination. Management strategies using ultrasound 1521-6934/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved. Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 18, No. 1, pp. 125–143, 2004 doi:10.1016/j.bpobgyn.2003.10.001, available online at http://www.sciencedirect.com * Corresponding author. Tel.: þ46-40332110; Fax: þ46-40962600. E-mail address: elisabeth.epstein@obst.mas.lu.se (E. Epstein).