## Clinical Context Postmenopausal bleeding with thickened endometrium (>10 mm) on imaging is an indication for tissue diagnosis to rule out endometrial malignancy. ## Management Algorithm ```mermaid flowchart TD A[Postmenopausal bleeding]:::outcome --> B[Transvaginal ultrasound]:::action B --> C{Endometrial thickness?}:::decision C -->|< 5 mm| D[Reassure, follow-up]:::action C -->|5-10 mm| E[Consider biopsy if risk factors]:::action C -->|> 10 mm| F[Tissue diagnosis required]:::action F --> G[Hysteroscopy + biopsy]:::action G --> H{Histology}:::decision H -->|Benign| I[Medical management]:::action H -->|Malignant| J[Staging: MRI/CT]:::action ``` ## Key Point: **Hysteroscopy with endometrial biopsy is the gold standard for tissue diagnosis** when endometrial thickness is >10 mm or when clinical suspicion is high, regardless of ultrasound findings. It allows direct visualization and targeted sampling. ## High-Yield: - Endometrial thickness >10 mm in postmenopausal women warrants biopsy - Hysteroscopy has 95–100% sensitivity and specificity for endometrial pathology - It is both diagnostic and therapeutic (can remove polyps, fibroids) - Fractional curettage is outdated; hysteroscopy is preferred ## Clinical Pearl: In this patient, the irregular heterogeneous appearance on ultrasound increases suspicion for malignancy and makes tissue diagnosis urgent. A normal Pap smear does not exclude endometrial cancer (Pap detects cervical, not endometrial lesions). ## Warning: **Do NOT order MRI for staging before confirming histological diagnosis.** Staging investigations (MRI, CT) are performed AFTER malignancy is proven on biopsy. [cite:Robbins 10e Ch 22]
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