Synopsis
Investigate postmenopausal and abnormal uterine bleeding promptly, obtain representative endometrial histology, integrate anatomical and molecular risk and coordinate curative surgery, fertility-sparing care, adjuvant treatment and recurrence management.
- Postmenopausal bleeding is the key early presentation. Most cases are not cancer, but every episode needs timely assessment and a cervical smear is not an endometrial test.
- First-line evaluation commonly combines speculum and bimanual examination with transvaginal ultrasound; an endometrial thickness of 4 mm or less lowers risk but does not end investigation of persistent bleeding.
- The diagnostic reference standard is representative endometrial histology from outpatient biopsy or hysteroscopy-directed sampling; focal lesions and repeated bleeding favour hysteroscopy.
- Do not reassure from an insufficient sample when ultrasound, symptoms or risk remains concerning; repeat with hysteroscopic visualisation under suitable analgesia or anaesthesia.
- Pathology should report histological type and grade, myometrial and lymphovascular invasion after surgery and molecular markers including mismatch repair, p53 and POLE where required for risk classification.
- MRI pelvis is preferred for local myometrial and cervical staging when it changes surgery; CT chest, abdomen and pelvis assesses nodes and distant spread in higher-risk disease.
- First-line curative treatment for most operable disease is total hysterectomy with bilateral salpingo-oophorectomy, generally minimally invasive, with sentinel or nodal assessment selected by risk.
- Low-risk stage I endometrioid cancer may need surgery alone; vaginal brachytherapy, external-beam radiotherapy and chemotherapy are added according to stage, histology, molecular group and recurrence risk.
- Fertility-sparing progestogen treatment is exceptional: grade 1 endometrioid cancer must be confined to endometrium, pathology reviewed, MRI reassuring and serial hysteroscopic biopsies mandatory.
- Offer definitive hysterectomy after childbearing or if conservative treatment fails, progresses or cannot be monitored reliably.
- Recurrent and advanced treatment uses surgery or radiotherapy for selected sites and carboplatin–paclitaxel, immune or hormone-based systemic therapy according to molecular biology, pace and prior treatment.
- Universal tumour mismatch-repair assessment identifies an immune-treatment biomarker and a Lynch-screening pathway; abnormal tumour testing is not automatically a germline diagnosis.
- Address surgical menopause, fertility, obesity, diabetes, thrombosis, bone, sexual function and lymphoedema as part of cancer treatment.
Key red flags
Any postmenopausal bleeding requires prompt endometrial assessment even when the volume is small, anticoagulation is present or cervical screening is normal.
Persistent or recurrent bleeding despite a thin endometrium or benign blind sample needs hysteroscopic reassessment for a focal lesion.
Heavy bleeding with syncope, tachycardia, chest pain or severe anaemia requires same-day stabilisation and source control.
Purulent discharge, fever and a distended fluid-filled uterus suggests pyometra with possible cervical obstruction and sepsis.
Hydronephrosis, leg swelling, pelvic pain, ascites or supraclavicular nodes suggests locally advanced or metastatic disease.
A young patient with endometrial cancer or a Lynch-associated family pattern requires tumour mismatch-repair testing and genetics completion.
Fever, uterine tenderness, purulent discharge or haemodynamic bleeding requires urgent infection and haemostasis management.
Investigation priorities
Measure endometrial thickness and morphology and identify focal lesions, fibroids, adnexal disease and pelvic fluid.
Obtain tissue efficiently for diffuse hyperplasia and carcinoma in a patient able to tolerate office sampling.
Management branches
A patient reports any vaginal bleeding after menopause.
- Confirm the bleeding source with speculum and pelvic examination, assess haemodynamic state and arrange transvaginal ultrasound through the urgent pathway.
- Obtain outpatient biopsy for a thickened or suspicious lining and use hysteroscopy-directed sampling for a focal lesion, insufficient biopsy or recurrent bleeding despite a thin lining.
- Communicate histology and close the loop on inadequate or discordant results, returning confirmed cancer to the specialist gynaecological oncology MDT.