Risk Management

Q&A With NCI’s Dr Megan Clarke: Postmenopausal Bleeding as a Red Flag for Cancer

Although many women can experience bleeding or spotting as they go through menopause, it is not normal for postmenopausal bleeding to continue 1 year or more after their last menstrual period.

Postmenopausal bleeding can be benign in many cases, with common causes including hormone replacement therapy and vaginal atrophy.

However, this symptom is not always innocuous, said Megan Clarke, PhD, MHS, cancer prevention fellow in the Division of Cancer Epidemiology and Genetics at the National Cancer Institute in Rockville, Maryland.

In fact, postmenopausal bleeding can sometimes signal the presence of harmful underlying conditions—including malignancy—and warrants medical attention, she said.

In a study published in JAMA Internal Medicine, Dr Clarke and colleagues investigated the diagnostic potential of postmenopausal bleeding as an early detection measure for endometrial cancer.

They found that, although most women who experience postmenopausal bleeding will not receive an endometrial cancer diagnosis, a staggering 90% of women who develop this type of cancer experience postmenopausal bleeding as an early symptom of their disease.

Consultant360 discussed these findings further with Dr Clarke, who shed light on the role of postmenopausal bleeding in the early diagnosis of endometrial cancer, how to determine when cancer testing might be necessary, and the available screening options.

Consultant360: Why might postmenopausal bleeding in particular present important opportunities for early detection of endometrial cancer, even though this symptom is not specific for endometrial cancer?

Megan Clarke: Endometrial cancer can be highly curable if detected at an early stage, with a 5-year survival of approximately 95% compared with less than 45% in late-stage cancers.

In many other types of cancers, symptoms are usually indicative of late-stage disease. However, in endometrial cancer, our study demonstrated that even women with early stage disease are symptomatic with postmenopausal bleeding, representing a unique opportunity for early detection of endometrial cancers when they are highly amenable to treatment.

Therefore, recognition of postmenopausal bleeding followed by prompt diagnostic evaluation are critical for early diagnosis and improved survival of endometrial cancer.

C360: Knowing that most women with postmenopausal bleeding will not actually be diagnosed with endometrial cancer, when should clinicians test for endometrial cancer in women with postmenopausal bleeding? What other factors are important to consider in order to avoid unnecessary testing?

MC: The clinical approach to postmenopausal bleeding may vary by patient risk factors, practice setting, patient and provider preferences, and resources. It involves prompt evaluation using one or a combination of the following tests:

  • Transvaginal ultrasound
  • Endometrial biopsy
  • Hysteroscopy with biopsy


Clinical factors that increase risk of endometrial cancer and should be considered when evaluating women with postmenopausal bleeding include age, obesity, use of unopposed estrogen, medical conditions such as type 2 diabetes and polycystic ovary syndrome, and family history of gynecologic cancer.

Transvaginal ultrasound can be used for initial evaluation of postmenopausal bleeding as an alternative to endometrial biopsy in women with low prior risk. Women with a thin endometrium can be assured of a low risk of cancer.

Persistent or recurrent bleeding is also associated with a greater risk of endometrial cancer and requires endometrial biopsy, even in women with an apparent thin endometrium.

C360: With the findings from your study in mind, what are the next steps in your research?

MC: By accurately quantifying the risk of endometrial cancer in women with postmenopausal bleeding, our study can aid in the assessment of new risk markers and will help inform clinical decision making.

We and others are evaluating new technologies and biomarkers that may be able to distinguish women with postmenopausal bleeding who have a high risk of developing endometrial cancer from those who can be reassured of a low risk. We are also evaluating tampon sampling as an alternative early detection strategy for women with postmenopausal bleeding.

For our coverage of Dr Clarke’s study, click here.

—Christina Vogt


Clarke MA, Long BJ, Del Mar Morillo A, et al. Association of endometrial cancer risk with postmenopausal bleeding in women: a systematic review and meta-analysis [Published online August 6, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2018.2820