In postmenopausal bleeding, which workup is typically performed?

• A. Transvaginal ultrasound and endometrial sampling
• B. MRI of the pelvis only
• C. Serum estrogen levels only
• D. Hormonal therapy trial without imaging

Answer: (A)

In evaluating postmenopausal bleeding, the priority is to assess endometrial pathology with imaging and obtain a tissue diagnosis. Transvaginal ultrasound provides a noninvasive way to measure the endometrial thickness and detect abnormalities such as polyps or masses, helping to stratify risk. If the endometrium is thickened or suspicious, endometrial sampling (biopsy) is performed to obtain histology and determine whether hyperplasia or cancer is present. This tissue confirmation is essential before pursuing treatment decisions. MRI of the pelvis isn’t the initial step; it’s mainly used for staging if cancer is suspected. Serum estrogen levels don’t guide the workup in this context, and starting hormonal therapy without imaging and tissue diagnosis could miss a malignancy.