What is the best diagnostic approach to postmenopausal vaginal bleeding in women taking hormone replacement therapy?
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Women on standard estrogen/progestin hormone replacement therapy (HRT) regimens frequently have irregular bleeding during the first 12 months of treatment. Therefore, those taking HRT should usually be evaluated after 1 year of treatment if bleeding continues. (Grade of recommendation: C, based on case series.) Evaluation of this bleeding should begin with a pelvic examination and Papanicolaou (Pap) test (if not done in the previous 12 months), then transvaginal ultrasound (TVUS), followed by endometrial biopsy or hysteroscopy, if indicated. (Grade: B, based on a systematic review of studies.)