Postmenopausal or menopausal bleeding refers to any vaginal bleeding that occurs after a woman has gone 12 consecutive months without a period. Common causes include endometrial atrophy (thinning of the uterine lining), hormone therapy, endometrial polyps, or hyperplasia (overgrowth of the uterine lining). More concerning, however, is the possibility of endometrial cancer, which accounts for about 10% of postmenopausal bleeding cases. Bleeding in this population is concerning because the endometrium should no longer thicken and shed after menopause, making any bleeding a potential red flag for underlying pathology, particularly malignancy. Women experiencing postmenopausal bleeding should seek prompt evaluation to rule out serious conditions, especially if the bleeding is recurrent or heavy. 

The evaluation of postmenopausal bleeding typically begins with a pelvic ultrasound to measure endometrial thickness; a thin lining (<4 mm) often suggests atrophy, while a thicker lining may warrant further testing. Hysteroscopy, a minimally invasive procedure using a camera to visualize the uterine cavity, is more accurate for detecting structural abnormalities like polyps or fibroids and allows for targeted biopsies. While ultrasound is non-invasive and valuable for initial screening, hysteroscopy provides direct visualization and the ability to obtain tissue samples, making it the gold standard for diagnosing intrauterine pathology. The choice between methods depends on clinical suspicion, availability, and patient factors, but hysteroscopy is generally preferred when a detailed evaluation or biopsy is needed.

Endometrial polyps are benign, localized overgrowths of the endometrial tissue that project into the uterine cavity. They consist of a mixture of glands, stroma, and blood vessels and can vary in size from a few millimeters to several centimeters. The exact cause of polyps is unclear, but they are often linked to hormonal factors, particularly excess estrogen stimulation, which is why they are more common in perimenopausal women or those on hormone therapy. Presenting symptoms include irregular or heavy menstrual bleeding, intermenstrual spotting, and postmenopausal bleeding. While most polyps are benign, some may harbor hyperplasia or, rarely, malignancy, particularly in postmenopausal women. Diagnosis is typically made using transvaginal ultrasound, which may show a thickened endometrium or a focal lesion, but saline infusion sonography (SIS) or hysteroscopy provides better visualization. Hysteroscopy is the gold standard for diagnosis, as it allows direct visualization and targeted biopsy or removal.  Hysteroscopic polypectomy can frequently be performed in an office setting with minimal anesthesia.

Abnormal uterine bleeding (AUB) is any variation from normal menstrual bleeding in frequency, duration, regularity, or volume. This includes heavy menstrual bleeding (HMB), bleeding between periods (intermenstrual bleeding), irregular cycles, and postmenopausal bleeding. Common symptoms include prolonged bleeding (>7 days), cycles shorter than 21 days or longer than 35 days, passing large clots, and bleeding that soaks through pads or tampons frequently. AUB can result from structural causes (e.g., polyps, fibroids, adenomyosis) or non-structural conditions (e.g., ovulatory dysfunction, coagulopathies, or endometrial disorders). Pelvic ultrasound, often the first-line diagnostic tool, may reveal findings such as thickened endometrium, intracavitary lesions (polyps or fibroids), or adenomyosis. Saline infusion sonography (SIS) can further enhance the detection of structural abnormalities.  Office hysteroscopy allows direct visualization of the uterine cavity to identify and often treat causes of AUB, such as endometrial polyps, small submucosal fibroids, or retained products of conception, and allows for visually targeted biopsies.

Intrauterine device (IUD) placement is typically a “blind” procedure, meaning the clinician relies on tactile feedback and external landmarks rather than direct visualization of the uterine cavity. While IUD insertion is generally safe, risks include perforation (partial or complete), expulsion, malposition (e.g., embedded in the endometrium or displaced into the cervix), and rarely, infection or pain. The IUD may need adjustment or removal if placement is incorrect, suspected due to pain, abnormal bleeding, missing strings, or imaging confirmation. Traditional removal methods, such as blindly retrieving the device with a hook or forceps, can be uncomfortable or unsuccessful, particularly if the IUD is embedded or malpositioned. In such cases, hysteroscopy provides a safer, more controlled approach. 

Hysteroscopy is highly effective for removing misplaced IUDs, as it allows direct visualization of the device within the uterine cavity, minimizing unnecessary manipulation. Office hysteroscopy is particularly beneficial for patients with prior traumatic IUD experiences, including painful insertions, difficult removals, or a history of medical or violent trauma. The office setting offers a more comfortable, less intimidating environment than an operating room, and providers can use gentle techniques, local anesthesia, or oral sedatives if needed. By using hysteroscopy, clinicians can confirm proper IUD placement during insertion or retrieve malpositioned devices with precision, reducing patient anxiety and improving outcomes. This approach aligns with trauma-informed care principles, prioritizing patient comfort, control, and safety.