When a woman experiences bleeding after menopause — an early warning sign of endometrial cancer — doctors usually order a transvaginal ultrasound. But if that medical scan is unclear, guidelines say the next step is simple: follow up with a biopsy.

Yet a new study led by experts from the Duke Cancer Institute’s Gynecologic Cancer Program reveals that doesn’t always happen, especially for Black women, and the reason may be familiar.

Researchers at Duke, Mount Sinai Hospital and Columbia University examined the records of more than 6,400 women with postmenopausal bleeding. They found that nearly one in four non-Hispanic Black women who had abnormal or inconclusive ultrasound results did not receive a timely biopsy to check for cancer.

That delay can mean a missed or late diagnosis of endometrial cancer, which is more aggressive and deadly in Black woman. Endometrial cancer is one of the few cancers in the United States with an increasing mortality rate.

Black women are more likely to have unclear ultrasound images. The reason? Fibroids. These noncancerous tumors that are more common in Black women can interfere with ultrasound imaging, making it harder to see the uterine lining clearly.

Doctors may mistakenly attribute postmenopausal bleeding to fibroids, skipping the biopsy altogether.

“Larger fibroids make it so physicians can’t see the uterine stripe in an ultrasound,” said Angela Nolin, MD, a gynecologic fellow in the Duke Department of Obstetrics and Gynecology, who presented the research findings at the 2025 Society of Gynecologic Oncology Annual Meeting. “Patients are supposed to have a biopsy in these cases, but often that does not happen. Postmenopausal bleeding is blamed on the fibroids.”

The Duke-led Performance of Ultrasound in Postmenopausal Bleeding Assessment (PUMBA) team is now digging deeper into cancer outcomes to better understand how fibroids, cancer type, and imaging challenges intersect.

At the same time, the American College of Obstetricians and Gynecologists is re-evaluating its recommendations for how postmenopausal bleeding should be assessed.

As a possible solution, the PUMBA team is recommending a simple sweeping shift to biopsy for all patients with postmenopausal bleeding, regardless of what the ultrasound shows. It’s a move they hope will close the gap in care and catch more cases earlier.