Background: Postmenopausal bleeding (PMB) is considered a red flag symptom and warrants further examination and evaluation. Trans-vaginalsonography (TVS) can be used reliably to diagnose fibroids, polyps and thickened endometrium. Hysteroscopy is considered “gold standard” for evaluating endometrial cavity. It provides direct visualization of endometrial cavity. It can have both diagnostic as well as operative purpose however, it is not cost effective, an invasive procedure and requires anesthesia and expertise. Present study was designed and carried out to study aetiology and prevalence of PMB in Central India as well as to evaluate the efficacy of TVS and hysteroscopy in diagnosis of different endometrial pathologies in patients with PMB. Methods: This prospective study included 82 post-menopausal women with PMB who attended the gynaecological clinic from December, 2019 to December, 2020 at Motherhood hospital, Indore, India after ethical clearance. A detailed history, examination followed by transvaginal sonography was made. Hysteroscopy was then performed, and biopsy was obtained in all patients. Hysteroscopic and sonographic images were then analyzed and conformed with the histopathologic diagnosis. Results: Most common endometrial pathology was atrophic endometrium followed by endometrial polyp and hyperplasia. Endometrial carcinoma was observed in (3.66%) females. Other findings in cases of secretory, proliferative endometrium and endometritis accounted for 6.09%. The diagnostic accuracy of ET by TVS at a cut-off point of 5 mm was 94% with sensitivity 89.3%, specificity 100%, PPV 100% and NPV 88%. The diagnostic accuracy of hysteroscopy was 98% with sensitivity 96.4%, specificity 100%, PPV 100% and NPV 95.7%. Conclusions: TVS with ET measurement should first line investigation in the evaluation of women with PMB with suspected endometrial pathology because of cost effectiveness, easy accessibility and non-invasive method of diagnosis. Although hysteroscopy is more specific and sensitive, in poor resource settings it should be limited to cases with illdefined endometrial lining, recurrent/ persistent bleeding and cases with endometrial thickness greater than 5 mm irrespective of endometrial echotexture.