Non-assessable endometrium in women with post-menopausal bleeding: to investigate or ignore

Abstract

Background

In women presenting with post-menopausal bleeding (PMB), the incidence of endometrial cancer is 1–10 %; Trans-vaginal scan (TVS) is offered as the first line of investigation to triage women further and a thick endometrium (>4 mm) merits endometrial tissue sampling for further evaluation. When it is difficult and not possible to assess the endometrium sonographically, decision to investigate further lies with the clinician.

Aim

Study outcomes for women with PMB and endometrium not assessable on TVS.

Methods

We collected data retrospectively between September 2007 and December 2010. We identified our study group from the radiology database. Data collected include ultrasound findings, methods of endometrial sampling, and the result of cytology/histology.

Results

In our study period of 40 months, 671 women with post-menopausal bleeding were referred to the ultrasound department for TVS to assess endometrial thickness. 92 % (614/671) women had the assessment. In 57 women (8 %), endometrial thickness was not assessable and this formed our study group. 3/57 records were not retrievable and excluded from our study. 43/54 (79 %) had some form of endometrial sampling done. Among the 81 % adequate samples (35/43), 7 (20 %) had endometrial cancer; 1 (3 %) had CAH, 1 (3 %) was diagnosed with cervical cancer. In women who had thickened endometrium (>4 mm; n = 448), there were 29 cases of endometrial cancers detected giving an incidence of 6.4 %. In women with PMB and non-assessable endometrial thickness, there is increased incidence of endometrial cancer when compared to the group where endometrial thickness could be measured. (Odds ratio = 3.3 [95 % CI = 1.2–9]). This is a statistically (p = 0.017) and clinically significant finding.

Conclusion

In women with PMB, there will be a subgroup in which ultrasound cannot assess endometrial thickness. When compared to women where endometrial thickness is measurable, this group stands a higher risk of endometrial cancer and hysteroscopy/ hysterosonography with endometrial sampling is recommended in this group.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Lotfallah H, Farag K, Hassan I, Watson R (2005) One-stop hysteroscopy clinic for postmenopausal bleeding. J Reprod Med 50(2):101–107

    PubMed  Google Scholar 

  2. 2.

    Ferrazzi E, Torri V, Trio D et al (1996) Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal bleeding. An Italian multicenter study. Ultrasound Obstet Gynecol 7(5):315–321

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Scottish Intercollegiate Guidelines Network. Investigation of postmenopausal bleeding (2002) Ref Type: Online Source

  4. 4.

    Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, Marini C, Sessa C (2011) Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 22(Suppl 6):vi35–vi39

    PubMed  Article  Google Scholar 

  5. 5.

    American College Of Obstetricians and Gynecologists (ACOG) committee opinion (2011) The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. No 440

  6. 6.

    Dubinsky TJ (2004) Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound 32(7):348–353

    PubMed  Article  Google Scholar 

  7. 7.

    Goldtstein SR (1994) The endometrial echo revisited: have we created a monster? Am J Obstet Gynecol 191:1092–1096

    Article  Google Scholar 

  8. 8.

    http://info.cancerresearchuk.org/cancerstats/types/uterus/incidence/uk-uterus-cancer-incidence-statistics

  9. 9.

    Hawwa ZM, Nahhas WA, Copenhaver EH (1970) PMB. Lahey Clin Found Bull 19:61

    PubMed  CAS  Google Scholar 

  10. 10.

    Goldstein SR (1994) Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol 170:565–570

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    van Hanegem N, Breijer MC, Khan KS, Clark TJ, Burger MP, Mol BW, Timmermans A (2011) Diagnostic evaluation of the endometrium in postmenopausal bleeding: an evidence-based approach. Maturitas 68(2):155–164 (Epub 2010 Dec 8)

    PubMed  Article  Google Scholar 

  12. 12.

    Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, Brand R, Grady D (1998) Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 280(17):1510–1517

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Timmermans A, van Doorn LC, Opmeer BC, Kroeks MV, Duk MJ, Bouwmeester AM, Kruitwagen RF, Dijkhuizen FP, Mol BW (2008) Dutch Study in Postmenopausal Bleeding (DUPOMEB). Follow-up of women after a first episode of postmenopausal bleeding and endometrial thickness greater than 4 millimeters. Obstet Gynecol 111(1):137–143

    PubMed  Article  Google Scholar 

  14. 14.

    Siddiqui J, De Bono, Phillips K (2009) Assessing the impact of ultrasound on a PMB hysteroscopy clinic. Gynecol Surg 6: s171–s172, 1613–2076

  15. 15.

    Werkgroep Dutch Study in Postmenopausal Bleeding (2005) Gynaecological diagnosis of postmenopausal women with abnormal vaginal bleeding: a comparison with the guideline. Ned Tijdschr Geneeskd 149(48):2676–2682

    Google Scholar 

  16. 16.

    Karlsson B, Granberg S, Wikland M, Ylöstalo P, Torvid K, Marsal K, Valentin L (1995) Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding–a nordic multicenter study. Am J Obstet Gynecol 172(5):1488–1494

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP (2000) The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer 89(8):1765–1772

    PubMed  Article  CAS  Google Scholar 

Download references

Conflict of interest

We declare that we have no conflict of interest.

Author information

Affiliations

Authors

Corresponding author

Correspondence to K. Ragupathy.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Ragupathy, K., Cawley, N., Ridout, A. et al. Non-assessable endometrium in women with post-menopausal bleeding: to investigate or ignore. Arch Gynecol Obstet 288, 375–378 (2013). https://doi.org/10.1007/s00404-013-2746-7

Download citation

Keywords

  • Non-assessable endometrium
  • PMB