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.
Study outcomes for women with PMB and endometrium not assessable on TVS.
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.
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.
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.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Lotfallah H, Farag K, Hassan I, Watson R (2005) One-stop hysteroscopy clinic for postmenopausal bleeding. J Reprod Med 50(2):101–107
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
Scottish Intercollegiate Guidelines Network. Investigation of postmenopausal bleeding (2002) Ref Type: Online Source
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
American College Of Obstetricians and Gynecologists (ACOG) committee opinion (2011) The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. No 440
Dubinsky TJ (2004) Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound 32(7):348–353
Goldtstein SR (1994) The endometrial echo revisited: have we created a monster? Am J Obstet Gynecol 191:1092–1096
Hawwa ZM, Nahhas WA, Copenhaver EH (1970) PMB. Lahey Clin Found Bull 19:61
Goldstein SR (1994) Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol 170:565–570
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)
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
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
Siddiqui J, De Bono, Phillips K (2009) Assessing the impact of ultrasound on a PMB hysteroscopy clinic. Gynecol Surg 6: s171–s172, 1613–2076
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
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
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
Conflict of interest
We declare that we have no conflict of interest.
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
- Non-assessable endometrium