How Thick Is Too Thick? Endometrial Cut-Off in Postmenopausal Patients
Women with postmenopausal bleeding require immediate and efficient evaluation to exclude or to diagnose endometrial carcinoma or atypical hyperplasia. Transvaginal ultrasound (TVUL) is the gold standard to evaluate the endometrium for further diagnostic methods. If the endometrial thickness is equal to or less than 4 mm endometrial sampling is not required. If the endometrium has an irregular delineation and/or is thicker than 4 mm or TVUL is not applicable endometrial sampling is required.
The blind methods have a low sensitivity and specificity, thus visually guided sampling might be an option during either mini-hysteroscopy with a biopsy cup or during hysteroscopy as a resection-biopsy. Risk factors for endometrial cancer should be considered in the evaluation of the endometrium (obesity, hypertension, diabetes).
The threshold for invasive diagnostics is lower in asymptomatic postmenopausal women with risk factors, than in asymptomatic postmenopausal women without any risk factors. The risk factors are obesity, continuous estrogen, Tamoxifen, late onset of menopause (>55 years), nulliparity, anovulation, infertility, diabetes, Lynch syndrome (HNPCC), or age (>60 years). Endometrial thickness of 8 mm is the limit with risk factors and 11 mm without risk factors. Transvaginal ultrasound can be useful in the triage of postmenopausal women, but the above factors including diagnostic options and the cooperation of the patient must be considered. Screening by TVUL is not recommended in asymptomatic postmenopausal women. Thickened endometrium by TVUL due to intracavity pathologies such as polyps and fibroids and the treatment of these, is not discussed in this chapter.
KeywordsPostmenopausal bleeding Asymptomatic postmenopausal women Transvaginal ultrasound Endometrial thickness Endometrial biopsy Endometrial sample Saline infusion sonography (SIS) Pipelle/vabra (blind endometrial sample) Endometrial neoplasm Risk factors for endometrial cancer Atypical hyperplasia
Postmenopausal bleeding; vaginal bleeding >1 year after menopause
Saline infusion sonography
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