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Managing women with post-menopausal bleeding

https://doi.org/10.1016/j.bpobgyn.2003.10.001Get rights and content

Abstract

Transvaginal ultrasound examination can reliably distinguish women with post-menopausal bleeding (PMB) who are at low risk of endometrial pathology (endometrial thickness ≤4 mm) from those who are at high risk (endometrium ≥5 mm) and can rule out focally growing lesions in the uterine cavity using saline infusion into the cavity as a negative contrast agent (hydrosonography). The 5 mm cut-off is applicable irrespective of the use of hormone replacement therapy. It is justified to refrain from endometrial sampling in women with PMB and an endometrial thickness of ≤4 mm because the risk of endometrial cancer in these women is low (0.1–1.0%). However, it is not known whether these women need follow-up. About 80% of women with PMB and an endometrium of ≥5 mm have focally growing pathological lesions in the uterine cavity. These should be removed by operative hysteroscopy because dilatation and curettage (D and C) will fail to diagnose and remove a large proportion of these lesions. However, D and C is a reliable diagnostic method for women without focal lesions in the uterine cavity. It is not known whether simple outpatient sampling devices (e.g. Pipelle®) are as reliable as D and C in women without focal lesions. A measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer. The reliability of ultrasound evaluation of endometrial morphology and/or vascularization for risk estimation of endometrial malignancy remains to be determined.

Section snippets

Guidelines for the management of women with post-menopausal bleeding

Post-menopausal bleeding (PMB) is the most common symptom of endometrial cancer. Therefore all women presenting with PMB should undergo further evaluation. Having undergone both a clinical examination and a cervical smear, all women with PMB should undergo transvaginal ultrasound examination. Management strategies using ultrasound as the primary investigation tool seem to be more cost-effective in the investigation of PMB than those using endometrial biopsy.1 Transvaginal ultrasound

Measurement technique, reproducibility of measurements, and relevance of intracavitary fluid

Measuring the endometrium in post-menopausal women is often more difficult than in women of fertile age because of the upright position of the uterus, the presence of vessel calcification, and a more diffuse endometrial–myometrial border. In women whose endometrium cannot be measured endometrial cancer is common.8 In cases where the endometrium is indistinct or unmeasurable, the scan should be interpreted as non-diagnostic and other means of evaluating the endometrium should be used.

Is it safe to refrain from endometrial sampling in women with PMB and an endometrial thickness of ≤4 mm? If not, who should undergo sampling?

Unfortunately there is very little scientific evidence to answer these questions. We do know that the risk of finding endometrial cancer in women with PMB and endometrium ≤4 mm is very low (0.1–1%),4 and that these women probably do not have a higher risk of developing endometrial cancer later in life than the general female population of the same age.13 By omitting endometrial sampling in these women approximately 4% (95% CI, 2–6%) of endometrial cancers will be missed.4 On the other hand we

Dilatation and curettage (D and C) is inappropriate for women with focally growing lesions

In women with PMB and an endometrium of ≥5 mm, an endometrial biopsy should be obtained because 80% have endometrial pathology.5 Most endometrial pathology has a focal growth pattern.5 The results of several studies show that D and C often fails to diagnose benign pathology, and sometimes endometrial cancer, because it leaves the whole or parts of the focal lesions behind in the uterine cavity in 38–100% of cases.5., 23., 24., 25., 26., 27., 28. In our hands D and C failed to diagnose 44% of

Hydrosonography can easily and reliably detect focal lesions

The reported sensitivity of hydrosonography with regard to the detection of focally growing lesions in the uterine cavity is 93–100%, and the false-positive rate 6–15%, when hysteroscopy or hysterectomy are used as gold standard.7., 11., 33., 34., 35. However, hydrosonography cannot reliably discriminate between benign and malignant focal lesions.11., 33. Hydrosonography has advantages over out-patient hysteroscopy. It is less painful, better tolerated by patients and less expensive.6., 7., 36.

Estimating the risk of endometrial cancer by means other than measuring endometrial thickness

A reliable estimate of the probability of endometrial carcinoma can help us to optimize the timing of an endometrial biopsy procedure in women at high risk of endometrial cancer, or make us refrain from further invasive diagnostic procedures such as D and C or hysteroscopy in women at low risk of endometrial cancer but at high operative risk. There is scientific evidence that endometrial thickness measurements can be used to discriminate accurately between women at high and low risk of

Summary

Measurement of endometrial thickness by transvaginal ultrasound in women with PMB confidently discriminates between women with a high and low risk of endometrial cancer. A ≥5 mm cut-off to indicate pathological endometrium is appropriate for all women irrespective of HRT use, but the false-positive rate is higher among women on HRT. In women whose endometrium cannot be measured, endometrial pathology is common, and further diagnostic evaluation is necessary. It is reasonable to refrain from

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