Diagnostic accuracy of endometrial thickness to exclude polyps in women with postmenopausal bleeding

An overview of the main intrauterine pathologies in the postmenopausal period

Hysteroscopy is the gold standard for evaluating the uterine cavity, diagnosing intrauterine pathology, and operative intervention for some causes of abnormal uterine bleeding. The American College of Obstetricians and Gynecologists concluded that, when the endometrium measures ≤4 mm with transvaginal ultrasonography, the likelihood that bleeding is secondary to endometrial carcinoma is less than 1% (negative predictive value 99%), and endometrial biopsy is not recommended. Endometrial sampling in this clinical scenario will likely result in insufficient tissue for evaluation and it is reasonable to consider initial management for atrophy. A thickened endometrium on transvaginal ultrasonography (>4 mm in a postmenopausal woman with postmenopausal bleeding) warrants additional evaluation with endometrial sampling. A negative tissue biopsy following 'blind' endometrial sampling in women with postmenopausal bleeding is not considered to be an endpoint, and further evaluation of the endometrial cavity with hysteroscopy to exclude focal disease is imperative.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

Thickened Endometrium in Postmenopausal Women With an Initial Biopsy of Limited, Benign, Surface Endometrium: Clinical Outcome and Subsequent Pathologic Diagnosis

Endometrial biopsy or curetting is indicated for postmenopausal women with abnormal uterine bleeding and/or thickened endometrium. Often, endometrial biopsy or curetting yields limited benign surface endometrium, which may indicate insufficient sampling. This study addresses the clinical outcome and subsequent pathologic diagnoses in postmenopausal women who received this initial diagnosis. Among a total of 370 endometrial biopsy or curetting between 2012 and 2015, 192 (52%) were diagnosed as limited benign surface endometrial epithelium. The women ranged in age from 55 to 91 yr old. Their clinical presentations mainly included postmenopausal bleeding, pelvic pain, and enlarged uterus. Primarily because the initial report was interpreted as "benign," 108 (57%) had no subsequent follow-up. Interestingly, women with an increased endometrial thickness were more likely to receive repeat evaluation. Among the 84 women who underwent follow-up endometrial sampling, 6 (7%) had hyperplasia with atypia or malignancy, 21 (25%) had a repeat diagnosis of limited surface sample, 4 (5%) had insufficient materials, and 53 (63%) had other benign findings. Among the subset of women who did receive subsequent follow-up, endometrial atypia or malignancies are more likely found in those with increased body mass index. In conclusion, a slight majority of women with postmenopausal bleeding and/or thickened endometrium had an initial limited surface endometrial sample. Most had no subsequent endometrial sampling. Among those with subsequent follow-up, the majority had benign findings. The study highlights the inconsistencies in adequacy criteria for endometrial sampling and the lack of standardization of subsequent management.

Blood microvasculature and lymphatic densities in endometrial polyps and adjacent and distant endometrium

Objective:

Endometrial polyps are localised growths of endometrial tissue containing glands, stroma and blood vessels, covered with epithelium. The reported prevalence of endometrial polyps is dependent upon the population being studied and the uterine imaging technique utilised. The light microscopy literature provides very little information regarding their microvasculature and lymphatic systems; however, a plethora of ultrasound data demonstrating single central arteries in most medium- or large-sized endometrial polyps are well documented.

Methods:

Archived formalin-fixed paraffin-embedded blocks of endometrial curettings were retrieved from files for women with confirmed endometrial polyps (n = 20) and women with normal endometrium (control endometrium; n = 32). Immunohistochemistry was performed with the antibodies CD31 (blood vessels) and D2-40 (lymphatics). Blood vessels and lymphatics were quantified in endometrial polyps and adjacent, distant and control endometrium.

Results:

CD31 and D2-40 staining was present in all specimens, although there were no significant differences in blood vessel (F(3,70) = 2.36, p = 0.079) and lymphatic (F(3,70) = 0.16, p = 0.920) densities between endometrial polyps as well as adjacent, distant and control endometrium. There were also no significant differences in women with endometrial polyp-associated bleeding and those with no bleeding. In relation to infertility, there were no significant differences found in blood and lymphatic densities between women with endometrial polyps who were infertile and those with endometrial polyps who were fertile.

Conclusion:

Small blood vessel wall and perivascular structures rather than the distribution of vessels may be associated with abnormal bleeding.

Evaluation of transvaginal sonography in detecting endometrial polyps and the pregnancy outcome following hysteroscopic polypectomy in infertile women

The aims of the present study were to evaluate the effectiveness of transvaginal sonography (TVS) in the detection of endometrial polyps (EPs), and to assess the pregnancy outcome in infertile women following hysteroscopic polypectomy. A total of 145 women diagnosed with primary or secondary infertility and intrauterine disorders by TVS and hysterosalpingography (HSG) were included in the current study. All subjects were divided into three groups based on hysteroscopic findings, including the EP, intrauterine adhesion and normal groups. EPs were removed for biopsy and intrauterine adhesions were treated. Pregnancy rates between groups were compared. In total, 34 EPs were detected by TVS, while 45 subjects were later confirmed with EP by hysteroscopy. The sensitivity, specificity, positive predictive value and negative predictive value of TVS in the detection of EPs were 67, 96, 88.23 and 86.49%, respectively. Of the included patients, 120 subjects were followed up, including 40 patients diagnosed with EPs, 42 with intrauterine adhesions and 38 with normal cavities. The results indicated no statistically significant differences in the age, type and duration of infertility, least function (LF) score and classification of the extent of tubal disease with the distal fimbrial obstruction between the three groups. In addition, pregnancy rate and spontaneous abortion rate in the EP group following hysteroscopic polypectomy were 45 and 5.6%, respectively. No significant difference was observed in the fertility rate following surgery. In conclusion, TVS features high sensitivity, specificity and certain unique sonographic characteristics in diagnosing EPs, and may be used as a preliminary diagnostic procedure to select patients for hysteroscopy. Furthermore, hysteroscopic polypectomy is an important approach for the treatment of infertile patients with EPs and appears to help increase the pregnancy rate of previously infertile women.

Diagnostic value of sonography for detecting endometrial pathologies in postmenopausal women with and without bleeding

PURPOSE

To investigate the diagnostic value of endometrial thickness measurement on sonography in predicting endometrial pathologies in postmenopausal women with vaginal bleeding and in those with asymptomatic thickened endometrium.

METHODS

Six hundred two postmenopausal women with vaginal bleeding or asymptomatic thickened endometrium were evaluated in this study. Two hundred seventy-four women with postmenopausal bleeding regardless of endometrial thickness (group 1: symptomatic) and 328 women with an incidental finding of thickened endometrium (≥5 mm) without bleeding (group 2: asymptomatic) underwent endometrial biopsy for histopathologic examination. The receiver operating characteristics curves of endometrial thickness measurement for prediction of endometrial pathologies were analyzed.

RESULTS

Endometrial carcinoma was detected in eight women (2.9%) in group 1 and in three (0.9%) in group 2. The best cutoff point for endometrial thickness in predicting endometrial carcinoma in group 1 was 8.2 mm, which provided 75% sensitivity (95% confidence interval [CI], 40.9-92.9%) and 74% specificity (95% CI, 68-78.5%); area under the receiver operating characteristics curve (AUC), 0.88; 95% CI, 0.76-1.00%; p = 0.0001. In group 2, the AUC was 0.76 (95% CI, 0.46-1.00; p = 0.114); the evidence was inconclusive as to the relationship between endometrial thickness and malignancy. For the prediction of polyps, the AUCs of endometrial thickness were 0.77 for group 1 (95% CI, 0.71-0.83%; p = 0.0001) and 0.61 for group 2 (95% CI, 0.54-0.67%; p = 0.002).

CONCLUSIONS

Sonographically determined endometrial thickness measurement shows high diagnostic performance for detection of endometrial cancer in symptomatic postmenopausal women at the optimal cutoff thickness of approximately 8 mm, although the evidence supporting the use of sonography for predicting malignancy in asymptomatic women is inconclusive. For polyp detection, this technique shows moderate diagnostic ability in symptomatic women, but its predictive value is low in asymptomatic women. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:339-346, 2016.

The utility of endometrial thickness measurement in asymptomatic postmenopausal women with endometrial fluid

The aim of this study was to assess the clinical usefulness of sonographic endometrium thickness measurement in asymptomatic postmenopausal women with endometrial fluid collection. Fifty-two asymptomatic postmenopausal women with endometrial fluid, who underwent endometrial sampling were evaluated. Histopathological findings revealed that 25 (48.1%) women had insufficient tissue, 20 (38.4%) had atrophic endometrium and 7 (13.5%) had endometrial polyps. No case of malignancy was found. There was no statistically significant difference between the various histopathological categories (insufficient tissue, atrophic endometrium and polyp) with regard to the mean single-layer endometrial thickness (1.54 ± 0.87, 2.04 ± 1.76 and 1.79 ± 0.69 mm, respectively, p = 0.436). Out of 44 patients with endometrial thickness of less than 3 mm, 38 (86.4%) had atrophic changes or insufficient tissue and 6 (13.6%) had endometrial polyps. In conclusion, if the endometrial thickness is 3 mm or less, endometrial sampling is not necessary in asymptomatic postmenopausal women with endometrial fluid.

Effectiveness of transcervical hysteroscopic endometrial resection based on the prevention of the recurrence of endometrial polyps in post-menopausal women

BACKGROUND

The objectives of this study were to determine the effectiveness the effectiveness of post-polypectomy hysteroscopic endometrial resection in preventing the recurrence of endometrial polyps in post-menopausal patients and analyse the complications and necessity of additional surgery in patients, in addition to their degree of satisfaction.

METHODS

A prospective longitudinal study of post-menopausal patients diagnosed with endometrial polyps was conducted including polypectomy and hysteroscopic endometrial resection following the therapeutic purposes (endometrial polyp removal) and prevention of recurrence of endometrial polyps. We evaluated the general condition and characteristics of the patients, including age, BMI, smoking habits, medical, surgical, and obstetrics history and menstrual status. The results were analysed at several time points, 6, 18, 42 and 60 months by hysteroscopy, including the presence of vaginal bleeding and/or possible intracavitary pathology.

RESULTS

A total of 89.5% (n = 355) of our patients had profile factors associated with the increased incidence of endometrial polyps and hyperestrogenism (diabetes mellitus, hypertension and overweight); 89.5% (n = 355) of patients were overweight; 34% had grade I obesity. The surgical procedure was safe, with a 90% (n = 357) success rate without complications, which was higher than the 95-99.5% at the beginning and end time points of the study. Patient acceptance and satisfaction was 90 and 84%, respectively.

CONCLUSIONS

Endometrial resection proved effective in preventing the recurrence of endometrial polyps. It is a safe and effective method. Post-menopausal bleeding reduces the presence of endometrial polyps. Patients reported satisfaction and acceptance of the procedure.

Value of 3-dimensional and power Doppler sonography for diagnosis of endometrial polyps

OBJECTIVES

To investigate whether the endometrial thickness, endometrial volume, and endometrial and subendometrial vascularization index, flow index, and vascularization-flow index were useful for diagnosing endometrial polyps in infertility.

METHODS

Transvaginal and 3-dimesional power Doppler sonography was performed to calculate the endometrial echogenicity, endometrial thickness, endometrial volume, and endometrial and subendometrial vascularization index, flow index, and vascularization-flow index, followed by hysteroscopy in the follicular phase of the menstrual cycle (postmenstrual days 3-7). A total of 555 patients were selected, and 4 groups were defined according to the comparison of sonographic and hysteroscopic diagnoses: group A (sonographically positive but hysteroscopically negative), group B (sonographically and hysteroscopically negative), group C (sonographically negative but hysteroscopically positive), and group D (sonographically and hysteroscopically positive).

RESULTS

A total of 426 patients were enrolled in the final analysis. Significantly higher endometrial thickness and volume were found in groups C and D compared with groups A and B (P < .05). There were no significant differences among the 4 groups in terms of the endometrial and subendometrial vascularization index, flow index, and vascularization-flow index (P > .05). The sensitivity, specificity, and positive and negative predictive values of endometrial thickness and volume in predicting endometrial polyps were 62.7%, 69.8%, 26.9%, and 91.9% and 39.3%, 88.2%, 35.8%, and 89.7%, respectively. Combined sonographic evaluation (sonographic echogenicity, endometrial thickness, and endometrial volume) showed higher sensitivity, specificity, and positive and negative predictive values (65.6%, 89.0%, 50.0%, and 93.9%) compared with a single indicator.

CONCLUSIONS

A combination of endometrial echogenicity, thickness, and volume on sonography may be better than a single indicator for predicting endometrial polyps in infertility. However, the endometrial or subendometrial vascularization index, flow index, and vascularization-flow index are not useful for prediction.

Detection of intracavitary uterine pathology using offline analysis of three-dimensional ultrasound volumes: interobserver agreement and diagnostic accuracy

OBJECTIVE

To estimate the diagnostic accuracy and interobserver agreement in predicting intracavitary uterine pathology at offline analysis of three-dimensional (3D) ultrasound volumes of the uterus.

METHODS

3D volumes (unenhanced ultrasound and gel infusion sonography with and without power Doppler, i.e. four volumes per patient) of 75 women presenting with abnormal uterine bleeding at a 'bleeding clinic' were assessed offline by six examiners. The sonologists were asked to provide a tentative diagnosis. A histological diagnosis was obtained by hysteroscopy with biopsy or operative hysteroscopy. Proliferative, secretory or atrophic endometrium was classified as 'normal' histology; endometrial polyps, intracavitary myomas, endometrial hyperplasia and endometrial cancer were classified as 'abnormal' histology. The diagnostic accuracy of the six sonologists with regard to normal/abnormal histology and interobserver agreement were estimated.

RESULTS

Intracavitary pathology was diagnosed at histology in 39% of patients. Agreement between the ultrasound diagnosis and the histological diagnosis (normal vs abnormal) ranged from 67 to 83% for the six sonologists. In 45% of cases all six examiners agreed with regard to the presence/absence of intracavitary pathology. The percentage agreement between any two examiners ranged from 65 to 91% (Cohen's κ, 0.31-0.81). The Schouten κ for all six examiners was 0.51 (95% CI, 0.40-0.62), while the highest Schouten κ for any three examiners was 0.69.

CONCLUSION

When analyzing stored 3D ultrasound volumes, agreement between sonologists with regard to classifying the endometrium/uterine cavity as normal or abnormal as well as the diagnostic accuracy varied substantially. Possible actions to improve interobserver agreement and diagnostic accuracy include optimization of image quality and the use of a consistent technique for analyzing the 3D volumes.

Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis

OBJECTIVE

To estimate the accuracy of endometrial thickness measurement in the detection of endometrial cancer among women with postmenopausal bleeding with individual patient data using different meta-analytic strategies.

DATA SOURCES

Original data sets of studies detected after reviewing the included studies of three previous reviews on this subject. An additional literature search of published articles using MEDLINE databases was preformed from January 2000 to December 2006 to identify articles reporting on endometrial carcinoma and sonographic endometrial thickness measurement in women with postmenopausal bleeding.

METHODS OF STUDY SELECTION

We identified 90 studies reporting on endometrial thickness measurements and endometrial carcinoma in women with postmenopausal bleeding.

TABULATION, INTEGRATION, AND RESULTS

We contacted 79 primary investigators to obtain the individual patient data of their reported studies, of which 13 could provide data. Data on 2,896 patients, of which 259 had carcinoma, were included. Several approaches were used in the analyses of the acquired data. First, we performed receiver operator characteristics (ROC) analysis per study, resulting in a summary area under the ROC curve (AUC) calculated as a weighted mean of AUCs from original studies. Second, individual patient data were pooled and analyzed with ROC analyses irrespective of study with standardization of distributional differences across studies using multiples of the median and by random effects logistic regression. Finally, we also used a two-stage procedure, calculating sensitivities and specificities for each study and using the bivariate random effects model to estimate summary estimates for diagnostic accuracy. This resulted in rather comparable ROC curves with AUCs varying between 0.82 and 0.84 and summary estimates for sensitivity and specificity located along these curves. These curves indicated a lower AUC than previously reported meta-analyses using conventional techniques.

CONCLUSION

Previous meta-analyses on endometrial thickness measurement probably have overestimated its diagnostic accuracy in the detection of endometrial carcinoma. We advise the use of cutoff level of 3 mm for exclusion of endometrial carcinoma in women with postmenopausal bleeding.

Diagnostic strategies for postmenopausal bleeding

Postmenopausal bleeding (PMB) is a common clinical problem. Patients with PMB have 10%-15% chance of having endometrial carcinoma and therefore the diagnostic workup is aimed at excluding malignancy. Patient characteristics can alter the probability of having endometrial carcinoma in patients with PMB; in certain groups of patients the incidence has been reported to be as high as 29%. Transvaginal sonography (TVS) is used as a first step in the diagnostic workup, but different authors have come to different conclusions assessing the accuracy of TVS for excluding endometrial carcinoma. Diagnostic procedures obtaining material for histological assessment (e.g., dilatation and curettage, hysteroscopy, and endometrial biopsy) can be more accurate but are also more invasive. The best diagnostic strategy for diagnosing endometrial carcinoma in patients with PMB still remains controversial. Future research should be focussed on achieving a higher accuracy of different diagnostic strategies.