Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis

Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time

Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.

Abnormal Pathology Following Vaginal Hysterectomy for Pelvic Organ Prolapse Repair

Objective: Uterine-sparing surgery for pelvic organ prolapse (POP) repair has shown good results, but the potential negative implications of leaving the uterus in place are yet to be fully defined. We aimed to assess the risk of unanticipated abnormal gynecological pathology at the time of reconstructive pelvic surgery. Methods: A retrospective consecutive case series including women who underwent vaginal hysterectomy for POP repair at a tertiary medical center in 2006-2020. All patients were offered a free Pap smear test at the age of 65 years as part of a national screening program. Transvaginal ultrasound was routinely performed preoperatively. Standard 3 pedicle hysterectomy was performed with/without bilateral salpingo-oophorectomy (BSO). Results: The study comprised 462 women of mean age 63 ± 9.3 years without previous known malignant or premalignant pathology. Benign pathology was observed in 286 patients (61.9%). Endometrial malignancy was found in three patients (0.7%) and significant premalignant pathology in 15 patients (3.2%), including cervical intraepithelial neoplasia stage 2-3 in seven patients (1.5%) and complex hyperplasia with atypia in eight patients (1.7%). All these pathologies were found in postmenopausal women. None had preoperative clinical symptoms or endometrial thickness of ≥5 mm on preoperative ultrasound. In the 35 patients after BSO, adnexal findings were normal (77.2%) or benign (22.8%). Conclusions: Premenopausal women with uterovaginal prolapse and normal preoperative evaluation have a minimal risk of significant abnormal uterine pathology. In postmenopausal women, the risk of unanticipated malignant uterine pathology is 0.7% and 3.2% for significant premalignancy.

Estimating risk of endometrial malignancy and other intracavitary uterine pathology in women without abnormal uterine bleeding using IETA-1 multinomial regression model: validation study

OBJECTIVES

To assess the ability of the International Endometrial Tumor Analysis (IETA)-1 polynomial regression model to estimate the risk of endometrial cancer (EC) and other intracavitary uterine pathology in women without abnormal uterine bleeding.

METHODS

This was a retrospective study, in which we validated the IETA-1 model on the IETA-3 study cohort (n = 1745). The IETA-3 study is a prospective observational multicenter study. It includes women without vaginal bleeding who underwent a standardized transvaginal ultrasound examination in one of seven ultrasound centers between January 2011 and December 2018. The ultrasonography was performed either as part of a routine gynecological examination, during follow-up of non-endometrial pathology, in the work-up before fertility treatment or before treatment for uterine prolapse or ovarian pathology. Ultrasonographic findings were described using IETA terminology and were compared with histology, or with results of clinical and ultrasound follow-up of at least 1 year if endometrial sampling was not performed. The IETA-1 model, which was created using data from patients with abnormal uterine bleeding, predicts four histological outcomes: (1) EC or endometrial intraepithelial neoplasia (EIN); (2) endometrial polyp or intracavitary myoma; (3) proliferative or secretory endometrium, endometritis, or endometrial hyperplasia without atypia; and (4) endometrial atrophy. The predictors in the model are age, body mass index and seven ultrasound variables (visibility of the endometrium, endometrial thickness, color score, cysts in the endometrium, non-uniform echogenicity of the endometrium, presence of a bright edge, presence of a single dominant vessel). We analyzed the discriminative ability of the model (area under the receiver-operating-characteristics curve (AUC); polytomous discrimination index (PDI)) and evaluated calibration of its risk estimates (observed/expected ratio).

RESULTS

The median age of the women in the IETA-3 cohort was 51 (range, 20-85) years and 51% (887/1745) of the women were postmenopausal. Histology showed EC or EIN in 29 (2%) women, endometrial polyps or intracavitary myomas in 1094 (63%), proliferative or secretory endometrium, endometritis, or hyperplasia without atypia in 144 (8%) and endometrial atrophy in 265 (15%) women. The endometrial sample had insufficient material in five (0.3%) cases. In 208 (12%) women who did not undergo endometrial sampling but were followed up for at least 1 year without clinical or ultrasound signs of endometrial malignancy, the outcome was classified as benign. The IETA-1 model had an AUC of 0.81 (95% CI, 0.73-0.89, n = 1745) for discrimination between malignant (EC or EIN) and benign endometrium, and the observed/expected ratio for EC or EIN was 0.51 (95% CI, 0.32-0.82). The model was able to categorize the four histological outcomes with considerable accuracy: the PDI of the model was 0.68 (95% CI, 0.62-0.73) (n = 1532). The IETA-1 model discriminated very well between endometrial atrophy and all other intracavitary uterine conditions, with an AUC of 0.96 (95% CI, 0.95-0.98). Including only patients in whom the endometrium was measurable (n = 1689), the model's AUC was 0.83 (95% CI, 0.75-0.91), compared with 0.62 (95% CI, 0.52-0.73) when using endometrial thickness alone to predict malignancy (difference in AUC, 0.21; 95% CI, 0.08-0.32). In postmenopausal women with measurable endometrial thickness (n = 848), the IETA-1 model gave an AUC of 0.81 (95% CI, 0.71-0.91), while endometrial thickness alone gave an AUC of 0.70 (95% CI, 0.60-0.81) (difference in AUC, 0.11; 95% CI, 0.01-0.20).

CONCLUSION

The IETA-1 model discriminates well between benign and malignant conditions in the uterine cavity in patients without abnormal bleeding, but it overestimates the risk of malignancy. It also discriminates well between the four histological outcome categories. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Developing a Nomogram for Prioritizing Hysteroscopy in Endometrial Cancer Diagnosis: A Case-Control Study

(1) Background: The pandemic led to significant healthcare disruptions, resulting in postponed surgeries and extended waiting times for non-urgent treatments, including hysteroscopies essential for diagnosing endometrial cancer. This study aims to formulate a risk stratification model to enhance the prioritization of hysteroscopy procedures in Brazil; (2) Methods: A case-control study was conducted at Vila Santa Catarina Hospital in São Paulo, analyzing the medical records of 2103 women who underwent hysteroscopy between March 2019 and March 2022. We used bivariate analysis and multivariate linear regression to identify risk factors associated with endometrial cancer and formulate a nomogram; (3) Results: The findings revealed a 5.5% incidence of pre-invasive and invasive endometrial disease in the study population, with an average waiting time of 120 days for hysteroscopy procedures. The main risk factors identified were hypertension, diabetes, postmenopausal bleeding, and obesity; (4) Conclusions: This research highlights the urgent need for efficient prioritization of hysteroscopy procedures in the wake of the pandemic. The developed nomogram is an innovative tool for identifying patients at higher risk of endometrial cancer, thus facilitating timely diagnosis and treatment and improving overall patient outcomes in a strained healthcare system.

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

Combination of serum CST1 and HE4 for early diagnosis of endometrial cancer

Purpose

Optimal serological biomarkers have been absent for the early diagnosis of endometrial cancer, to date. In this study, we aimed to define the diagnostic performances of individual and combined detection of serum cysteine protease inhibitor 1 (CST1) with traditional tumor markers, including glycated antigen 125 (CA125) and human epididymis protein 4 (HE4), in patients with early-stage endometrial cancer (EC).

Methods

The performances of individual and combined detection of serum CST1, HE4, and CA125 were evaluated by enzyme-linked immunosorbent assay (ELISA) and chemiluminescent immunoassay, respectively. A training data set of 67 patients with early EC, 67 patients with endometrial benign lesion (EBL), and 67 healthy controls (HC) was used to develop a predictive model for early EC diagnosis, which was validated by an independent validation data set.

Results

In the training data set, serum CST1 and HE4 levels in the early EC group were significantly higher than in EBL/HC groups (P < 0.05), while there was no significant difference of serum CA125 level between the early EC and EBL/HC groups (P > 0.05). Serum CST1 and HE4 exhibited areas under the curve (AUC) of 0.715 with 31.3% sensitivity at 90.3% specificity, and 0.706 with 23.9% sensitivity at 95.5% specificity, respectively. Combined detection of serum CST1 and HE4 exhibited an AUC of 0.788 with 49.3% sensitivity at 92.5% specificity. The combination of serum CST1 and HE4 showed promise in diagnosis.

Conclusion

CST1 is a prospective serological biomarker for early EC diagnosis, and the combination of CST1 and HE4 contributes to the further improvement in the diagnosis of patients with early-stage EC.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Incidental Finding of Thickened Endometrium in Postmenopausal Women: A Survey of Endometrial Cancer

Objectives The primary objective was to determine the prevalence of endometrial cancer in asymptomatic and symptomatic postmenopausal women referred to the hysteroscopy service for incidental finding of thickened endometrium. The secondary objectives were to identify, for the asymptomatic cohort, an acceptable threshold of endometrial thickness (ET) which should trigger endometrial sampling and its related sensitivity and specificity. Methods This was a retrospective cohort study of 136 asymptomatic and 602 symptomatic postmenopausal women with an ET of >4 mm referred to the endometrial cancer diagnostic service in a gynecology oncology center over a period of one year. Clincal and demographic data were analyzed. Histopathological diagnosis was completed and receiver operating characteristic (ROC) curves for acceptable ET cutoff in asymptomatic women were evaluated. Results The prevalence of malignancy and atypical hyperplasia in asymptomatic women was 3.7% and 4.4%, respectively. Within the asymptomatic subgroup with ET <11 mm, the yield rate for atypical hyperplasia (AH)+cancer was 2.2%. An ET <10 mm gave a similar yield; however, specificity decreased. ET (t-test p-value=0.037) correlates with endometrial pathology. Receiver operating characteristic (ROC) curves identified a cutoff of 11 mm as an acceptable threshold for triggering further investigations. Conclusion Based on our findings, 11 mm may represent an acceptable threshold for further investigation in asymptomatic postmenopausal women. We strongly advocate qualitative assessment of the endometrium and evaluation of individual risk factors in women with ET between 4 mm and 11 mm. This study will contribute to the existing body of evidence for the management of asymptomatic postmenopausal women with incidental increased ET. Further studies are required.

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis

OBJECTIVE

This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation.

DATA SOURCES

MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions.

STUDY ELIGIBILITY CRITERIA

Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis.

METHODS

This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group.

RESULTS

A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I2=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I2=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I2=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I2=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I2=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs.

CONCLUSION

Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.

Value of endometrial thickness for the detection of endometrial cancer and atypical hyperplasia in asymptomatic postmenopausal women

BACKGROUND

The role of transvaginal sonography (TVS) in screening endometrial cancer and hyperplasia is significant in postmenopausal women. The objective of this study is to determine the endometrium thickness (ET) cut-off to distinguish premalignancy and malignancy in asymptomatic postmenopausal women.

METHODS

We retrospectively evaluated data of 968 eligible patients among 2537 asymptomatic postmenopausal women with ET ≥ 5 mm examined by TVS who were subjected to hysteroscopy and endometrial biopsy between January 1, 2017, and June 30, 2020 in an urban tertiary specialized hospital in China. The patients were divided into two groups according to the pathology outcomes: benign, and atypical hyperplasia (AH) and endometrial carcinoma (EC). The risk factors and the optimal cut-off of ET for detecting AH and EC were determined by logistic regression analysis and receiver operating characteristic curve.

RESULTS

2537 patients were offered hysteroscopy during a 42-month period. Finally, 968 patients were included for further analysis. Of these, 8 (0.8%) women were diagnosed with EC and 5 (0.5%) women with AH. The mean ET of AH and EC group was substantially higher than that in benign group (10.4 mm vs. 7.7 mm, P < 0.05). ET was significantly correlated with AH and EC shown by logistic regression analysis with an odds ratio (OR) of 1.252 (95% confidence interval [CI] 1.107-1.416, P < 0.001). The optimal cut-off value for AH and EC was found to be 8 mm with the maximum AUC of 0.715 (95% CI 0.686-0.743, P < 0.001), with a sensitivity of 0.846, a specificity of 0.609, positive likelihood ratio (LR+) of 2.164 and negative likelihood ratio (LR-) of 0.253.

CONCLUSION

An ET cut-off of ≥ 8 mm shows a reasonable performance to detect AH and EC in asymptomatic postmenopausal women, thereby avoiding more invasive endometrial biopsy.

Endometrial Hyperplasia

The objectives of this Clinical Expert Series on endometrial hyperplasia are to review the etiology and risk factors, histologic classification and subtypes, malignant progression risks, prevention options, and to outline both surgical and nonsurgical treatment options. Abnormal uterine and postmenopausal bleeding remain the hallmark of endometrial pathology, and up to 10-20% of postmenopausal bleeding will be either hyperplasia or cancer; thus, immediate evaluation of any abnormal bleeding with either tissue procurement for pathology or imaging should be undertaken. Although anyone with a uterus may develop atypical hyperplasia, also known as endometrial intraepithelial neoplasia (EIN), genetic predispositions (eg, Lynch syndrome), obesity, chronic anovulation, and polycystic ovarian syndrome all markedly increase these risks, whereas use of oral contraceptive pills or progesterone-containing intrauterine devices will decrease the risk. An EIN diagnosis carries a high risk of concomitant endometrial cancer or eventual progression to cancer in the absence of treatment. The definitive and curative treatment for EIN remains hysterectomy; however, the obesity epidemic, the potential desire for fertility-sparing treatments, the recognition of varying rates of malignant transformation, medical comorbidities, and an aging population all may factor into decisions to employ nonsurgical treatment modalities.

Comparison of 3D ultrasound, 2D ultrasound and 3D Doppler in the diagnosis of endometrial carcinoma in patients with uterine bleeding: A systematic review and meta-analysis

Endometrial cancer is a common malignancy affecting women worldwide. Usually, it clinically manifests with uterine bleeding, although identical clinical manifestations occur in benign conditions as well, with several endometrial biopsies being conducted unnecessarily. Therefore, an accurate, non-invasive diagnostic test is needed for first-line assessment, so as unnecessary biopsies are limited as much as possible. This systematic review aims to assess the diagnostic accuracy of three-dimensional ultrasound, a relatively novel method in gynecologic assessment, compared to two-dimensional ultrasound and three-dimensional Doppler in the prediction of uterine malignancy in women with abnormal uterine bleeding. The accuracy of endometrial volume, as a diagnostic parameter assessed by three-dimensional ultrasound is compared to diagnostic parameters from the other two methods, namely endometrial thickness and 3D Doppler indices (vascularization index, flow index and vascularization flow index). Articles relevant to our research question were systematically sought in the Web of Science, Scopus and MEDLINE/PubMed databases and underwent rigorous evaluation for inclusion according to the PRISMA 2020 guidelines. Eligible studies were thoroughly assessed for risk of bias and relevant data was extracted and analyzed. Studies were heterogenous and extracted data varied from study to study. Data on endometrial volume was compared to other diagnostic parameters. Forest plots with pooled percentages and hierarchical summary receiver operating characteristic curves were constructed for each comparison. Relative sensitivity and specificity ratios were calculated for each comparison to test for statistical significance. Endometrial volume and thickness comparison showed sensitivity 83% for both parameters and specificity 75% and 69% respectively, with volume being more specific than thickness (p < 0.05). Endometrial volume and Doppler indices comparison showed that sensitivity was 73%, 82%, 81% and 82%, while specificity was 72%, 76%, 75% and 76% for endometrial volume, vascularization index, flow index and vascularization-flow index respectively. All three Doppler indices were significantly more sensitive in the diagnosis of malignancy compared to endometrial volume (p < 0.05) While endometrial thickness remains a reliable predictor of uterine malignancy, endometrial volume appears promising as a method with higher specificity and more reliable measurements. Similarly, vascular indices seem as competent and even more sensitive than endometrial volume as predictors, with the added advantage of semi-automated and reproducible measurements that reflect the whole organ. More comparative studies with standardized protocols should be established, so as reliable cut-off values can be determined and thus standardize and streamline the diagnostic algorithm via the implementation of the three-dimensional modalities in the settings that they are available.

Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3)

OBJECTIVES

The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB.

METHODS

This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology.

RESULTS

In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized.

CONCLUSIONS

We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Endometrial cancer

Endometrial cancer is the most common gynaecological cancer in high income countries and its incidence is rising globally. Although an ageing population and fewer benign hysterectomies have contributed to this trend, the growing prevalence of obesity is the major underlying cause. Obesity poses challenges for diagnosis and treatment and more research is needed to offer primary prevention to high-risk women and to optimise endometrial cancer survivorship. Early presentation with postmenopausal bleeding ensures most endometrial cancers are cured by hysterectomy but those with advanced disease have a poor prognosis. Minimally invasive surgical staging and sentinel-lymph-node biopsy provides a low morbidity alternative to historical surgical management without compromising oncological outcomes. Adjuvant radiotherapy reduces loco-regional recurrence in intermediate-risk and high-risk cases. Advances in our understanding of the molecular biology of endometrial cancer have paved the way for targeted chemotherapeutic strategies, and clinical trials will establish their benefit in adjuvant, advanced, and recurrent disease settings in the coming years.

New Light on Endometrial Thickness as a Risk Factor of Cancer: What Do Clinicians Need to Know?

Transvaginal ultrasound (TVUS) represents an accurate and noninvasive technique to investigate endometrial thickness (ET) in the early diagnosis of endometrial cancer (EC). In the literature, for maximum ET there is no consensus on the cutoff value for normal ET in postmenopause for either symptomatic or asymptomatic women. Most patients with EC present with postmenopausal bleeding (PMB) and in these patients is necessary to perform TVUS to evaluate ET as an indicator for endometrial biopsy. On the contrary, if ET is incidentally detected in postmenopausal patients without bleeding, endometrial sampling for a postmenopausal woman without bleeding should not be routinely performed, although it is estimated that up to 15% of EC occurs in women without vaginal bleeding. The aim of our review was to give clinicians necessary and useful knowledge on the role of TVUS and ET for early detection of EC in their daily routine practice. Based on the most important studies in the literature, we summarized that in premenopausal woman with abnormal uterine bleeding, an optimal cutoff for ET has not yet been established. For postmenopausal women with PMB, at low risk, and ET <4 mm, a follow-up scan could be offered, and for women with ET ≥4 mm, office hysteroscopy–guided endometrial sampling is recommended independently of ET results. On the other hand, in postmenopausal women with PMB and at high risk of EC, office hysteroscopy–guided endometrial sampling is necessary. In postmenopausal women without PMB and ET ≥4 mm, arbitrary endometrial sampling is not recommended, but evaluated case by case based on risk factors. In conclusion, there is broad consensus on the importance of TVUS and the need for further investigation based on risk factors of EC.

Executive Summary of the Uterine Cancer Evidence Review Conference

Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized.

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Can a higher endometrial thickness threshold exclude endometrial cancer and atypical hyperplasia in asymptomatic postmenopausal women? A systematic review

BACKGROUND

Asymptomatic postmenopausal women incidentally found to have thickened endometrium (>4 mm) on transvaginal ultrasound (TVUS) often undergo hysteroscopy and dilatation and curettage despite having a low absolute risk of endometrial cancer. A low threshold for investigation may be unnecessary in these women.

AIM

This systematic literature review examines whether an increased TVUS endometrial thickness threshold has superior diagnostic accuracy for endometrial malignancies and premalignancies in asymptomatic postmenopausal women than the current threshold of ≥4 mm.

METHODS

Pubmed, EMBASE and Cochrane Database of Systematic Reviews were systematically searched using keywords for publications between 2011 and 2021. Studies were included if they reported TVUS endometrial thickness analysis in asymptomatic postmenopausal women and excluded if they were written in a non-English language. Quality of evidence in the included articles was evaluated according to recommendations by the Grading of Recommendations Assessment Development and Evaluation Working Group and reported results were tabulated.

RESULTS

Of seven studies (N = 2986), better evidence identified 12 mm as the optimal diagnostic threshold (area under the curve receiver operating characteristic (AUC ROC) 0.716, 95% CI 0.534-0.897, P = 0.019) for endometrial cancer in asymptomatic postmenopausal women. Two higher quality studies (n = 488 and n = 4751) identified 11 mm as optimal for diagnosing both endometrial carcinoma and atypical hyperplasia (AUC ROC 0.587, 95% CI 0.465-0.708, P = 0.144 and 2.59 relative risk, 95% CI 1.66-4.05, P < 0.001).

CONCLUSION

Evidence for improved detection of endometrial premalignancies and malignancies using alternative endometrial thickness thresholds is not rigorous. Evidence for improved outcomes using alternative thresholds is inadequate. Observation of asymptomatic postmenopausal women without risk factors and with an endometrial thickness of less than 10 mm may be reasonable.

Asymptomatic postmenopausal women: what are the risk factors for endometrial malignancies? A multicentric retrospective study

OBJECTIVE

To evaluate the prevalence and risk factors for endometrial malignancies in asymptomatic postmenopausal women.

METHODS

Multicentric retrospective analytical study in two Brazilian Reference Centers. All women without postmenopausal bleeding who were submitted to hysteroscopy with biopsy were included (1665). Excluded women without anatomopathological results (625) and whose medical records were incomplete (37). The variables analyzed were age; parity; body mass index; duration of menopausal status; systemic arterial hypertension; diabetes mellitus; use of hormone replacement therapy; use of tamoxifen; duration of use of tamoxifen; endometrial thickness and biopsy results.

RESULTS

The frequency of endometrial malignancies in asymptomatic postmenopausal women was 2.39%. Endometrial thickness ≥8 mm increased the chance of endometrial malignancies, even more, with an endometrial thickness ≥12.55 mm the chance of endometrial malignancies increased by 4.68 times (p < .001 and 95% CI: 1.99-11.03).

CONCLUSION

The prevalence of endometrial malignancies was low and the only risk factor for endometrial malignancies in asymptomatic postmenopausal women was endometrial thickness.

Cystic endometrium on ultrasound scan: Sonographic-hysteroscopic-pathologic correlation

OBJECTIVE

To assess the correlation between ultrasound findings of cystic endometrium and hysteroscopic and histopathologic findings.

METHODS

A retrospective study was performed across two London hospital sites between January and December 2020.

RESULTS

The percentage chance of having either endometrial hyperplasia or cancer was lower in our cohort of women with postmenopausal bleeding and ultrasound findings of cystic endometrium, compared with population estimates for women with postmenopausal bleeding alone (4.1% vs 10%-15% for endometrial cancer and 1.4% vs 5%-10% for endometrial hyperplasia). Conversely, a higher proportion of women in our cohort were diagnosed with endometrial polyps compared with population estimates for postmenopausal bleeding (68% vs 2%-12%). The rate of endometrial hyperplasia was significantly higher in our cohort of premenopausal women with abnormal uterine bleeding and cystic endometrium compared with population estimates for premenopausal patients with abnormal uterine bleeding (15.4% vs 1.4%).

CONCLUSION

Cystic endometrium appears to be a powerful predictor of endometrial pathology. The high rate of endometrial hyperplasia in premenopausal women with cystic endometrium would advocate the need to obtain histologic diagnoses. Further studies are required to confirm whether cystic endometrium in women with postmenopausal bleeding confers a lower risk of endometrial hyperplasia and cancer.

Thickened Endometrium: When to Intervene? A Clinical Conundrum

The endometrium is a dynamic target organ in a woman's reproductive life. It undergoes cyclical change regulated by the fine balance between oestrogen and progesterone. The endometrial thickness (ET) varies according to the phases of the menstrual cycle. Endometrium contains both oestrogen and progesterone receptors, which respond to above hormones, irrespective of whether the woman is in reproductive or menopausal phase. Abundance of oestrogen leads to endometrial hyperplasia, and paucity causes endometrial atrophy. The initial best modality of assessing ET or aberration is high resolution transvaginal ultrasonogram. Thickened endometrium is always a clinical conundrum. Dilemma does remain as to the thickness of endometrium which requires intervention, mostly in symptomatic pre and perimenopausal women. In post-menopausal women with bleeding, the cut-off of ET that warrants investigation is almost defined. However, the cut-off value of ET in asymptomatic postmenopausal women; beyond which intervention is required, is still debated. Dilemma also exists about the cut-off of ET in both symptomatic and asymptomatic women on HRT and Tamoxifen. This article will discuss the above issues and reach at some consensus about the cut-off of ET after critical analysis of evidence and experience and will help clinicians in arriving at a proper decision in dealing with such clinically confounding situations.

Clinical and Sonographic Evaluation of Postmenopausal Bleeding (PMB) Followed by Diagnostic and/or Therapeutic Hysteroscopy and Guided Biopsy in Jordanian Hospitals

Background and Objectives: The goal of this study was to evaluate the clinical sonographic evaluation of postmenopausal bleeding (PMB) followed by diagnostic and/or therapeutic hysteroscopy and guided biopsy in Jordanian hospitals. Materials and Methods: A retrospective multi-centric study was performed in hospitals in Al-Karak and Amman from 2014-2016. The study recruited 189 cases to evaluate the aetiology of postmenopausal bleeding. Atrophic endometrium was observed as a major cause of postmenopausal bleeding according to histopathology. The cases were also distributed according to parity in which nulliparous patients were observed. Results: Hysteroscopy was observed to be effective for the diagnosis of postmenopausal bleeding. Conclusion: There is a need to assess more approaches for the diagnosis of postmenopausal bleeding among women.

The significance of sonographically thickened endometrium in asymptomatic postmenopausal women

Objective

To investigate the correlation between sonographic, hysteroscopic, and pathological findings in postmenopausal asymptomatic patients with sonographically thickened endometrium.

Methods

The records of postmenopausal patients who attended the Menopause Outpatient Clinic of a tertiary women's hospital in Ankara, Turkey between January 1, 2012 and December 15, 2013 were retrieved. A total of 266 postmenopausal women without vaginal bleeding underwent hysteroscopic evaluation and endometrial sampling. Patients whose pathological records indicated an endometrial thickness equal to or greater than 6 mm (double layer) on transvaginal ultrasonography without any symptoms were included in the study.

Results

The most frequently detected focal intrauterine lesions in asymptomatic women were endometrial polyps, which were diagnosed in 168 (63.1%) cases. Twenty-four (9%) patients were diagnosed as having simple hyperplasia, 4 (1%) atypical hyperplasia, and 8 (3%) endometrial adenocarcinoma. Two of the patients with adenocarcinoma were diagnosed based on endometrial polyps, and 6 cases showed endometrial hyperplasia on hysteroscopy, while histological examination showed endometrial carcinoma.

Conclusion

We suggest 10.5 mm as the cutoff value for endometrial thickness and recommend hysteroscopy following dilatation and curettage to increase diagnostic efficacy and provide definitive treatment in asymptomatic postmenopausal women with thickened endometrium.

Risk of malignancies among asymptomatic postmenopausal women with thickened endometrium: A cohort study

The risk of malignancies and related factors among asymptomatic postmenopausal women with thickened endometrium in transvaginal sonography (TVS) are unclear.In this longitudinal study at a tertiary teaching hospital, all medical records of hysteroscopy were searched and retrospectively reviewed according to age, TVS results and diseases coded as International Classification of Diseases version 10. Asymptomatic postmenopausal women with endometrial thickness ≥5 mm from January 2006 to January 2016 were included. A follow-up was provided up to January 2017.Four hundred eighty-eight patients were included with a median endometrial thickness of 8 mm (range 5-30) in TVS. The most common pathologic findings were polyps (51.0%) and normal endometrium (34.2%). Fifteen (3.1%) and 10 cases (2.0%) had endometrial intraepithelial neoplasia (EIN) and carcinoma. Patients with carcinoma had significantly more abnormal serum CA125, thicker endometrium, and more lesions with positive Doppler flow signals. In receiver operating characteristic curve analysis, endometrial thickness of 12 mm had the best predictive ability for malignancies. In multivariate analysis, endometrial lesion with positive Doppler flow signals in TVS was the only independent factor for EIN/carcinoma (odds ratio [OR] 8.0, 95% confidence interval [CI] 1.4-45.1) and for carcinoma (OR 16.0, 95% CI 1.3-192.8). After a median follow-up of 45 months, carcinoma occurred in 1 of 35 (2.8%) women with repeated thickened endometrium.Among asymptomatic postmenopausal women with thickened endometrium, the risk of EIN and malignancy was minimal but worth of long-term follow-up. Endometrial lesions with positive Doppler flow signals in TVS suggested a high risk of malignancy.

Risk of endometrial cancer and endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥11 mm: A systematic review and meta-analysis

PURPOSE

To evaluate the risk of endometrial cancer and/or endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥ 11 mm.

METHODS

Systematic review of literature using database search (PubMed and Web of Science) of articles published between January 1990 and December 2016 evaluating the correlation between endometrial thickness as measured by transvaginal ultrasound (double layer) and histopathological findings in asymptomatic postmenopausal women, using the following terms: "endometrial thickness," "postmenopausal," "postmenopause," and "asymptomatic." Inclusion criteria were prospective or retrospective studies of more than 150 cases that provided information on endometrial thickness and its correlation with histopathological data. Studies that included patients with hormone replacement therapy, tamoxifen, or aromatase inhibitors were excluded. The overall relative risk (RR) for EC/EHA was calculated, stratifying the patients into two groups according to endometrial thickness (<11 mm and ≥11 mm). Heterogeneity was assessed by calculating I² .

RESULTS

The search identified 289 studies. After exclusions, nine articles that met all the inclusion criteria were included, comprising data from 4751 women. The prevalence of endometrial cancer and/or endometrial hyperplasia with atypia was 2.4%. The relative risk of endometrial cancer and/or endometrial hyperplasia with atypia in the ≥11 mm group was 2.59 (95% CI: 1.66-4.05). High heterogeneity was observed between studies (I² : 57.3%, P = .016).

CONCLUSIONS

Overall the risk for EC/EHA was 2.6 times greater in women with ET ≥11 mm vs women with ET 5-10 mm, although there was significant heterogeneity in estimates across studies.

Risk of endometrial cancer in asymptomatic postmenopausal patients with thickened endometrium: data from the FAME-Endo study: an observational register study

PURPOSE

To evaluate the risk for endometrial cancer (EC) in a large series of asymptomatic patients with thickened endometrium at ultrasound examination based on previously published data of a theoretical cohort.

METHODS

In a prospective register study, a total of 1024 women with thickened endometrium in ultrasound examination undergoing histological diagnosis by dilation, hysteroscopy and curettage were evaluated. 124 patients were excluded due to current medication with tamoxifen and/or presence of HNPCC leaving 900 patients for further analysis.

RESULTS

Mean [standard deviation (SD)] age of patients was 65.6 (8.6) years. Mean (SD) endometrial thickness was 11.9 (5.8) mm. 32 and 6 cases of EC and complex endometrial hyperplasia with atypia were found, respectively. In the univariate analysis, a statistically significant association between endometrial thickness, current use of antihypertensive medication, number of deliveries, and the presence of endometrial fluid in preoperative vaginal ultrasound (p < 0.05) with EC was found. A multivariate logistic regression model incorporating these parameters showed a statistically significant independent association of endometrial thickness, number of deliveries, and the presence of endometrial fluid in preoperative vaginal ultrasound (p < 0.05), but not current use of antihypertensive medication, with EC. Using a cut-off of the endometrial thickness of > 11 mm, the risk for "EC alone" and "EC and complex endometrial hyperplasia with atypia combined" was found to be 6.7% and 7.9%, respectively.

CONCLUSIONS

Our data compare favorably to a theoretical cohort suggesting a clinically reasonable cut-off of > 11 mm endometrial thickness to discriminate between "normal" and "pathological". The data regarding "risk for endometrial cancer" can be used for counseling affected women.

Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study

BACKGROUND

Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking.

OBJECTIVE

To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer.

STUDY DESIGN

This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared.

RESULTS

There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II-IV (23.5% vs 23.8%; P = .9) or in high-grade histology (41.0% vs 38.4%; P = .12). Among patients with stage-I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P < .01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5-year recurrence-free survival (79.1% vs 79.4%; P = .85), disease-specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37).

CONCLUSION

Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

Value of endometrial thickness assessed by transvaginal ultrasound for the prediction of endometrial cancer in patients with postmenopausal bleeding

PURPOSE

Histological confirmation of endometrial cancer by dilatation/curettage (D/C) in women with postmenopausal bleeding (PMB) can be challenging due to anesthesiological and/or surgical risks. Thus, less invasive methods for diagnostics are required to identify patients with minimal risk for endometrial cancer (EC) to avoid unnecessary surgical intervention. The objective of this single-center cohort study was to assess the diagnostic validity of transvaginal ultrasound (TVUS) measurements of endometrial thickness (ET) in patients with PMB for the detection of EC.

METHODS

A retrospective analysis of data from patients presenting between January 2005 and August 2014 at the Department of Obstetrics and Gynecology, University Hospital Ulm, Germany, with PMB and subsequent D/C was performed. Complete data with TVUS documentation of ET and histological results of tissue samples were available from 254 patients. In addition, data on age, body mass index (BMI), ASA-score, diabetes, hypertension, and hematological laboratory values (for a smaller subsample) were recorded. To identify independent risk factors, a multivariate logistic regression with endometrial cancer as binary response variable (yes/no) was performed. Diagnostic efficacy data for different ET cutoff points (≤1 to ≤26 mm) were obtained by a receiver operator characteristic (ROC) curve analysis.

RESULTS

The multivariate logistic regression revealed a significant independent predictive value for age and ET. However, none of the analyzed ET cutoff points showed optimal diagnostic validity, as all cutoff points with sensitivity rates above 90% (≤1 to ≤5 mm) had false positive rates of 70% and higher.

CONCLUSIONS

There is no ET cutoff point that provides good diagnostic accuracy and/or reliably excludes the presence of endometrial cancer in patients with PMB. Thus, our data analysis supports the actual German approach of histological evaluation of any PMB to confirm or exclude EC.

Hysteropexy: Evidence and Insights

Uterovaginal prolapse may be treated with or without concomitant hysterectomy. Many patients express interest in uterine-sparing prolapse procedures, for which there are increasing evidence available regarding techniques and outcomes. Uterine-sparing procedures to treat uterovaginal prolapse require a unique set of surgical considerations including uterine abnormalities, possibility of occult malignancy, and future pregnancy. Data, including randomized controlled trials, support the use of sacrospinous hysteropexy. Other prospective trials detailing outcomes following uterosacral hysteropexy, mesh augmented sacrospinous hysteropexy, and sacrohysteropexy are also encouraging.

Hysteroscopy: A necessary method for detecting uterine pathologies in post-menopausal women with abnormal uterine bleeding or increased endometrial thickness

Objective:

To investigate the histologic and hysteroscopic findings of post-menopausal women with uterine bleeding and asymptomatic women with increased endometrial thickness equal or more than 5 mm.

Materials and Methods:

This cross-sectional study was performed between May 2014 and June 2015 on 110 post-menopausal women aged 40-82 years. The women were divided into two groups: Women with abnormal uterine bleeding (AUB group) and asymptomatic women with increased endometrial thickness (asymptomatic group).

Results:

Among the participants, 67 women had AUB and 43 women were asymptomatic. In the AUB group sensitivity, specificity, and positive and negative predictive values of hysteroscopy for normal findings were 98%, 100%, 100% and 90%, respectively. In the asymptomatic group, the same parameters were 98%, 100%, 100% and 85%, respectively. The sensitivity, specificity, and positive and negative predictive values of hysteroscopy for polyps and myomas were 100%. Also, the sensitivity, specificity, and positive and negative predictive values were 100% in hyperplasia cases found during hysteroscopy in both groups.

Conclusion:

Increased endometrial thickness in postmenopausal women with or without AUB is mostly due to benign lesions such as polyps and submucosal myomas. Hysteroscopy is a safe and reliable method for evaluating and treating these lesions.

Through thick and thin: a pictorial review of the endometrium

The purpose of this pictorial review is to describe the normal appearance of the endometrium and to provide radiologists with an overview of endometrial pathology utilizing case examples. The normal appearance of the endometrium varies by age, menstrual phase, and hormonal status with differing degrees of acceptable endometrial thickness. Endometrial pathology most often manifests as either focal or diffuse endometrial thickening, and patients frequently present with abnormal vaginal bleeding. Endovaginal ultrasound (US) is the first-line modality for imaging the endometrium. This article will discuss the endometrial measurements used to direct management and workup of symptomatic patients and will discuss when additional imaging may be appropriate. Three-dimensional US is complementary to two-dimensional ultrasound and can be used as a problem-solving technique. Saline-infused sonohysterogram is a useful adjunct to delineate and detect focal intracavitary abnormalities, such as polyps and submucosal fibroids. Magnetic resonance imaging is the preferred imaging modality for staging endometrial cancer because it best depicts the depth of myometrial invasion and cervical stromal involvement. Unique imaging features and complications of endometrial ablation will be introduced. At the completion of this article, the reader will understand the spectrum of normal endometrial findings and will understand the workup of common endometrial pathology.

Dynamic monitoring of menopause hormone therapy and defining the cut-off value of endometrial thickness during uterine bleeding

The aim of this study was to evaluate the effects of low-dose tibolone therapy on ovarian area, uterine volume and endometrial thickness, and define the cut-off value of endometrial thickness for curettage during uterine bleeding. We followed 619 postmenopausal women, aged 40-60 years, for two years. There were 301 subjects in the low-dose tibolone treatment group and 318 subjects in the control group. The ovarian area, uterine volume and endometrial thickness in all participants were measured by transvaginal ultrasound prior to, one and two years post enrollment, respectively. Endometrial specimens were collected from all subjects with abnormal uterine bleeding during the follow-up period. We found that the uterine volume in the treatment group was greater than that in the control group, and the difference was significant (P<0.05), but there were no significant differences in ovarian area and endometrial thickness between the two groups (P>0.05). When the cut-off value for endometrial thickness was 7.35 mm, the sensitivity and specificity were 100% and 79.07%, respectively, and 85.71% and 93.02% when 7.55 mm was set as the cut-off during tibolone therapy. The results indicate that low-dose tibolone therapy may postpone uterine atrophy and the cut-off value of endometrial thickness may be appropriately adjusted for curettage.

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.

Two-Dimensional Sonographic Evaluation of Endometrial Polyps - Parameters That Are Reassuring

AIMS

To assess intra-endometrial lesions according to five two-dimensional sonographic parameters for predicting malignancy.

MATERIAL AND METHODS

This is a retrospective analysis of stored digital images from consecutive pathological reports of patients with benign endometrial polyps and stage 1 endometrial carcinoma. Five sonographic parameters were evaluated: heterogeneous or complex echogenicity of the lesion, presence of a 'bright edge sign,' regular endometrial-myometrial junction, the presence of a normal endometrium adjacent to the lesion, and detection of small intralesional cysts. The sensitivity, specificity, PPV, and NPV of these parameters were calculated, as well as combinations of pairs of parameters.

RESULTS

Seventy-nine patients were eligible for the current study, 26 with benign endometrial polyps and 53 with stage 1 endometrial carcinoma. The sonographic appearance of numerous small intralesional cysts (cystic formation) was highly related to benign polyp; the presence of a lesion with heterogeneous echogenicity had sensitivity and specificity for malignancy of 63.5 and 88.5%, respectively.

CONCLUSIONS

We have shown that asymptomatic endometrial lesions, which are homogenous, have bright edges, and small intralesional cysts are likely to be benign Determining these parameters during sonographic evaluation can assist in identifying patients who will benefit from a follow-up strategy instead of an unnecessary surgical intervention.

An epidemiological model for prediction of endometrial cancer risk in Europe

Endometrial cancer (EC) is the fourth most frequent cancer in women in Europe, and as its incidence is increasing, prevention strategies gain further pertinence. Risk prediction models can be a useful tool for identifying women likely to benefit from targeted prevention measures. On the basis of data from 201,811 women (mostly aged 30-65 years) including 855 incident EC cases from eight countries in the European Prospective Investigation into Cancer and Nutrition cohort, a model to predict EC was developed. A step-wise model selection process was used to select confirmed predictive epidemiologic risk factors. Piece-wise constant hazard rates in 5-year age-intervals were estimated in a cause-specific competing risks model, five-fold-cross-validation was applied for internal validation. Risk factors included in the risk prediction model were body-mass index (BMI), menopausal status, age at menarche and at menopause, oral contraceptive use, overall and by different BMI categories and overall duration of use, parity, age at first full-term pregnancy, duration of menopausal hormone therapy and smoking status (specific for pre, peri- and post-menopausal women). These variables improved the discriminating capacity to predict risk over 5 years from 71% for a model based on age alone to 77% (overall C statistic), and the model was well-calibrated (ratio of expected to observed cases = 0.99). Our model could be used for the identification of women at increased risk of EC in Western Europe. To achieve an EC-risk model with general validity, a large-scale cohort-consortium approach would be needed to assess and adjust for population variation.

Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse

Hysterectomy has historically been a mainstay in the surgical treatment of uterovaginal prolapse, even in cases in which the removal of the uterus is not indicated. However, uterine-sparing procedures have a long history and are now becoming more popular. Whereas research on these operations is underway, hysteropexy for the treatment of prolapse is not as well studied as hysterectomy-based repairs. Compared with hysterectomy and prolapse repair, hysteropexy is associated with a shorter operative time, less blood loss, and a faster return to work. Other advantages include maintenance of fertility, natural timing of menopause, and patient preference. Disadvantages include the lack of long-term prolapse repair outcomes and the need to continue surveillance for gynecological cancers. Although the rate of unanticipated abnormal pathology in this population is low, women who have uterine abnormalities or postmenopausal bleeding are not good candidates for uterine-sparing procedures. The most studied approaches to hysteropexy are the vaginal sacrospinous ligament hysteropexy and the abdominal sacrohysteropexy, which have similar objective and subjective prolapse outcomes compared with hysterectomy and apical suspension. Pregnancy and delivery have been documented after vaginal and abdominal hysteropexy approaches, although very little is known about outcomes following parturition. Uterine-sparing procedures require more research but remain an acceptable option for most patients with uterovaginal prolapse after a balanced and unbiased discussion reviewing the advantages and disadvantages of this approach.

American Cancer Society Colorectal Cancer Survivorship Care Guidelines

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.

Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study

OBJECTIVE

To estimate the accuracy of transvaginal ultrasound (TVS) measurement of endometrial thickness (ET) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding (PMB).

DESIGN

Retrospective cohort study.

SETTING

One-stop PMB clinic in a Hong Kong teaching hospital.

POPULATION

A cohort of 4383 women with PMB.

METHODS

Transvaginal ultrasonic measurement of ET and endometrial biopsies were obtained in women presenting with PMB between 2002 and 2013. Endometrial histology was used as the reference standard to calculate accuracy estimates.

MAIN OUTCOME MEASURES

Accuracy data for TVS ET presented as sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve.

RESULTS

Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89-0.94). The sensitivity for the detection of endometrial cancer at 3-, 4-, and 5-mm cut-offs were 97.0% (95% CI 94.5-99.6%), 94.1% (95% CI 90.5-97.6%), and 93.5% (95% CI 89.7-97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8-46.8%), 66.8% (65.4-68.2%), and 74.0% (72.7-75.4%).

CONCLUSIONS

Transvaginal ultrasound using a 3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy.

Efficacy of the Levonorgestrel-Releasing Intrauterine System on IVF-ET Outcomes in PCOS With Simple Endometrial Hyperplasia

OBJECTIVE

This study investigated the in vitro fertilization (IVF) outcome of levonorgestrel-releasing intrauterine system (LNG-IUS) pretreatment for simple endometrial hyperplasia (EH) in patients with polycystic ovary syndrome (PCOS) undergoing IVF embryo transfer (IVF-ET).

METHODS

One hundred ninety patients with PCOS and simple EH without cytologic atypia were allocated randomly to 2 independent arms, that is, the LNG-IUS group (90 patients) and the non-LNG-IUS group (100 patients). Four hundred fourteen patients with PCOS without endometrial disease comprised the control group. Each patient was reevaluated by transvaginal ultrasonography (TVS) and endometrial biopsy after 6 months. For each patient, IVF outcome measures, such as number of recombinant follicle-stimulating hormone, endometrial thickness on human chorionic gonadotropin (HCG) day, hormone levels (progesterone, luetinizing hormone, and serum estradiol) on HCG day, number of oocytes, fertilization rate, clinical pregnancy rate, and miscarriage rate were compared among the 3 groups.

RESULTS

In general, the 3 groups did not differ with respect to the main clinical and biochemical data. After 6 months, patients in LNG-IUS group had an EH resolution rate of 87.77%. In the non-LNG-IUS group, the resolution rate was 15.00%, and 3% of these patients showed progression of EH. The clinical pregnancy rates in the non-LNG-IUS group were significantly lower (28.04%) than that in the LNG-IUS group (46.06%) and the control group (44.65%). The miscarriage rate was highest in the non-LNG-IUS group, but no significant difference in miscarriage rate existed among the 3 groups.

CONCLUSION

The study illustrates that the LNG-IUS can be safely used for 6 months as a treatment for patients with PCOS and simple EH. Additionally, use of the LNG-IUS can increase the clinical pregnancy rates and implantation rates of patients with PCOS and simple EH who undergo gonadotropin-releasing hormone agonist IVF-ET protocols.

Vaginal hysterectomy for uterovaginal prolapse: what is the incidence of concurrent gynecological malignancy?

INTRODUCTION AND HYPOTHESIS

Vaginal hysterectomy (VH) is a commonly performed procedure for the operative treatment of uterovaginal prolapse (UVP). The reported incidence of unexpected gynecological cancer in cases of VH for UVP ranges between 0.3 and 0.8 %. Aim of the study is to assess the incidence of malignant and premalignant gynecological histopathological findings among women who underwent a VH for UVP and had a normal preoperative workup.

METHODS

The histopathology reports of women who underwent VH for the treatment of UVP were retrospectively assessed. All women had a history of normal cervical smear tests and a normal preoperative transvaginal scan. Patients with a history of a premalignant or malignant gynecological pathological condition and women with abnormal uterine bleeding were excluded.

RESULTS

Overall, 14 out of 333 women who underwent VH (4.2 %) were found to have abnormal histopathological findings of the uterus. Among them, there were 9 cases of endometrial hyperplasia of any type (2.7 %), 1 case of cervical cancer (0.3 %), 1 case of cervical intraepithelial neoplasia (CIN) III (0.3 %), and 3 cases of CINI (0.9 %). No cases of endometrial cancer were detected. Among women who underwent salpingo-oophorectomy (n = 86) three simple serous cysts (3.5 %) were found, with no cases of ovarian cancer.

CONCLUSIONS

The incidence of unexpected premalignant or malignant gynecological pathological conditions among asymptomatic women who underwent VH, with a history of normal cervical smear tests and normal preoperative TVS, was low but not negligible. This information should be included in the preoperative counseling of women planning to undergo surgery for UVP.

Endometrial abnormalities on transvaginal ultrasonography and histopathology in women after quinacrine sterilization

OBJECTIVE

To describe endometrial abnormalities on transvaginal ultrasonography and histopathology in women after quinacrine sterilization.

METHODS

It was an analytical cross sectional study conducted during February 2012 to April 2013. The sample size calculated at 95% confidence level was 540. Sampling technique used was simple random sampling. The medical history, examination, transvaginal ultrasonography and biopsy of suspected lesion was performed in quinacrine sterilized women.

RESULTS

The calculation of statistics showed the mean age at quinacrine sterilization was 38.5 years, standard deviation 6.517, and standard error 0.461. The endometrium was regular and smooth with homogenous images in 86% (n= 466), irregular endometrium with heterogeneous images on transvaginal ultrasound in 9.4% (n =51) and endometrial growth with high level echoes in 4.2% women (n= 23). The histological findings included hyperplasia and well differentiated adenocarcinoma in two patients respectively.

CONCLUSION

The irregular endometrium, adhesions, and growths were found after quinacrine sterilization. The risk of endometrial growth was more after 10 years duration of quinacrine sterilization.

Diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies and appropriateness of performed hysteroscopies among asymptomatic postmenopausal women

OBJECTIVE

To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies.

STUDY DESIGN

Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4 mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies.

RESULTS

No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8 mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10 mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52).

CONCLUSION

Using an endometrial thickness cut-off value ≥4 mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8 mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.