Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium

When is it necessary to perform biopsy in asymptomatic postmenopausal women with incidental finding of thickened endometrium?

OBJECTIVE

To determine the cutoff value for endometrial thickness (ET) that prompts a biopsy in asymptomatic postmenopausal women with an incidental finding of thickened endometrium, and to develop a risk prediction model.

METHODS

This is a retrospective cohort analysis of the clinical records of the Hysteroscopic Center of Fu Xing Hospital, Capital Medical University, Beijing, China. We collected asymptomatic postmenopausal women who presented with an ET of ≥4 mm (double-layer) as an incidental finding. We stratified the participants into non-malignant and malignant groups based on pathology results and assessed differences between the two groups. A receiver operating characteristic curve (ROC) was used to identify the cutoff value of ET for predicting endometrial malignancy. Logistic regression models were also constructed to predict the risk of malignancy.

RESULTS

A total of 581 consecutive eligible cases were included. The optimal cutoff value for ET was 8 mm, with a maximum area under the curve (AUC) of 0.755 (95 % CI: 0.645-0.865). In addition to ET, the regression model incorporated diabetes, blood flow signal, BMI, and hypertension to predict the risk of malignancy. A ROC curve constructed for the model yielded an AUC of 0.834 (95 % CI: 0.744-0.924).

CONCLUSION

It is reasonable to offer hysteroscopy and visually-directed endometrial biopsy for asymptomatic postmenopausal women when ET is 8 mm or above. For those with an ET between 4 and 8 mm, further decision to perform biopsy should be determined on an individual basis, considering risk factors and blood flow signals of the endometrium.

The optimal endometrial thickness threshold for prediction of endometrial cancer in postmenopausal women without bleeding remains uncertain-Systematic review and meta-analysis

The incidental finding of endometrial thickness (ET) >4 mm in the absence of postmenopausal bleeding (PMB) is a common cause of referring women to secondary care. However, there is lack of consensus amongst gynecologists as regards the management. It is estimated that up to 15 % of endometrial cancers occur in women without PMB. The aim this study was to determine the optimal ET threshold, on trans-vaginal ultrasound scan, that discriminates normal endometrium from endometrial hyperplasia and cancer in this cohort. On using a thorough search strategy, a total 16 studies including 4088 women were deemed eligible. However, the data were not amenable to meta-analysis. There were wide variations in the thresholds reported with potential bias given the retrospective nature of the majority of the studies. Despite contacting authors, we could not obtain the primary data to generate a Receiver Operating Characteristic (ROC) Curve. No linear or curvilinear association was found between ET thresholds and the percentage of women diagnosed with endometrial hyperplasia and cancer using either Pearson's correlation, linear or curvilinear regression, or a simple visual scan/scatter diagram. The result of this study reveals the lack of evidence to inform clinical practice in this area, and there is a need for a well-designed multi-center prospective study.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

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.

Asymptomatic endometrial thickening in postmenopausal women: predictor of malignant pathology?

It is not standardised what is the endometrial thickness that discriminates between normal and potentially malignant. The objective of this study was to determine the endometrial thickness cut-off point from which the risk of endometrial cancer (EC) increases in asymptomatic postmenopausal women; and to evaluate the risk factors linked to malignant endometrial pathology as well as other associated ultrasound findings.This was a retrospective observational study that included hysteroscopies performed at the Hospital Materno-Infantil on 267 asymptomatic menopausal women with an increase in endometrial thickness (AET) >5 mm, from 2015 to 2019. The results shows that the prevalence of malignant pathology in asymptomatic postmenopausal women with a casual finding of endometrial thickening was 3.7%. This percentage was 16.3% when the cut-off point of AET was established at 10 mm. There was a significant association for the diagnosis of malignant pathology with this cut-off point.There is a significant association between the 10 mm endometrial thickness cut-off point from which the risk of EC increases in asymptomatic postmenopausal women.Impact statementWhat is already known on this subject? Several studies have established the cut-off point for asymptomatic endometrial thickening (AET) for atypical endometrial hyperplasia and endometrial cancer at 10 mm. Although no cut-off point has optimal accuracy for the diagnosis of malignant endometrial pathology, it has been found that with a cut-off value of AET >10 mm no cases are missed. Likewise, a cut-off point of AET > 11 mm may provide a balance between cancer detection and histopathological workup extension.What do the results of this study add? A significant association was found at the cut-off point of AET > 10 mm, which suggests that screening postmenopausal women at this thickness is acceptable and unlikely to miss cases of endometrial hyperplasia and endometrial cancer.What are the implications of these findings for clinical practice and/or further research? After analysing our results we can conclude, like other published studies, that by establishing a cut-off point of 10 mm we obtain a good discrimination between benign and malignant pathology, which would allow us to diagnose 100% of malignant pathology. Above this cut-off point, the risk of endometrial cancer increases, and it would therefore be advisable to extend the study. A multicentre study is needed to confirm the cut-off point at which the risk of endometrial cancer increases in postmenopausal women with asymptomatic endometrial thickening.

Clinicopathological features of endometrial lesions in asymptomatic postmenopausal women with thickened endometrium

OBJECTIVE

To analyze the clinical and pathological features of asymptomatic postmenopausal women with an incidentally detected increase in endometrial thickness (ET) by transvaginal ultrasound examination and discuss the cutoff value of ET for the timely discovery of endometrial malignancy.

METHODS

This was a retrospective study of postmenopausal women with asymptomatic thickened endometrium (greater than or equal to 5 mm) screened by transvaginal ultrasound who were referred to the gynecology department at Xuanwu Hospital between January 2018 and March 2021. Data on participant demographics, clinical characteristics, and histopathology outcomes were collected. We stratified the participants into the benign group and malignant group according to pathology results and assessed differences between the two groups. A receiver operating characteristic curve was used to identify the cutoff value of ET for predicting endometrial malignancy in postmenopausal women with asymptomatic thickened endometrium.

RESULTS

A total of 163 eligible cases were included in the analysis. The results showed that only ET was significantly different between the two groups. The median ET was significantly higher in the malignant group than in the benign group (1.20 vs 0.80, P = 0.023). The optimal cutoff value of ET was 10 mmwith the maximum AUC (0.881, 95% CI 0.810-0.952, P = 0.024), and the sensitivity and specificity for the diagnosis of endometrial malignancy were 100%and 80%, respectively. Among the 47 women with ET ≥ 10mm, the prevalence of endometrial malignancy was 6.3%, which was significantly higher than that among women with ET < 10mm ( P = 0.023).

CONCLUSION

For postmenopausal women with asymptomatic endometrial thickening, the prevalence of endometrial malignancy is significantly higher when ET is ≥ 10 mm. If ET is ≥ 10mm, further histopathological testing should be recommended to exclude endometrial malignancy. Further large-sample and prospective studies are needed to determine the predictive value of ET.

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.

Management of asymptomatic postmenopausal women referred to outpatient hysteroscopy service with incidental finding of thickened endometrium - A UK District General Hospital Experience

STUDY OBJECTIVE

The objective of this study was to review the management and outcome of asymptomatic postmenopausal women with increased endometrial thickness as there is lack of robust guidance for the same.

DESIGN

Retrospective case series over a period of 2 years.

SETTING

District general hospital.

PATIENTS

Eighty-three.

INTERVENTIONS

No prospective interventions were done. Only a review of the interventions done in an outpatient setting, namely, hysteroscopy and endometrial sampling, was carried out.

MEASUREMENTS AND MAIN RESULTS

Retrospective review of 1453 referrals to outpatient hysteroscopy service over a period of 2 years was carried out, and 83 patients referred with asymptomatic thickened endometrium on imaging were identified. Patients underwent hysteroscopy on the basis of the local policy, that is, if the endometrial thickness was more than 10 mm or in the presence of additional risk factors. The yield rate of endometrial cancer and atypical hyperplasia was 1.2% and 2.4%, respectively, among all patients (n = 83). The yield rate of endometrial cancer and atypical hyperplasia was 1.81% and 3.63%, respectively, among patients referred with endometrial thickness ≤10 mm after considering other risk factors.

CONCLUSION

It is reasonable to use endometrial thickness of 10 mm or above as a cutoff threshold to offer endometrial biopsy or outpatient hysteroscopy for asymptomatic postmenopausal women. For asymptomatic women with endometrial thickness between 4 and 10 mm, decisions about further investigations should be made on a case-by-case basis, taking into account any risk factors for endometrial pathology. As this study had a reasonably good sample size, it can contribute toward formulation of robust guidance for management of postmenopausal women with asymptomatic endometrial thickening.

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.

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.

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.

Hysteroscopic assessment of postmenopausal endometrial thickening

Introduction

Endometrial thickness is measured by transvaginal sonography and thickening indicates an increased risk of malignancy or other pathology (hyperplasia or polyp) in the postmenopausal period. The main screening methods for the uterine cavity are dilatation and curettage, and hysteroscopy. We sought to correlate hysteroscopic and pathological findings in asymptomatic postmenopausal women with sonographically thickened endometrium (> 5 mm) in this study.

Material and methods

This retrospective cross-sectional study involved case records of 197 women who have thickened (> 5 mm) endometrium in the postmenopausal period. All these women underwent hysteroscopy with diagnostic dilatation and curettage between January 2012 and January 2013 at the Bursa Zübeyde Hanım Maternity Hospital. Sensitivity, specificity, positive, negative predictive values and p value of hysteroscopy were calculated. Dilatation and curettage was set as the gold standard.

Results

For the evaluation of postmenopausal thickened endometrium, hysteroscopy revealed sensitivity, specificity, positive predictive value and negative predictive value as 76.4%, 76.9%, 73.1%, 79.8%, respectively.

Conclusions

Hysteroscopy is a fast and accurate technique in evaluation of the intrauterine space occupying lesions (polyp, fibroid) but only moderate for endometrial hyperplasia. Hysteroscopic view combined with direct biopsy could be a gold standard for endometrial assessment.

Roles of sonography and hysteroscopy in the detection of premalignant and malignant polyps in women presenting with postmenopausal bleeding and thickened endometrium

BACKGROUND

To assess the role of sonographic endometrial thickness and hysteroscopic polyp size in predicting premalignant and malignant polyps in postmenopausal women.

MATERIALS AND METHODS

A total of 328 postmenopausal women with abnormal uterine bleeding and thickened endometrium underwent operative hysteroscopy due to detection of endometrial polyps were included in this retrospective study. Preoperative endometrial thickness measured by transvaginal ultrasonography and polyp size on hysteroscopy were noted. Hysteroscopic resection with histology was performed for endometrial polyps. Endometrial thickness and polyp size were evaluated on the basis of final diagnosis established by histologic examination. Receiver operator characteristic curves were calculated to assess the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of endometrial thickness and polyp size for detecting premalignant and malignant polyps.

RESULTS

Premalignant and malignant polyps were identified in 26 (7.9%) of cases. Sonographic measurement showed a greater endometrial thickness in cases of premalignant and malignant polyps when compared to benign polyps. On surgical hysteroscopy, premalignant and malignant polyps were also larger. Endometrial thickness demonstrated a sensitivity of 53.8%, specificity of 85.8%, PPV of 24.6% and NPV of 95.6% at a cut-off limit of 11.5 mm with diagnostic accuracy of 83.2%. Polyp size has a diagnostic accuracy of 94.8% with a sensitivity of 92.3%, specificity of 95.0%, PPV of 61.5% and NPV of 99.3% at a cut-off point of 19.5mm.

CONCLUSIONS

Endometrial thickness measured by transvaginal ultrasonography is not sufficient in predicting premalignant and malignant endometrial polyps in postmenopausal women with abnormal uterine bleeding and thickened endometrium. Polyp size on hysteroscopy is a more accurate parameter, because of better sensitivity and specificity. However, while polyp size ≥ 19.5mm seems to have a great accuracy for predicting premalignancy and malignancy, histologic evaluation is still necessary to exclude premalignant and malignant polyps.

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.

Malignant Potential of Endometrial Polyps: A retrospective study

To estimate the potential risk of malignancy in endometrial polyps and to investigate the possible clinical risk factors. Clinical, sonographic, hysteroscopic and pathological data were reviewed of 337 women with pathologically confirmed endometrial polyps diagnosed in Qatar between 2000 and 2010. The polyps were benign in 95.6% of cases, pre-malignant in 2.3%, and malignant in 2.1 % of cases. Advanced age, menopausal status and vaginal bleeding were strongly associated with atypical hyperplasia and cancer. There appeared to be no association between the risk of malignancy and other clinical risk factors.

Conclusions: There is a small risk of malignancy in endometrial polyps, mainly in post-menopausal patients of advanced age with symptomatic vaginal bleeding. In these circumstances, endometrial polyps should be managed aggressively as potential cancer and removalfor histology is mandatory.

The significance of a thickened endometrial echo in asymptomatic postmenopausal patients

OBJECTIVE

The purpose of this study was to evaluate the significance of a thickened endometrial echo in an asymptomatic, postmenopausal patient.

STUDY DESIGN

A retrospective review was conducted of all women who underwent transvaginal ultrasonography between January 2003 and August 2008, were found to have an endometrial thickness of at least 5mm and were subjected to endometrial sampling.

RESULTS

Sixty-five postmenopausal women, without vaginal bleeding underwent ultrasonographic evaluation with subsequent endometrial sampling. The mean endometrial stripe thickness was 9.7 mm (range: 5.4-22). Four (6.2%) cases of simple/complex hyperplasia were identified and two (3.1%) cases of atypical hyperplasia were diagnosed. Zero (0%) specimens were identified as adenocarcinoma. Twenty-eight (43.1%) polyps and eleven (16.9%) leiomyomata were identified.

CONCLUSION

The use of transvaginal sonography as a screening tool in this population is not validated and need not trigger routine evaluation.

Feasibility of office hysteroscopy through the "see and treat technique" in private practice: a prospective observational study

PURPOSE

The purpose of the study was to examine the feasibility of office hysteroscopy through the no-touch "see and treat technique" in a routine basis in private practice.

METHODS

In the private practice of two trained gynecologists, women with an indication for further investigation of the uterine cavity were treated with the technique. A total of 112 consecutive women were prospectively allocated to a "no-touch" and "see and treat" technique of hysteroscopy. Neither anaesthesia nor analgesia was used as soon as criteria were met. Hysteroscopy was performed using a rigid 3.4-mm hysteroscope and a medium of 0.9% saline.

RESULTS

Treatment efficacy and patient compliance were evaluated through scores on a visual analogue scale (VAS) for pain, complications and success rates, along with the symphony between hysteroscopic findings and histology. The patients' pain score on the VAS was low and only in 2 out of 112 cases there was a marked discomfort. In four cases suggested treatment was not successful, because of the fear of the patient. In 60.71% of cases that hysteroscopy was indicated, the uterine cavity was normal. No complications or adverse effects were noted. Apart from one case, there was a full agreement between hysteroscopic findings and histology.

CONCLUSION

Office hysteroscopy is a successful and well-tolerated procedure. Through adequate expertise it should be considered the method of choice in private basis, at the same time when exploration of the uterine cavity is needed.