Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Afro-Caribbean Jamaican women with postmenopausal bleeding

Risk of endometrial polyp and surgical intervention in postmenopausal women with proliferative endometrium

OBJECTIVE

To study the long-term risks of postmenopausal women with proliferative endometrium developing benign uterine pathologies (endometrial polyps and uterine fibroids) and requiring future gynecological interventions, and to compare them with women with atrophic endometrium.

DESIGN

Retrospective cohort study of all women aged 55 or over who underwent endometrial biopsy between 1/1997 and 12/2008. Outcome data were available through to 2/2018. Women with proliferative endometrium were compared with those with atrophic endometrium for the presence of endometrial polyps, uterine fibroids, future endometrial biopsy for recurrent vaginal bleeding, and future hysteroscopy or hysterectomy. Logistic regression models were used to evaluate the association of endometrial histology and other covariates with the risk of morbidities.

MAIN FINDINGS

Postmenopausal women with proliferative endometrium are at higher risk of developing endometrial polyps, uterine fibroids and need for surgical intervention. Of 1808 women who underwent endometrial biopsy during the study period, 962 met inclusion criteria: 278 had proliferative and 684 had atrophic endometrium. Length of surveillance was similar in the two groups (11.9 vs. 11.5 years, p = 0.2). Compared with women with atrophic endometrium, women with proliferative endometrium had significantly higher rates of endometrial polyps (17.3 % vs 9.7 % p = 0.001). Multivariable logistic regression confirmed that women with proliferative endometrium had more fibroids on ultrasound (62.1 % vs 50.3 % 3 = 0.02), and had increased risks of developing endometrial polyps (aOR 1.9, 95 % CI 1.28-3.07, p = 0.002), repeat endometrial biopsy (34.9 % vs. 16.8%p < 0.001) and future hysterectomy or hysteroscopy (26.6 % vs 16.2 % p < 0.001).

CONCLUSIONS

In addition to the long-term increased risk of cancer, postmenopausal women with proliferative endometrium are more likely to have future bleeding, surgical interventions and diagnosis of endometrial polyps. Medical management to reduce estrogenic activity and associated risks may be considered in these cases.

Estimated Performance of Transvaginal Ultrasonography for Evaluation of Postmenopausal Bleeding in a Simulated Cohort of Black and White Women in the US

IMPORTANCE

Black women in the US with endometrial cancer (EC) are more likely to be diagnosed with advanced-stage disease independent of insured status and histologic type. The most common way of diagnosing EC at early stages is through screening of people with postmenopausal bleeding to detect endometrial thickness (ET). This approach may disproportionately underperform in Black women secondary to a higher prevalence of fibroids and nonendometrioid EC in this population, both of which affect the quality of ET measurement.

OBJECTIVE

To compare the performance of recommended transvaginal ultrasonography (TVUS) ET thresholds as a screening method to prompt endometrial biopsy by race in a simulated cohort of symptomatic women.

DESIGN, SETTING, AND PARTICIPANTS

In a simulated retrospective cohort study, based on data from Surveillance, Epidemiology, and End Results (SEER) national cancer registry 2012-2016; the US census; and published estimates of ET distribution and fibroid prevalence, diagnostic test characteristics of the 3-mm or more, 4-mm or more, and 5-mm or more ET thresholds for biopsy to capture EC diagnoses were calculated. The simulated cohort was constructed from February 2, 2020 (date of access to SEER data), to August 31, 2020. Analysis occurred from September 30, 2020, to March 30, 2021, including the primary analysis and the sensitivity calculations.

MAIN OUTCOMES AND MEASURES

The main outcome measured was accuracy of the TVUS ET threshold to accurately identify cases of EC, measured by sensitivity, negative predictive value, and area under the curve (AUC).

RESULTS

A total of 367 073 simulated Black and White women with postmenopausal bleeding were evaluated, including 36 708 with EC. Among Black women, the currently recommended 4-mm or greater ET threshold prompted biopsy for fewer than half of EC cases (sensitivity, 47.5%; 95% CI, 46.0%-49.0%); of women referred for biopsy, 13.1% were EC cases (positive predictive value, 13.1%; 95% CI, 12.5%-13.6%). The AUC for the 4-mm or more threshold was 0.57 (95% CI, 0.56-0.57). In contrast, among the White women, the 4-mm or more threshold led to biopsy for most with EC (sensitivity, 87.9%; 95% CI, 87.6%-88.3%). Of those referred for biopsy, 14.6% had EC (positive predictive value, 14.6%; 95% CI, 14.4%-14.7%); AUC was 0.73 (95% CI, 0.73-0.74). The same variations held for the 3-mm or more and 5-mm or more ET thresholds: sensitivity, positive predictive value, and AUC were consistently lower for Black women than White women.

CONCLUSIONS AND RELEVANCE

The findings of this simulated cohort study suggest that use of ET as measured by TVUS to determine the need for EC diagnostic testing in symptomatic women may exacerbate racial disparities in EC stage at diagnosis. In simulated data, TVUS ET screening missed almost 5 times more cases of EC among Black women vs White women owing to the greater prevalence of fibroids and nonendometrioid histologic type in Black women.

Long-term outcome of postmenopausal women with proliferative endometrium on endometrial sampling

BACKGROUND

Proliferative endometrium has been reported in 15% of endometrial biopsies of women aged 50 years and older. Contrary to endometrial hyperplasia, proliferative endometrium has not been associated with the risk of endometrial cancer.

OBJECTIVE

This study aimed to report on the long-term outcome of postmenopausal women who received a diagnosis of proliferative endometrium.

STUDY DESIGN

This is a retrospective cohort study of 1808 women aged 55 years and older who underwent endometrial sampling between January 1997 and December 2008. Outcome data were available through February 2018. Women with a proliferative endometrium were compared with those with an atrophic endometrium for future development of endometrial hyperplasia or cancer. A subanalysis was performed for those who presented with postmenopausal bleeding. Uni- and multivariable logistic regression analyses were used to assess for confounders.

RESULTS

In this study, 297 women (16.4%) received a diagnosis of proliferative endometrium. Furthermore, 962 women met the inclusion criteria. Among those women, 278 had a proliferative endometrium, and 684 had an atrophic endometrium. Women with a proliferative endometrium were younger (61.2 vs 64.5 years; P<.0001) and had a higher body mass index (33.9 vs 30.6 kg/m²; P<.0001). More African American women had a proliferative endometrium. Both groups had a similar length of surveillance (11.9 vs 11.5 years; P=.27). Women with a proliferative endometrium had a higher risk of developing endometrial hyperplasia or cancer (11.9% vs 2.9%; P<.0001), any endometrial cancer (5.8% vs 1.8%; P=.002), atypical endometrial hyperplasia (2.2% vs 0.4%; P=.02), and nonatypical endometrial hyperplasia (2.0% vs 0.7%; P=.001). The risk of developing endometrial cancer and endometrial hyperplasia remained similar after excluding cases on hormonal replacement therapy (12.2% vs 3%; P=.001). On logistic regression analysis, proliferative endometrium histology (odds ratio, 3.89; 95% confidence interval, 2.03-7.49; P<.0001), age >60 years (odds ratio, 1.98; 95% confidence interval, 1.03-3.82; P=.04), and body mass index >35 kg/m² (odds ratio, 2.3; 95% confidence interval, 1.09-4.83; P<.0001) remained significant risk factors for progression to cancer.

CONCLUSION

One of the 6 postmenopausal women who underwent endometrial sampling had a proliferative endometrium. Furthermore, 11.9% of women developed endometrial hyperplasia or cancer, a 4-fold greater incidence than women with an atrophic endometrium. The findings of this study suggest that long-term monitoring is warranted for women with postmenopausal bleeding and a proliferative endometrium histology. Further studies are needed to examine if a treatment is required to negate the risk of unopposed estrogen.

The Impact of Fibroids and Histologic Subtype on the Performance of US Clinical Guidelines for the Diagnosis of Endometrial Cancer among Black Women

Objective

To assess the predicted performance of the American College of Obstetrics and Gynecology (ACOG)'s recommended endometrial thickness (ET) of ≥4mm via transvaginal ultrasound (TVUS) for a simulated cohort of US Black women with postmenopausal bleeding (PMB).

Main Outcome Measure

Performance characteristics of 3+, 4+, and 5+mm ET thresholds were assessed including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operator Characteristic (ROC) curves, and the area under the curve (AUC).

Methods

We used endometrial cancer parameters from ET studies upon which guidelines are based, as well as documented population characteristics of US Black women, to simulate a cohort of US Black women with PMB. Annual endometrial cancer (EC) prevalence overall and by histology type (I and II), history and current diagnosis of uterine fibroids, and visibility of endometria were estimated. Sensitivity analyses were performed to assess performance changes with quality of baseline parameters and impact of fibroids on ET visibility.

Results

In the main model with the 4+mm recommended threshold, TVUS ET showed a sensitivity of 47.5% (95% CI: 46.0-49.0%); specificity of 64.9% (95% CI: 64.4-65.3%); PPV of 13.1% (95% CI: 12.5-13.6%); NPV of 91.7% (95% CI: 91.4-92.1%), and AUC of .57 (95% CI: .56-.57).

Conclusions

Among a simulated cohort of US Black women, the recommended 4+mm ET threshold to trigger diagnostic biopsy for EC diagnosis performed poorly, with more than 50% of cases missed and an 8-fold higher frequency of false negative results than reported for the general population.

Ultrasound detection of endometrial cancer in women with postmenopausal bleeding: Systematic review and meta-analysis

OBJECTIVE

To assess the performance of endometrial thickness (ET) cut-offs for detecting endometrial cancer (EC) in women with postmenopausal bleeding (PMB) and evaluate the clinical utility of additional ultrasound measures such as endometrial volume (EV), vascular flow index (VFI), vascularization index (VI), and uterine artery flow index (FI).

METHODS

Clinicaltrials.gov and MEDLINE database via PubMed were queried for studies published between 1/1990 and 3/2016 using specific MeSH terms. Original, peer-reviewed cohort studies reporting EC outcomes and specific ultrasound findings by PMB status were included.

RESULTS

Study design, country, clinical setting inclusion/exclusion criteria, aggregate study-level demographic and clinical data were extracted from 44 studies including 17,339 women with PMB and 1341 cases of EC (7.7%). In women with PMB and EC (n = 417), pooled mean ET was 16.4 mm (95% CI, 14.8-18.1 mm). In women with PMB without EC, pooled mean ET was 4.1 mm. 31 studies reported outcomes using different ET cut-off values ranging from 3 to 20 mm. Compared to ≥3 or 4 mm, a cutoff of ≥5 mm had similar sensitivity (96.2, 95%CI 92.3, 98.1) with improved specificity for EC (51.5, 95%CI 42.3-60.7), allowing to reduce the rate of invasive workup for PMB by 17%. EV, VI, VFI, and FI were significantly correlated with EC, but performance of specific cut-offs was not analyzed due to limited data.

CONCLUSION

Among women with PMB mean ET is substantially higher in women with EC compared to those without EC. An ET cutoff of ≥5 mm shows an acceptable tradeoff between sensitivity and specificity for diagnosis of EC.

Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis

IMPORTANCE

As the worldwide burden of endometrial cancer continues to rise, interest is growing in the evaluation of early detection and prevention strategies among women at increased risk. Focusing efforts on women with postmenopausal bleeding (PMB), a common symptom of endometrial cancer, may be a useful strategy; however, PMB is not specific for endometrial cancer and is often caused by benign conditions.

OBJECTIVE

To provide a reference of the prevalence of PMB in endometrial cancers and the risk of endometrial cancer in women with PMB.

DATA SOURCES

For this systematic review and meta-analysis, PubMed and Embase were searched for English-language studies published January 1, 1977, through January 31, 2017.

STUDY SELECTION

Observational studies reporting the prevalence of PMB in women with endometrial cancer and the risk of endometrial cancer in women with PMB in unselected populations were selected.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers evaluated study quality and risk of bias using items from the Newcastle-Ottawa Quality Assessment Scale and the Quality Assessment of Diagnostic Accuracy Studies tool. Studies that included highly selected populations, lacked detailed inclusion criteria, and/or included 25 or fewer women were excluded.

MAIN OUTCOMES AND MEASURES

The pooled prevalence of PMB in women with endometrial cancer and the risk of endometrial cancer in women with PMB.

RESULTS

A total of 129 unique studies, including 34 432 unique patients with PMB and 6358 with endometrial cancer (40 790 women), were analyzed. The pooled prevalence of PMB among women with endometrial cancer was 91% (95% CI, 87%-93%), irrespective of tumor stage. The pooled risk of endometrial cancer among women with PMB was 9% (95% CI, 8%-11%), with estimates varying by use of hormone therapy (range, 7% [95% CI, 6%-9%] to 12% [95% CI, 9%-15%]; P < .001 for heterogeneity) and geographic region (range, 5% [95% CI, 3%-11%] in North America to 13% [95% CI, 9%-19%] in Western Europe; P = .09 for heterogeneity).

CONCLUSIONS AND RELEVANCE

Early detection strategies focused on women with PMB have the potential to capture as many as 90% of endometrial cancers; however, most women with PMB will not be diagnosed with endometrial cancer. These results can aid in the assessment of the potential clinical value of new early detection markers and clinical management strategies for endometrial cancer and will help to inform clinical and epidemiologic risk prediction models to support decision making.

Racial differences in fibroid prevalence and ultrasound findings in asymptomatic young women (18-30 years old): a pilot study

OBJECTIVE

1) To determine the prevalence of fibroids in asymptomatic young black and white women (ages 18-30 y); 2) to determine other differences in uterine and adnexal anatomy; and 3) to obtain preliminary data for sample size calculations.

DESIGN

Pilot cross-sectional study.

SETTING

Academic medical center.

PATIENT(S)

One hundred one nonparous black and white women, ages 18-30 years, with no known diagnosis of fibroids or clinically suggestive symptoms.

INTERVENTION(S)

A transvaginal ultrasound was performed in the follicular phase in all subjects.

MAIN OUTCOME MEASURE(S)

1) Presence of fibroids; 2) endometrial thickness; 3) ovarian findings.

RESULT(S)

Of the 101 participants (mean age 24.5 ± 3.5 y), 43% self-identified as black and 57% as white. The prevalence of ultrasound-diagnosed fibroids was 15% overall (26% in black women and 7% in white women). The mean fibroid size was 2.3 ± 2.1 cm. There was a significant difference in endometrial thickness between races, even after adjusting for contraception use and fibroid presence.

CONCLUSION(S)

Racial differences in fibroid prevalence exist even before women become symptomatic. Findings of thicker endometrium in black women could have clinical implications and warrants further investigation.

Hysteroscopy in postmenopausal bleeding

OBJECTIVES

1) To study the etiology of postmenopausal bleeding (PMB). 2) To study the significance of hysteroscopy in evaluation of the etiopathogenic factors. 3) Correlating the diagnosis after transvaginal sonography (TVS), hysteroscopy and histopathologic diagnosis. 4) Feasibility of conservative management with hysteroscopy in PMB.

DESIGN

Prospective study from January 2008 to June 2009.

SETTING

Department of Obstetrics and Gynecology of Ruby Hall Clinic, Pune.

PATIENTS

Sixty postmenopausal women with complaint of bleeding per vaginum.

INTERVENTIONS

Clinical and sonographic evaluation, followed by diagnostic and/or therapeutic hysteroscopy and guided biopsy. Hysteroscopic images were analyzed and compared with histopathologic results.

MEASUREMENTS AND MAIN RESULTS

On hysteroscopy, endometrium was classified as suggestive of normal, atrophic, endometrial hyperplasia or endometrial carcinoma. Histopathologic diagnosis is taken as a gold standard to determine the efficacy of hysteroscopy in diagnosing endometrial pathologies. The sensitivity and specificity of hysteroscopy in diagnosing endometrial pathologies was assessed.

CONCLUSIONS

In women with PMB, hysteroscopy is the basic tool that allows precise diagnosis of various endouterine pathologies. The average sensitivity of hysteroscopy was 97% in our study and the specificity was 98.66%. Hence, we can conclude that it is highly accurate for evaluating endometrial pathologies. For obvious benign lesions, it also provides treatment in the same sitting, therefore avoiding an extensive, morbid, and expensive procedure like hysterectomy.

A thin and regular endometrium on ultrasound is very unlikely in patients with endometrial malignancy

OBJECTIVE

To evaluate the clinical and sonographic features in patients with endometrial malignancy in whom endometrial thickness on ultrasound examination had been recorded in our database to be < 5 mm.

METHODS

This was a retrospective observational study on 187 consecutive patients diagnosed with endometrial malignancy in whom an ultrasound evaluation of the endometrium had been performed in our institution. The characteristics of those patients presenting with an endometrial thickness < 5 mm were analyzed.

RESULTS

The median endometrial thickness was 15 mm: 12 mm for the women who underwent endometrial sampling before ultrasound examination vs. 17 mm in those who did not (P = 0.0086). In 13 women (6.9%), the endometrial thickness recorded in our database was < 5 mm. In 12 of these the measurement was compromised in some way: nine of these patients had undergone endometrial sampling (Pipelle biopsy in one and dilatation and curettage in eight patients) before the ultrasound examination, in two cases, focal malignant lesions were not included in the recorded endometrial thickness and in one, the endometrial thickness was visualized poorly due to myometrial distortion. In only one case was was the endometrium correctly measured to be < 5 mm; this woman had diffuse uterine and endometrial metastases of a breast cancer.

CONCLUSIONS

A thin and regular endometrial line is very reliable for the exclusion of endometrial carcinoma. The suspicion of focal lesions as well as incomplete visualization of the endometrium on sonography should be considered abnormal. Recently performed endometrial sampling makes measurement of the endometrial thickness unreliable.

Histopathologic findings in women with postmenopausal bleeding: implication for endometrial thickness and circulating levels of sex steroid hormones

OBJECTIVE

The aim of this study is to compare the relationship between estrone (E1), estradiol (E2), androgens, and prolactin blood levels on the one hand, and endometrial thickness and related histopathologic results on the other, in postmenopausal women admitted with uterine bleeding.

METHODS

The study was conducted in Gazi University School of Medicine, Obstetrics and Gynecology Clinic with a total of 128 patients. The study group consisted of 64 postmenopausal patients admitted with uterine bleeding, whereas the control group consisted of 64 healthy postmenopausal women. Vaginal sonography was performed to evaluate the endometrial thicknesses of the patients. Serum levels of free testosterone, androstenedione and estrone (E1) were determined by radioimmunoassay while serum estradiol (E2), prolactin, and dehydroepiandrosterone sulfate (DHEA-S) levels were evaluated by chemiluminescent method.

RESULTS

The median age, duration of menopause, menopausal age and gravidity, and parity did not differ between women with postmenopausal bleeding and the control group (P > 0.05). However, DHEA-S level was lower (P < 0.05) and endometrial thickness was greater in the study group than the control group (P < 0.05). Furthermore, the study identified that median endometrial thickness of the patients in atrophic endometrium group was less than the endometrial hyperplasia and endometrium carcinoma group (P < 0.05).

CONCLUSION

In the current study, all these hormones seemed to be indifferent between groups of endometrial cancer and other pathological results. Based on our results regarding the safe margin of endometrial thickness in women with postmenopausal bleeding, it seems justifiable to refrain from curettage in patients with an endometrium of < or =4 mm.

Thin endometrial echo complex on ultrasound does not reliably exclude type 2 endometrial cancers

OBJECTIVE

The objective of this study was to determine the ultrasonographic characteristics of the uterus and endometrial echo-complex (EEC) of postmenopausal patients diagnosed with type 2 endometrial cancer, including uterine papillary serous carcinoma (UPSC), clear cell carcinoma (CCC), and other endometrial high-grade carcinomas (HGC).

METHODS

Postmenopausal patients with type 2 endometrial cancer who underwent preoperative pelvic ultrasound were identified. Histologic diagnoses were made by biopsy or hysterectomy. Ultrasound reports were abstracted for the following parameters: EEC thickness, presence of intracavitary fluid or lesion, myometrial mass, uterine size, and adnexal mass. Ultrasound films were re-reviewed by a single gynecologic ultrasonographer.

RESULTS

Fifty-two patients with detailed ultrasound reports comprised the study population. Twenty-six films were available for re-review and inter-examiner agreement was 92%. Forty-four women (85%) presented with abnormal vaginal bleeding. Thirty-four patients (65%) had a thickened EEC measuring >5 mm. In 9 cases (17%), the EEC measured <4 mm. In an additional 9 patients (17%) the EEC was indistinct. One or more other ultrasound abnormalities were found in each of the 18 cases with a non-thickened EEC: intracavitary fluid or lesion (8; 44%), myometrial mass (12; 67%), enlarged uterus (13; 72%), or adnexal mass (5; 28%).

CONCLUSION

A thin or indistinct endometrial stripe, especially when associated with other ultrasound abnormalities does not reliably exclude type 2 endometrial cancer. Postmenopausal vaginal bleeding requires endometrial sampling despite a thin EEC in the presence of other ultrasonographic abnormalities or persistent bleeding.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.