Transvaginal Ultrasonography of the Endometrium in Postmenopausal Japanese Women

A study evaluating liquid-based endometrial cytology test and transvaginal ultrasonography as a screening tool for endometrial cancer in 570 postmenopausal women

OBJECTIVE

To evaluate the combination of transvaginal ultrasonography (TVS) and endometrial cytology test (ECT) as a potential diagnostic strategy for endometrial cancer and endometrial precancerous lesions in postmenopausal patients.

METHODS

570 postmenopausal patients admitted in our hospital due to abnormal bleeding or other symptoms and/or with endometrium thickness over 5 mm on ultrasound. The endometrial thickness was evaluated by TVS. Following obtainment with written consent, all patients underwent ECT, hysteroscopy and then dilatation and curettage (D&C). Cytological sampling was conducted by scratching the uterus cavity using SAP-1 and the samples were prepared as liquid-based smear using SurePath technology. The samples were stained using Papanicolaou method. The correlation between cytological diagnosis and TVS results with the D&C histological diagnosis was analyzed. The WHO classification was used for diagnosis.

RESULTS

Sensitivity of ECT, TVS, ECT or TVS positive, ECT and TVS positive to diagnose atypical hyperplasia or worse were estimated at 80.7%, 86.8%, 97.4%, 70.2%, specificity at 94.7%, 20.4%, 17.5%, 88.4%, positive predictive value at 58.2%, 21.1%, 22.8%, 60.2%, negative predictive value at 94.4%, 86.1%, 96.4%, 92.2%, and accuracy at 84.6%, 33.7%, 33.5%, 84.7%, respectively.

CONCLUSIONS

Transvaginal ultrasonography and Endometrial cytology test may be regarded as a effective first-line method in endometrial pathology detection in postmenopausal women.

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.

Endometrial thickness cut-off value by transvaginal ultrasonography for screening of endometrial pathology in premenopausal and postmenopausal women

Objective

To assess the clinical usefulness and diagnostic accuracy of ultrasonographic measurement of endometrial thickness (ET) in women with endometrial hyperplasia or cancer (EH+).

Methods

This retrospective cohort study included 29,995 consecutive women who underwent transvaginal ultrasonography (TVS) for an incidental finding of a thickened endometrium at the health screening and promotion center at Asan Medical Center between 2006 and 2010. Among 959 patients with endometrial abnormalities, 92 patients were included in this study. A total of 867 patients were excluded: 416 were lost to follow-up; 263 did not undergo endometrial biopsy; 155 had endometrial polyps; 17 had submucosal myomas; and 16 had insufficient tissue samples. Endometrial histology was the reference standard for calculating accuracy.

Results

Of the 92 patients, 78 (84.8%) had normal pathology, while 14 (15.2%) had endometrial pathology (EH+), including 5 patients (35.7%) with simple hyperplasia without atypia, 3 (21.4%) with complex hyperplasia, and 6 (42.9%) with endometrial carcinoma, all stage Ia. The area under the receiver-operating characteristic curve was 0.75 (95% confidence interval [CI], 0.593-0.906). The cut-off value for ET was 8 mm, indicating that TVS ET had a fair accuracy in diagnosing carcinoma, had a sensitivity of 100% (95% CI, 62.9-100.0%) and a specificity of 24.3% (95% CI, 15.2-36.3%).

Conclusion

TVS is useful for detecting EH+, with a cut-off value for ET of 8 mm having a high sensitivity for detecting endometrial pathologies and the ability to identify women highly unlikely to have EH+, thereby avoiding more invasive endometrial biopsy.

Liquid-based endometrial cytology associated with curettage in the investigation of endometrial carcinoma in a population of 1987 women

PURPOSE

The aim of this study was to investigate the diagnostic accuracy of liquid-based endometrial cytology, in comparison with histology.

METHODS

1987 patients scheduled for hysteroscopy were enrolled in this study. All patients proceeded sequentially through endometrial cytology, hysteroscopy and then dilatation and curettage (D&C). Cytology sampling was performed by brushing the uterus cavity using SAP-1 and the sample was prepared to liquid-based smear using SurePath technology. The slides were stained by Papanicolaou method. All cytological diagnosis was correlated with the D&C histological diagnosis.

RESULTS

Cyto-histological correlations were possible in 1672 (89.3%) patients: in 254 (12.8%) patients the D&C was inadequate, in 75 (3.8%) patients the cytology was inadequate, and in 14 (0.7%) patients both were inadequate. In postmenopausal women, 758 of 790 cytologies (96.0%) were adequate, while 586 of 790 histologies (74.2%) were adequate. SAP-1 provided more sufficient materials for cytology than D&C for histology (P < 0.001). Taking atypical hyperplasia or worse as a positive result, the diagnostic accuracy of liquid-based endometrial cytology was 86.1%, sensitivity was estimated at 70.3%, specificity at 88.5%, positive predictive value at 48.0% and negative predictive value at 95.2%. Taking endometrial carcinoma as a positive result, the diagnostic accuracy of liquid-based endometrial cytology was 94.4%; sensitivity was estimated at 53.2%, specificity at 98.6%, positive predictive value at 79.8% and negative predictive value at 95.3%.

CONCLUSIONS

Liquid-based endometrial cytology can be considered a useful method for detecting of endometrial pathology as a first-line approach.

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

OBJECTIVES

Measurement of endometrial thickness is an important tool in the assessment of women with postmenopausal bleeding, but the role of endometrial thickness measurement by ultrasound in asymptomatic women is unclear. The aims of this study were to determine: (1) the normal endometrial thickness measured by ultrasonography, (2) the prevalence of serious endometrial pathology and (3) the sensitivity and specificity of endometrial thickness measurement by transvaginal ultrasonography (TVS) for diagnosing premalignant and malignant endometrial disease in asymptomatic postmenopausal women.

METHODS

A MEDLINE and EMBASE search (from inception to January 2011) was performed. Articles reporting on endometrial thickness measurement in the diagnosis of endometrial carcinoma and atypical hyperplasia in asymptomatic postmenopausal women not using hormone replacement therapy (HRT) were selected. Endometrial thickness and the prevalence of endometrial (pre)malignancies were recorded. If possible, 2 × 2 tables were extracted.

RESULTS

Thirty-two studies reporting on 11100 women were included. The estimated mean endometrial thickness was 2.9 mm (95% CI, 2.6-3.3 mm). The pooled estimated prevalences of endometrial carcinoma and atypical endometrial hyperplasia were 0.62% (95% CI, 0.42-0.82%) and 0.59% (95% CI, 0.22-0.96%), respectively. Summary estimates for sensitivity and specificity of TVS endometrial thickness measurement in the prediction of endometrial carcinoma were 0.83 (95% CI, 0.19-1.00) and 0.72 (95% CI, 0.23-0.95) for a 5-mm cut-off and 0.33 (95% CI, 0.04-0.85) and 0.94 (95% CI, 0.92-0.96) for a 6-mm cut-off.

CONCLUSIONS

The results from this systematic review do not justify the use of endometrial thickness as a screening test for endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women not using HRT.

Asymptomatic endometrial thickening

OBJECTIVE

To formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding.

OUTCOMES

Ensure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately.

EVIDENCE

Published literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., "asymptomatic endometrial thickness," "endometrial cancer," "postmenopausal bleeding," "transvaginal ultrasonography," "endometrial biopsy" and "endometrial polyp"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The level of evidence was determined according to the criteria established by the Canadian Task Force on Preventative Health Care (Table). Recommendations are ranked according to this method.

BENEFITS, HARMS, AND COSTS

It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions.

Sensitivity of transvaginal ultrasound screening for endometrial cancer in postmenopausal women: a case-control study within the UKCTOCS cohort

BACKGROUND

The increase in the worldwide incidence of endometrial cancer relates to rising obesity, falling fertility, and the ageing of the population. Transvaginal ultrasound (TVS) is a possible screening test, but there have been no large-scale studies. We report the performance of TVS screening in a large cohort.

METHODS

We did a nested case-control study of postmenopausal women who underwent TVS in the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) following recruitment between April 17, 2001, and Sept 29, 2005. Endometrial thickness and endometrial abnormalities were recorded, and follow-up, through national registries and a postal questionnaire, documented the diagnosis of endometrial cancer. Our primary outcome measure was endometrial cancer and atypical endometrial hyperplasia (AEH). Performance characteristics of endometrial thickness and abnormalities for detection of endometrial cancer within 1 year of TVS were calculated. Epidemiological variables were used to develop a logistic regression model and assess a screening strategy for women at higher risk. Our study is registered with ClinicalTrials.gov, number NCT00058032, and with the International Standard Randomised Controlled Trial register, number ISRCTN22488978.

FINDINGS

48,230 women underwent TVS in the UKCTOCS prevalence screen. 9078 women were ineligible because they had undergone a hysterectomy and 2271 because their endometrial thickness had not been recorded; however, 157 of these women had an endometrial abnormality on TVS and were included in the analysis. Median follow-up was 5·11 years (IQR 4·05-5·95). 136 women with endometrial cancer or AEH within 1 year of TVS were included in our primary analysis. The optimum endometrial thickness cutoff for endometrial cancer or AEH was 5·15 mm, with sensitivity of 80·5% (95% CI 72·7-86·8) and specificity of 86·2% (85·8-86·6). Sensitivity and specificity at a 5 mm or greater cutoff were 80·5% (72·7-86·8) and 85·7% (85·4-86·2); for women with a 5 mm or greater cutoff plus endometrial abnormalities, the sensitivity and specificity were 85·3% (78·2-90·8) and 80·4% (80·0-80·8), respectively. For a cutoff of 10 mm or greater, sensitivity and specificity were 54·1% (45·3-62·8) and 97·2% (97·0-97·4). When our analysis was restricted to the 96 women with endometrial cancer or AEH who reported no symptoms of postmenopausal bleeding at the UKCTOCS scan before diagnosis and had an endometrial thickness measurement available, a cutoff of 5 mm achieved a sensitivity of 77·1% (67·8-84·3) and specificity of 85·8% (85·7-85·9). The logistic regression model identified 25% of the population as at high risk and 39·5% of endometrial cancer or AEH cases were identified within this high risk group. In this high-risk population, a cutoff at 6·75 mm achieved sensitivity of 84·3% (71·4-93·0) and specificity of 89·9% (89·3-90·5).

INTERPRETATION

Our findings show that TVS screening for endometrial cancer has good sensitivity in postmenopausal women. The burden of diagnostic procedures and false-positive results can be reduced by limiting screening to a higher-risk group. The role of population screening for endometrial cancer remains uncertain, but our findings are of immediate value in the management of increased endometrial thickness in postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding.

Liquid-based endometrial cytology in the management of sonographically thickened endometrium

Liquid-based cytology represents an opportunity to re-evaluate endometrial cytology. We evaluated the accuracy of liquid-based endometrial cytology as compared to biopsy in 670 women scheduled for histeroscopy because of thickened endometrium (>4 mm), as evaluated by transvaginal sonography. Endometrial biopsy detected pathology in 41 (6%) of cases (21 of which were adenocarcinomas). Cytologic study found pathology in 62 (9%) cases (19 of which were adenocarcinomas). Two hundred ninety-one biopsies (43%) and 28 (4%) cytologies were inadequate. The sensitivity and the specificity were estimated, respectively, at 95% and 98%; the positive and negative predictive values were estimated, respectively, at 83% and 99%. Cytology provided sufficient material more often than biopsy (P < 0.01). We consider endometrial cytology an efficacious diagnostic opportunity. It could be usefully applied in association with transvaginal sonography. The combination of these procedures might reduce more invasive and expensive diagnostic procedures.

Endometrial thickness in Japanese women with hypertension or/and type 2 diabetes mellitus

OBJECTIVES

The purpose of this study was: (a) to examine whether the endometrium of postmenopausal women with hypertension (HT) and/or type 2 diabetes mellitus (DM) was thicker than that of healthy controls (HC) and (b) whether endometrial thickness (ET) was associated with endometrial cancer risk factors.

STUDY DESIGN

A total of 242 postmenopausal women were included in this study. Thirty women with type 2 DM, 49 women with HT, 23 women with DM and HT and 140 HCs were studied. Clinical evaluation of all women was done using TVS and endometrial cytology.

RESULTS

In the 140 HCs, the mean ET of nulliparous women was larger than multiparous women (3.0 mm versus 1.6 mm, p = 0.017). However, there was no significant relationship between ET and other clinical parameters such as a history of sterility or BMI. There was no significant difference in ET amongst the four groups. The relationship between ET, age, pregnancy history, menopause age, BMI and presence of DM or HT were analyzed using stepwise multivariate analysis. There was no significant relationship between these risk factors and ET (p = 0.063).

CONCLUSIONS

The risk factors such as age, pregnancy history, menopause age, BMI and presence of DM or HT were not related to ET in Japanese women.