A new clinical guide provides recommendations on endometrial assessment in perimenopausal and postmenopausal women and evaluates the indications and limitations of different assessment methods. The recommendations also address how to deal with inconclusive evaluations and persistent symptoms, as well as testing in women who use tamoxifen and unopposed estrogen.
Eva Dreisler, MD, from the Department of Gynaecology and Obstetrics at Copenhagen University Hospital Rigshospitalet in Copenhagen, Denmark, and colleagues from the European Menopause and Andropause Society report their recommendations in an article published online April 8 inMaturitas.
The recommendations are based on a review of the literature and a consensus of expert opinion. No single method is perfect, and a combination of methods may be necessary, the authors write.
"Speculum examination and palpation should always be done first to exclude non-endometrial gynaecological pathology," the authors write.
If speculum examination and cervical cytology have been assessed, transvaginal ultrasound scanning (TVS) should be performed initially because it is noninvasive and will measure endometrial thickness, as well as detect other pelvic pathology including leiomyomas and ovarian tumors. However, clinicians should be aware that the quality of ultrasound evaluation depends on the examiner's experience and the equipment used.
The primary indication for invasive methods should be to obtain endometrial tissue to diagnose or exclude endometrial cancer or premalignancies. Endometrial sampling can be done by dilatation and curettage or outpatient biopsy, using a disposable device. However, both procedures are "blind" and can miss focal lesions.
Hysteroscopy allows visually guided biopsies and the identification and removal of focal lesions, including endometrial polyps or submucous fibroids in the uterine cavity, but fibroids can obscure visualization. Previously, hospital admission and general anesthesia were required, but the procedure can now be performed in some cases in the office with local or no anesthesia.
"Diagnosing malignant and premalignant changes in the endometrium requires histology. However endometrial assessment is also required in various benign conditions such as investigation of abnormal uterine bleeding...and monitoring treatment of hyperplasia without atypia," the authors write.
Summary Recommendations
- Use TVS for initial assessment;
- perform endometrial biopsy as an outpatient procedure if possible;
- hysteroscopy provides direct visualization of the endometrial cavity and focal lesions;
- if results are inconclusive and abnormal uterine bleeding or postmenopausal bleeding continue, repeat TVS and perform hysteroscopy;
- endometrial thickness is increased in tamoxifen users, and hysteroscopy is recommended for postmenopausal bleeding in these patients;
- women who use unopposed estrogen therapy have an increased risk for endometrial cancer during and for several years after treatment is stopped, so continued assessment is recommended;
- endometrial assessment in the absence of bleeding should only be performed in women with high risk for endometrial cancer; and
- women who have no clear diagnosis or who have recurrent or persistent symptoms or previous hyperplasia should be followed-up, for example, after 6 months.
Brenda K. Jenkin, MD, a clinical professor of gynecology at the University of Wisconsin School of Medicine and Public Health in Madison, commented on the new guidelines in a telephone interview with Medscape Medical News.
"I have some hesitation about using ultrasound as the primary assessment tool in all age groups," Dr. Jenkin said. She was not involved in the development of the new recommendation.
"I recommend that practitioners follow the recent ACOG recommendations and use ultrasound as a tool to help in their assessment in certain situations, predominantly the postmenopausal patient," Dr. Jenkin explained.
One coauthor reports speaking at national and international meetings for Novo-Nordisk, Schering Plough MSD, AstraZeneca A/S, Novartis and Sanofi Pasteur MSD, and advising Shionogi and Danish health authorities. One coauthor reports consulting for Bristol-Myers Squibb, Pfizer and AstraZeneca, primarily as an advisor on local legislations regarding medical information. Dr. Jenkin has disclosed no relevant financial relationships.
