B. Karlsson

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding — a Nordic multicenter study

OBJECTIVE The purpose of this study was to use transvaginal ultrasonographic measurements to find the thickness of the endometrium below which the risk of endometrial abnormality in women with postmenopausal bleeding is low. STUDY DESIGN This multicenter study was carried out at eight clinics in four Nordic countries. The study included 1168 women with postmenopausal bleeding scheduled for curettage Before the curettage was performed, the thickness of the endometrium was measured with transvaginal ultrasonography. The measurement included both endometrial layers (double-layer technique). The transvaginal ultrasonographic measurement was compared with the histopathologic diagnosis of the curettage specimens. RESULTS In women with atrophic endometrium the mean endometrial thickness (+/- SD) was 3.9 +/- 2.5 mm. The corresponding figures for women with endometrial cancer were 21.1 +/- 11.8 mm. No malignant endometrium was thinner than 5 mm. In 30 women (2.8%) it was not possible to measure the thickness of the endometrium; one of these women had endometrial cancer. The 95% confidence limit for the probability of excluding endometrial abnormality was 5.5% when the endometrial thickness was < or = 4 mm as measured by transvaginal ultrasonography. CONCLUSION The risk of finding pathologic endometrium at curettage when the endometrium is < or = 4 mm as measured by transvaginal ultrasonography is 5.5%. Thus in women with postmenopausal bleeding and an endometrium < or = 4 mm it would seem justified to refrain from curettage.

Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality

Diagnostic curettage has for many years been the method of choice to diagnose endometrial cancer in women with postmenopausal bleeding. The costs for curettage performed today are huge, and approximately only 10% in this group of women will be diagnosed with endometrial cancer. Thus less expansive techniques to obtain endometrial samples have been evaluated, but all of them are invasive. The value of endovaginal ultrasonography for identifying endometrial abnormality in this group of women has not been evaluated until now. This study used endometrial thickness as measured by endovaginal ultrasonography as an indicator of endometrial abnormality. It was demonstrated in 205 women with postmenopausal bleeding that if the endometrium was less than 9 mm thick, no endometrial cancer was found at curettage. The mean endometrial thickness in those women with endometrial cancer was 18.2 +/- 6.2 mm as compared with 3.4 +/- 1.2 mm in those women with atrophic endometrium. If the cutoff limit for endometrial abnormality was 5 mm, the positive predictive value for identifying endometrial abnormality was 87.3%. If this limit had been used in this study, 70% of the curettage procedures could have been avoided.

Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding

OBJECTIVES To evaluate, in women with postmenopausal bleeding, the effect of hormonal replacement (HRT) therapy on the endometrial thickness as measured by transvaginal sonography in relation to endometrial histology. METHODS 1110 women with sequential/progestin treatment (E + P) (n = 202), with Estriol treatment (n = 149) or without HRT (n = 759) and postmenopausal bleeding were examined by transvaginal sonography (TVS) prior to curettage, with special reference to the relation of endometrial thickness to its histopathology. RESULTS The distribution of endometrial pathology was different in those women with E + P and Estriol compared with those without HRT. Endometrial pathology was found most frequently in women with an endometrium exceeding 8 mm in thickness. Furthermore, the incidence was found to increase with increasing endometrial thickness in all treatment groups. Atrophy was found significantly more often in women without HRT. Hormonal effects on the endometrium were found significantly more often in women with E + P and Estriol. Endometrial hyperplasia was found most commonly in women with Estriol in the thickness group 5 8 mm (P < 0.001) as compared to those with HRT and without HRT. Endometrial cancer occurs most in women without HRT, in those women with an endometrium exceeding 8 mm in thickness as compared both to the E + P (P < 0.001) group and to the Estriol (P < 0.001) group. Endometrial cancer did not occur in any woman (with E + P, Estriol or without HRT) with an endometrial thickness of < or = 4 mm. CONCLUSIONS TVS is of value for excluding endometrial pathology in women with HRT and postmenopausal bleeding. The distribution of endometrial findings and histopathological diagnosis in women with abnormal postmenopausal bleeding was different in women with E + P than in women without HRT. Furthermore, the cut-off for excluding endometrial abnormalities is the same in both groups i.e. < or = 4 mm.

Endometrial thickness as measured by transvaginal sonography: interobserver variation

Transvaginal sonography of the uterus has become an important tool for diagnosing endometrial pathology in women with postmenopausal bleeding. One parameter that has been claimed to be important for curly detection of endometrial pathology in this group of women is the endometrial thickness. The purpose of this study was to evaluate the reproducibility of measurements of endometrial thickness as performed by five inexperienced doctors and one doctor experienced in the transvaginal sonography technique. The endometrial thickness as measured by the experienced doctor was regarded as the ‘true measurement’, and the mean discrepancy from this true measurement was 1.5 mm for the inexperienced doctors. No endometrial pathology was found at the histopathological examination after dilatation and curettage (D & C) when the endometrial thickness was measured as ≤ 4 mm by both the inexperienced and the experienced doctors. However, there were considerable differences between the results obtained by the five inexperienced doctors. If this method is to be used for identifying those women who will not have a D & C performed, based on the findings of a thin endometrium (≤ 4 mm), training is needed in order to minimize the error. We believe that this will make measurement more accurate and it may then be used to exclude endometrial abnormality in women with postmenopausal bleeding.

Factors influencing the presence of uterine cavity fluid in a random sample of asymptomatic postmenopausal women

AIMS To assess possible endometrial pathology and other factors influencing the presence of uterine cavity fluid in postmenopausal women. STUDY DESIGN A random sample of 559 asymptomatic postmenopausal women, recruited from the total population, were examined by transvaginal sonography (TVS) for the presence of uterine cavity fluid. Women with uterine cavity fluid who had an endometrial thickness of > or = 8 mm (including fluid) were admitted for hysteroscopy and a dilatation and curettage (D & C), and those with <8 mm underwent a new TVS examination one year later. A medical history, including details regarding previous minor gynecological surgery, was taken from the women and from an age-matched control-group of women from the same population. RESULTS Uterine cavity fluid was found in 8.9% (50/559) of the women. In four women with an endometrium measuring > or = 8 mm, curettage revealed polyps in three women and atrophy with a pyometra in one woman. At the one-year follow-up, 22 women who originally had an endometrial thickness<8 mm had an endometrial thickness of<5 mm; 11 women had no cavity fluid and in the remaining 11 the cavity fluid had decreased. In 17 women, endometrial thickness measured > or = 5 mm and subsequent histology showed 11 endometrial biopsies with atrophy, four endometrial polyps and two cervical polyps. The prevalence of uterine cavity fluid increased with increasing age (p<0.0001) and was increased in smokers (p<0.013) but was unaltered by the presence or absence of hormone replacement therapy (HRT). CONCLUSION There were no indications that uterine cavity fluid was associated with malignancy. The prevalence of uterine cavity fluid increased with increasing age and was higher in smokers. We could not demonstrate an increased prevalence of fluid in HRT-users.

Replacing diagnostic curettage by vaginal ultrasound

Dilatation and curettage has for many years been the method of choice for diagnosing endometrial cancer in postmenopausal women. However, less than 10% of women with postmenopausal bleeding have an endometrial cancer. Vaginal sonography for measuring endometrial thickness, has in several studies proved to be a sensitive diagnostic method for diagnosing endometrial pathology. Our studies as well as others have shown that an endometrial thickness of 4 mm or less (including both endometrial layers) indicates a very low risk for endometrial carcinoma as well as any other major endometrial pathology in women with postmenopausal bleeding. Since vaginal sonography is such a simple and a non-invasive diagnostic method, it thus seems reasonable that vaginal sonographic assessment of the endometrium should be the primary method for excluding any endometrial abnormality in a woman with postmenopausal bleeding.

Bishop score and the outcome of labor induction with misoprostol.

Background. The aim of the study was to retrospectively identify possible factors for predicting the outcome of induction with misoprostol.

Assessment of the endometrium in the postmenopausal woman by vaginal sonography

Summary Dilatation and curettage (D&C) is still considered by many the method of choice for examining women with postmenopausal bleeding. However, only 10% of these women have an endometrial cancer. Ultrasound has long been used for studying pathology of the endometrium but did not gain much interest until vaginal sonography became available. Vaginal sonography for measuring endometrial thickness has proved to have a high detection rate and low false-positive rate for diagnosis of endometrial pathology. An endometrial thickness of ≤ 4mm (double layer) means that endometrial cancer almost can be excluded. This paper discusses further the use of vaginal sonography for examining the endometrium in women with postmenopausal bleeding.

Factors associated with endometrial thickness and uterine size in a random sample of postmenopausal women

Objective:  To investigate factors possibly associated with endometrial thickness and uterine size in a random sample of postmenopausal women.

OC143: Long‐term follow‐up for women with postmenopausal bleeding who have normal ultrasound scans—is ultrasound alone sufficient to manage these patients?

ultrasound examination contributes to a correct diagnosis of endometrial malignancy: the higher the color content of the endometrium the higher the risk of cancer. Multivariate logistic regression models including clinical variables (e.g., age, use of HRT, body mass index), gray scale ultrasound findings, and Doppler findings can be used to calculate the individual risk of malignancy. The clinical value of mathematical models has not been determined.