Clinical evaluation of women with PMB. Is it always necessary an endometrial biopsy to be performed? A review of the literature

Marina Dimitraki, Panagiotis Tsikouras, Sophia Bouchlariotou, Alexandros Dafopoulos, Vasileios Liberis, Georgios Maroulis, Alexander Tobias Teichmann, Marina Dimitraki, Panagiotis Tsikouras, Sophia Bouchlariotou, Alexandros Dafopoulos, Vasileios Liberis, Georgios Maroulis, Alexander Tobias Teichmann

Abstract

Background: Endometrial carcinoma is the most distressing cause of abnormal vaginal bleeding. The intention of clinical management in the case of postmenopausal bleeding is to achieve an accurate diagnosis without overinvestigation.

Method: We studied the available literature on the diagnostic evaluation of postmenopausal women with vaginal bleeding, accentuating the most important aspects on this topic: the accuracy of sonography and endometrial biopsy in predicting endometrial hyperplasia and endometrial carcinoma.

Results: The accuracy of the above tests in predicting endometrial hyperplasia and endometrial carcinoma is a subject of continuing debate. Μοreover, in the last decades, there has been an explosion of publications indicating that ultrasound may be useful in predicting endometrial pathology.

Conclusion: Since advanced endometrial carcinoma has been known to occur in cases without noticeable endometrial thickness on ultrasound, the clinician should beware of the diagnostic evaluation of postmenopausal women with vaginal bleeding.

References

    1. ACOG committee opinion no. 426 The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;113(2 Pt 1):462–464.
    1. Gemer O, Segal S. Endometrial cancer in patients undergoing diagnostic curettage. Arch Gynecol Obstet. 1998;261(2):79–81. doi: 10.1007/s004040050203.
    1. Bourne T, Hamberger L, Hahlin M, Granberg S. Ultrasound in gynecology: endometrium. Int J Gynecol Obstet. 1997;56:115–127. doi: 10.1016/S0020-7292(96)02813-5.
    1. Elsandabesee D, Greenwood P. The performance of Pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic. J Obstet Gynaecol. 2005;25:32–34. doi: 10.1080/01443610400025390.
    1. Dubinsky T. Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound. 2004;32(7):348–353. doi: 10.1002/jcu.20049.
    1. Epstein E, Valentin L. Gray-scale ultrasound morphology in the presence or absence of intrauterine fluid and vascularity as assessed by color Doppler for discrimination between benign and malignant endometrium in women with postmenopausal bleeding. Ultrasound Obstet Gynecol. 2006;28:89–95. doi: 10.1002/uog.2782.
    1. Epstein E, Skoog L, Isberg P-E, De Smet F, De Moor B, Olofsson P-Ε, Gudmundsson S, Valentin L. An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding. Ultrasound Obstet Gynecol. 2002;20:370–376. doi: 10.1046/j.1469-0705.2002.00800.x.
    1. Dragojevic S, et al. The role of transvaginal colour Doppler sonography in evaluation of abnormal uterine bleeding. Arch Gynecol Obstet. 2005;271(4):332–335. doi: 10.1007/s00404-004-0617-y.
    1. Kanat-Pektas M, Gungor T, Mollamahmutoglu L. The evaluation of endometrial tumors by transvaginal and Doppler ultrasonography. Arch Gynecol Obstet. 2008;277(6):495–499. doi: 10.1007/s00404-007-0517-z.
    1. Karlsson B, Granberg S, Wikland M, Ryd W, Norstrom A. Endovaginal scanning of the endometrium compared to cytology and histology in women with postmenopausal bleeding. Gynecol Oncol. 1993;50:173–178. doi: 10.1006/gyno.1993.1188.
    1. Auslender R. Vaginal ultrasound in patients with postmenopausal bleeding. Ultrasound Obstet Gynecol. 1993;3:426–428. doi: 10.1046/j.1469-0705.1993.03060426.x.
    1. Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer. 2000;89:1765–1772. doi: 10.1002/1097-0142(20001015)89:8<1765::AID-CNCR17>;2-F.
    1. Granberg S, Wikland M, Karlsson B, Norstrom A, Friberg LG. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol. 1991;164:47–52.
    1. Nasri MN, Shepherd JH, Setchell ME, Lowe DG, Chard T. The role of vaginal scan in measurement of thickness in postmenopausal women. Br J Obstet Gynaecol. 1991;98:470–475. doi: 10.1111/j.1471-0528.1991.tb10342.x.
    1. Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol. 1990;163:119–123.
    1. Buyuk E, Durmusoglu F, Erenus M, et al. Endometrial disease diagnosed by transvaginal ultrasound and dilation and curettage. Acta Obstet Gynecol Scand. 1999;78:419. doi: 10.1080/j.1600-0412.1999.780514.x.
    1. Botsis D, Kassanos D, Pyrgiotis E, Zourlas PA. Vaginal sonography of the endometrium in postmenopausal women. Clin Exp Obstet Gynecol. 1992;19:189–192.
    1. Ferrazzi E, Torri V, Trio D, Zannoni E, Filiberto S, Dordoni D. Sonographic thickness. A useful test to predict atrophy in patients with postmenopausal bleeding. An Italian multicenter study. Ultrasound Obstet Gynecol. 1996;7(5):315–321. doi: 10.1046/j.1469-0705.1996.07050315.x.
    1. Granberg S, Ylostalo P, Wikland M, Karlsson B. Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding. Maturitas. 1997;27:35–40. doi: 10.1016/S0378-5122(97)01107-9.
    1. Garuti G, Sambruni I, Cellani F, Garzia D, Alleva P, Luerti M. Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding. Int J Gynecol Obstet. 1999;65:25–33. doi: 10.1016/S0020-7292(98)00224-0.
    1. Bakour SH, Dwarakanath LS, Khan KS, Newton JR, Gupta JK. The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding. Acta Obstet Gynecol Scand. 1999;78:447–451. doi: 10.1080/j.1600-0412.1999.780519.x.
    1. Ciatto S, Cecchini S, Gervasi G, Landini A, Zappa M, Crocetti E. Association of endometrial thickness assessed at trans-vaginal ultrasonography to endometrial cancer in postmenopausal asymptomatic or with abnormal uterine bleeding. Radiol Med. 2002;104(5-6):437–442.
    1. Guner H, Tiras MB, Karabacak O, Sarikaya H, Erdem M, Yildirim M. Endometrial assessment by vaginal ultrasonography might reduce endometrial sampling in patients with postmenopausal bleeding: a prospective study. Aus NZ J Obstet Gynaecol. 1996;36:175–178. doi: 10.1111/j.1479-828X.1996.tb03280.x.
    1. Tsikouras P, Liberis V, Galazios G, Grapsas X, Kantari P, Papageorgiou S, Maroulis G. TV sonographic assessment in postmenopausal women with bleeding. Eur J Gynecol Oncol. 2008;XXIX(1):67–71.
    1. Briley M, Lindsell DRM. The role of transvaginal ultrasound in the investigation of women with post-menopausal bleeding. Clin Radiol. 1998;53:502–505. doi: 10.1016/S0009-9260(98)80169-4.
    1. Gupta JK, Wilson S, Desai P, Hau C. How should we investigate women with postmenopausal bleeding? Acta Obstet Gynecol Scand. 1996;75:475–479. doi: 10.3109/00016349609033357.
    1. Bruchim I, Biron-Shental T, Altaras MM, Fishman A, Beyth Y, Tepper R, Aviram R. Combination of endometrial thickness and time since menopause in predicting endometrial cancer in women with postmenopausal bleeding. J Clin Ultrasound. 2004;32(5):219–224. doi: 10.1002/jcu.20020.
    1. Gull B, Carlsson S, Karlsson B, Ylostalo P, Milsom I, Granberg S. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding. Is it always necessary to perform an endometrial biopsy? Am J Obstet Gynecol. 2000;182:509–515. doi: 10.1067/mob.2000.103092.
    1. Gull B, Karlsson B, Milsom I, Granberg S. Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer. Am J Obstet Gynecol. 2003;188(2):401–408. doi: 10.1067/mob.2003.154.
    1. Develioglu OH, et al. Transvaginal ultrasonography and uterine artery Doppler in diagnosing endometrial pathologies and carcinoma in postmenopausal bleeding. Arch Gynecol Obstet. 2003;268(3):175–180. doi: 10.1007/s00404-002-0364-x.
    1. Mateos F, Zarauz R, Seco C, Rayward JR, del Barrio P, Aguirre J, et al. Assessment with transvaginal ultrasonography of endometrial thickness in women with postmenopausal bleeding. Eur J Gynaecol Oncol. 1997;18:504–507.
    1. Epstein E, Skoog L, Valentin L. Comparison of Endorette and dilatation and curettage for sampling of the endometrium inwomen with postmenopausal bleeding. Acta Obstet Gynecol Scand. 2001;80:959–964.
    1. Fleischer AC, Kalemeris GC, Machin JE. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med. 1986;5:445–452.
    1. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004;24:558–565. doi: 10.1002/uog.1704.
    1. Gupta JK, Chien PF, Voit D, Clark TJ, Khan KS. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81:799–816. doi: 10.1034/j.1600-0412.2001.810902.x.
    1. Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R, et al. Evaluation of the woman with postmenopausal bleeding: society of radiologists in ultrasound sponsored consensus conference statement. J Ultrasound Med. 2001;20:1025–1036.
    1. Haller H, Matejcic N, Rukavina B, Krasevic M, Rupcic S, Mozetic D. Transvaginal sonography and hysteroscopy in women with postmenopausal bleeding. Int J Gynecol Obstet. 1996;54:155–159. doi: 10.1016/0020-7292(96)02677-X.
    1. Loverro G, Bettocchi S, Cormio G, Nicolardi V, Greco P, Vimercati A, et al. Transvaginal sonography and hysteroscopy in postmenopausal uterine bleeding. Maturitas. 1999;33:139–144. doi: 10.1016/S0378-5122(99)00023-7.
    1. Van Doorn HC, Timmermans A, Opmeer BC, Kruitwagen RF, Dijkhuizen FP, Kooi GS, Van De Weijer PH, Mol BW, Dupomeb F, et al. What is the recurrence rate of postmenopausal bleeding in women with a thin endometrium during a first episode of postmenopausal bleeding. Acta Obstet Gynecol Scand. 2008;87(1):89–93. doi: 10.1080/00016340701763130.

Source: PubMed

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