Evaluation of the endometrium for malignant or premalignant disease
- Sarah Feldman, MD, MPH
Sarah Feldman, MD, MPH
- Associate Professor
- Harvard Medical School
- Section Editors
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Director, Gynecologic Oncology
- University of Washington Medical Center
Evaluation of the endometrium is the key component in the diagnostic evaluation of women suspected of endometrial cancer or a premalignant endometrial lesion. An endometrial sampling procedure is the gold standard for diagnostic evaluation of women with abnormal uterine bleeding in whom endometrial hyperplasia or carcinoma is a possibility (table 1). (See "Endometrial sampling procedures".)
Endometrial biopsy — The development of equipment and techniques for office-based endometrial biopsy has generally replaced the need for diagnostic dilation and curettage (D&C) performed in the operating room . Advantages of office biopsy include:
●Minimal to no cervical dilation is required.
●Local or no anesthesia is generally required.
●Performing the procedure in an office setting is less expensive than a procedure in the operating room.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Grimes DA. Diagnostic dilation and curettage: a reappraisal. Am J Obstet Gynecol 1982; 142:1.
- Lipscomb GH, Lopatine SM, Stovall TG, Ling FW. A randomized comparison of the Pipelle, Accurette, and Explora endometrial sampling devices. Am J Obstet Gynecol 1994; 170:591.
- Silver MM, Miles P, Rosa C. Comparison of Novak and Pipelle endometrial biopsy instruments. Obstet Gynecol 1991; 78:828.
- Stovall TG, Solomon SK, Ling FW. Endometrial sampling prior to hysterectomy. Obstet Gynecol 1989; 73:405.
- Dijkhuizen FP, Mol BW, Brölmann 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.
- Clark TJ, Mann CH, Shah N, et al. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial cancer: a systematic quantitative review. BJOG 2002; 109:313.
- Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. J Reprod Med 1995; 40:553.
- Clark TJ, Mann CH, Shah N, et al. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia. Acta Obstet Gynecol Scand 2001; 80:784.
- APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, 2006.
- Epstein E, Ramirez A, Skoog L, Valentin L. Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. Acta Obstet Gynecol Scand 2001; 80:1131.
- Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol 1988; 158:489.
- Deckardt R, Lueken RP, Gallinat A, et al. Comparison of transvaginal ultrasound, hysteroscopy, and dilatation and curettage in the diagnosis of abnormal vaginal bleeding and intrauterine pathology in perimenopausal and postmenopausal women. J Am Assoc Gynecol Laparosc 2002; 9:277.
- Trimble CL, Method M, Leitao M, et al. Management of endometrial precancers. Obstet Gynecol 2012; 120:1160.
- Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96:266.
- 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.
- Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding--a Nordic multicenter study. Am J Obstet Gynecol 1995; 172:1488.
- The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. ACOG Committee Opinion No. 440. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:409.
- Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med 2001; 20:1025.
- Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998; 280:1510.
- Timmermans A, Opmeer BC, Khan KS, et al. Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. Obstet Gynecol 2010; 116:160.
- Gupta JK, Chien PF, Voit D, et al. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand 2002; 81:799.
- Tabor A, Watt HC, Wald NJ. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol 2002; 99:663.
- 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.
- Breijer MC, Peeters JA, Opmeer BC, et al. Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2012; 40:621.
- Debby A, Malinger G, Glezerman M, Golan A. Intra-uterine fluid collection in postmenopuasal women with cervical stenosis. Maturitas 2006; 55:334.
- Goldstein SR. Postmenopausal endometrial fluid collections revisited: look at the doughnut rather than the hole. Obstet Gynecol 1994; 83:738.
- Schmidt T, Nawroth F, Breidenbach M, et al. Differential indication for histological evaluation of endometrial fluid in postmenopause. Maturitas 2005; 50:177.
- Vuento MH, Pirhonen JP, Mäkinen JI, et al. Endometrial fluid accumulation in asymptomatic postmenopausal women. Ultrasound Obstet Gynecol 1996; 8:37.
- Pardo J, Kaplan B, Nitke S, et al. Postmenopausal intrauterine fluid collection: correlation between ultrasound and hysteroscopy. Ultrasound Obstet Gynecol 1994; 4:224.
- Zalel Y, Tepper R, Cohen I, et al. Clinical significance of endometrial fluid collections in asymptomatic postmenopausal women. J Ultrasound Med 1996; 15:513.
- Dijkhuizen FP, Brölmann HA, Potters AE, et al. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996; 87:345.
- Breitkopf DM, Frederickson RA, Snyder RR. Detection of benign endometrial masses by endometrial stripe measurement in premenopausal women. Obstet Gynecol 2004; 104:120.
- Goldstein SR, Zeltser I, Horan CK, et al. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997; 177:102.
- Holbert TR. Transvaginal ultrasonographic measurement of endometrial thickness in postmenopausal women receiving estrogen replacement therapy. Am J Obstet Gynecol 1997; 176:1334.
- Meuwissen JH, Oddens BJ, Klinkhamer PJ. Endometrial thickness assessed by transvaginal ultrasound insufficiently predicts occurrence of hyperplasia during unopposed oestrogen use. Maturitas 1996; 24:21.
- Kamel HS, Darwish AM, Mohamed SA. Comparison of transvaginal ultrasonography and vaginal sonohysterography in the detection of endometrial polyps. Acta Obstet Gynecol Scand 2000; 79:60.
- Mihm LM, Quick VA, Brumfield JA, et al. The accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding. Am J Obstet Gynecol 2002; 186:858.
- Krampl E, Bourne T, Hurlen-Solbakken H, Istre O. Transvaginal ultrasonography sonohysterography and operative hysteroscopy for the evaluation of abnormal uterine bleeding. Acta Obstet Gynecol Scand 2001; 80:616.
- de Kroon CD, de Bock GH, Dieben SW, Jansen FW. Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis. BJOG 2003; 110:938.
- van Dongen H, de Kroon CD, van den Tillaart SA, et al. A randomised comparison of vaginoscopic office hysteroscopy and saline infusion sonography: a patient compliance study. BJOG 2008; 115:1232.
- Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002; 109:800.
- Brown SE, Coddington CC, Schnorr J, et al. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril 2000; 74:1029.
- Lim PS, Nazarian LN, Wechsler RJ, et al. The endometrium on routine contrast-enhanced CT in asymptomatic postmenopausal women: avoiding errors in interpretation. Clin Imaging 2002; 26:325.
- Langer JE, Oliver ER, Lev-Toaff AS, Coleman BG. Imaging of the female pelvis through the life cycle. Radiographics 2012; 32:1575.
- Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand 2000; 79:321.
- Dessole S, Rubattu G, Farina M, et al. Risks and usefulness of sonohysterography in patients with endometrial carcinoma. Am J Obstet Gynecol 2006; 194:362.
- Berry E, Lindheim SR, Connor JP, et al. Sonohysterography and endometrial cancer: incidence and functional viability of disseminated malignant cells. Am J Obstet Gynecol 2008; 199:240.e1.
- Obermair A, Geramou M, Gucer F, et al. Does hysteroscopy facilitate tumor cell dissemination? Incidence of peritoneal cytology from patients with early stage endometrial carcinoma following dilatation and curettage (D & C) versus hysteroscopy and D & C. Cancer 2000; 88:139.
- Egarter C, Krestan C, Kurz C. Abdominal dissemination of malignant cells with hysteroscopy. Gynecol Oncol 1996; 63:143.
- Sagawa T, Yamada H, Sakuragi N, Fujimoto S. A comparison between the preoperative and operative findings of peritoneal cytology in patients with endometrial cancer. Asia Oceania J Obstet Gynaecol 1994; 20:39.
- Bradley WH, Boente MP, Brooker D, et al. Hysteroscopy and cytology in endometrial cancer. Obstet Gynecol 2004; 104:1030.
- Kuzel D, Tóth D, Kobilková J, Dohnalová A. Peritoneal washing cytology on fluid hysteroscopy and after curettage in women with endometrial carcinoma. Acta Cytol 2001; 45:931.
- Lo KW, Cheung TH, Yim SF, Chung TK. Hysteroscopic dissemination of endometrial carcinoma using carbon dioxide and normal saline: a retrospective study. Gynecol Oncol 2002; 84:394.
- Gu M, Shi W, Huang J, et al. Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washings in patients with endometrial carcinoma. Cancer 2000; 90:143.
- Arikan G, Reich O, Weiss U, et al. Are endometrial carcinoma cells disseminated at hysteroscopy functionally viable? Gynecol Oncol 2001; 83:221.
- Takac I. Saline infusion sonohysterography and the risk of malignant extrauterine spread in endometrial cancer. Ultrasound Med Biol 2008; 34:7.
- Yazbeck C, Dhainaut C, Batallan A, et al. [Diagnostic hysteroscopy and risk of peritoneal dissemination of tumor cells]. Gynecol Obstet Fertil 2005; 33:247.
- Devore GR, Schwartz PE, Morris JM. Hysterography: a 5-year follow-up in patients with endometrial carcinoma. Obstet Gynecol 1982; 60:369.
- Ben-Arie A, Tamir S, Dubnik S, et al. Does hysteroscopy affect prognosis in apparent early-stage endometrial cancer? Int J Gynecol Cancer 2008; 18:813.
- INVASIVE METHODS
- Endometrial biopsy
- Dilation and curettage
- NONINVASIVE METHODS
- Transvaginal ultrasound
- - Postmenopausal women
- Women with postmenopausal bleeding
- Asymptomatic women with endometrial thickening or fluid
- - Premenopausal women
- - Women on hormone therapy
- - Women on tamoxifen
- Saline infusion sonography
- Other imaging studies
- RISK OF TUMOR DISSEMINATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Initial evaluation
- Evaluation of persistent bleeding