SUMMARY:

ACOG has released a new committee opinion on the role of transvaginal ultrasound in the setting of postmenopausal bleeding.  Postmenopausal uterine bleeding needs to be evaluated quickly and transvaginal ultrasound can play an important role in the initial work-up.

Endometrial Thickness  

• Measure the maximum anterior-posterior thickness on a long-axis transvaginal view 
• Transvaginal ultrasound is appropriate for the initial evaluation  
• Thin endometrial echo  
  • Defined as ≤4mm   
  • Endometrial fluid should not be included in measuring endometrial thickness
  • >99% NPV for endometrial cancer 
  • Cannot exclude all pathology, including endometrial cancers such as uterine papillary serous, mucinous, clear cell  
• Thickened endometrium is not diagnostic of a particular pathology  

Recommended Management 

• Transvaginal ultrasound  
  • Should only be used as an initial evaluation if there is low prior probability for cancer or hyperplasia   
  • Additional evaluation is required if persistent/recurrent bleeding  
  • Either transvaginal ultrasound or endometrial sampling are ‘reasonable’ alternatives as first line – both not required if low risk
  • Proceed to endometrial sampling if abnormal endometrium is seen on transvaginal ultrasound  
• Endometrial sampling  
  • First-line test if clinical risk factors are present (see ‘Endometrial Cancer: The Basics’ in ‘Related ObG Topics’ below) or clinical presentation is suspicious  
  • Outpatient endometrial sampling using disposable device is method of choice  
  • NOTE: Proceed to hysteroscopy with D&C if persistent or recurring bleeding and blind sampling is negative for endometrial hyperplasia or malignancy 

KEY POINTS:  

• If transvaginal ultrasound image inadequate proceed to following options  
  • Sonohysterography | Office hysteroscopy | Endometrial sampling   
• If insufficient tissue on endometrial sampling 
  • Transvaginal ultrasound can be used to further evaluate and if a thin echo is seen and bleeding has stopped, no further work-up is necessary  
  • Persistent/recurrent bleeding needs a histologic evaluation even in the presence of a thin echo 
• Postmenopausal women who are not bleeding 
  • Transvaginal ultrasound should not be used as a screening tool for endometrial cancer in this population  
  • If an endometrial echo >4mm is found incidentally, this is not an automatic ‘trigger’ for further evaluation but rather should be placed in context and “individualized … based on patient characteristics and risk factors”  

Learn More – Primary Sources:  

ACOG Committee Opinion 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding

 

Related ObG Topics: