BACKGROUND AND PURPOSE:

• Vitale (AJOG, 2023) evaluated the risk of endometrial carcinoma (EC) and atypical endometrial hyperplasia (AEH) in asymptomatic postmenopausal women based on endometrial thickness

METHODS:

• Systematic review and diagnostic test accuracy (DTA) meta-analysis
• Study inclusion criteria
  • Crossover design
  • Evaluated the risk of AEH and EC in postmenopausal asymptomatic women
  • Calculated the diagnostic accuracy of transvaginal ultrasonography thresholds confirmed by histopathologic diagnosis
• Study design
  • ET thresholds (≥3.0 mm)
    • 3.0 to 5.9 mm
    • 6.0 to 9.9 mm
    • 10.0 to 13.9 mm
    • ≥14.0 mm
  • Quality of studies was assessed
• Primary outcome
  • Risk of EC and AEH according to each ET threshold
• Secondary outcomes
  • Positive likelihood ratio (PLR)
  • Negative likelihood ratio (NLR)

RESULTS:

• 18 studies | 10,334 women
• Risk for AEH or EC increased relative to women below the cutoff threshold
  • Overall: RR 3.77 (95% CI, 2.26 to 6.32); I²=74%
  • 3.0 and 5.9 mm: RR 5.08 (95% CI, 2.26 to 11.41); I²=0%
  • 6.0 and 9.9 mm: RR 4.34 (95% CI, 1.68 to 11.23); I²=0%
  • 10.0 and 13.9 mm: RR 4.11 (95% CI, 1.55 to 10.87); I²=86%
  • ≥14.0 mm: RR 2.53 (95% CI, 1.04 to 6.16); I²=78%
• For diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm to above 14.0 mm
  • <5.9 mm: RR 0.81 (95% CI, 0.49 to 0.85)
  • ≥14.0 mm: RR 0.28 (95% CI, 0.18 to 0.40)
• The specificity increased with greater ETs
  • 3.0 and 5.9 mm: RR 0.70 (95% CI, 0.61 to 0.78)
  • ≥14.0 mm: RR 0.86 (95% CI, 0.71 to 0.94)
• The highest diagnostic odds ratios (OR) were for 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds
  • 3.0 to 5.9 mm: OR 10 (95% CI, 3 to 41) | AUC 0.81 (95% CI, 0.77 to 0.84)
  • 10.0 to 13.9 mm: OR 11 (95% CI, 2 to 49) | AUC 0.82 (95% CI, 0.79 to 0.86)
• 3.0 to 5.9 mm cutoff point
  • Increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis within this ET range

CONCLUSION:

• Both low and high ET thresholds can be successfully used to diagnose EC and AEH in asymptomatic postmenopausal women
  • No substantial risk difference was found compared with higher ultrasonographic thresholds for ET
• 3.0 to 5.9 mm cutoff results in a lower specificity but higher sensitivity
•  The authors state

Sensitivity decreases with increased thresholds, whereas specificity increases when shifting from lower to higher cutoffs

Although the use of a threshold between 3.0 and 5.9 mm had the highest sensitivity, this should be balanced with cost and patient convenience as screening protocols when deciding which asymptomatic postmenopausal women with increased ET should have a subsequent biopsy 

Learn More – Primary Sources:

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis

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