What is the significance of a 12mm thickened endometrium (endometrial hyperplasia) in a postmenopausal female with postmenopausal bleeding, a subcentimeter exophytic cyst on the left ovary, and normal right kidney size with cortical scarring?

From the Guidelines

The patient should undergo an endometrial biopsy and pelvic MRI as soon as possible to rule out endometrial hyperplasia or malignancy and ovarian cancer. The endometrial thickness of 12mm in a postmenopausal woman with bleeding is concerning for endometrial hyperplasia or malignancy, as normal postmenopausal endometrium should be less than 5mm 1. According to the acr appropriateness criteria, an endometrial thickness of 4 mm in a postmenopausal woman conveys a negative predictive value for cancer of nearly 100% 1. Given the patient's symptoms and ultrasound findings, an endometrial biopsy is necessary to determine the cause of the thickened endometrium. The subcentimeter exophytic cyst on the left ovary with possible solid components requires further evaluation with MRI to rule out ovarian cancer, as solid components within ovarian cysts raise suspicion for malignancy. The right kidney appears normal with some cortical scarring, which likely represents previous injury or infection but doesn't require immediate intervention. These evaluations should be scheduled promptly, with the endometrial biopsy typically performed as an outpatient procedure under local anesthesia. The pelvic MRI should be performed with and without contrast if not contraindicated. Following these diagnostic procedures, treatment will depend on the results, potentially including hormonal therapy, surgical intervention, or oncology referral if malignancy is confirmed 1. It's essential to note that the use of ultrasonography remains justified, but with the recommendation to use cut-off level of ≤3 mm or ≤4 mm, followed by endometrial sampling 1. In this case, the endometrial thickness is significantly greater than the recommended cut-off, making an endometrial biopsy a necessary step in the diagnostic pathway. The patient's symptoms and ultrasound findings should be thoroughly evaluated, and a treatment plan should be developed based on the results of the endometrial biopsy and pelvic MRI. Key considerations in the diagnostic workup include:

• Endometrial biopsy to evaluate the thickened endometrium
• Pelvic MRI to further evaluate the subcentimeter exophytic cyst on the left ovary
• Review of the patient's medical history and symptoms to guide the diagnostic workup and treatment plan.

From the Research

Endometrial Biopsy Considerations

• Endometrial biopsy is a safe and efficient method to evaluate the endometrium for abnormal uterine bleeding and postmenopausal bleeding 2, 3
• The procedure is highly specific for diagnosing atypical hyperplasia and endometrial cancer in postmenopausal women 2, 3
• Pregnancy is the only absolute contraindication to the procedure 2

Indications for Endometrial Biopsy

• Abnormal uterine bleeding is a frequent medical concern for premenopausal and postmenopausal patients, and endometrial biopsy is a cost-effective option 3
• Endometrial biopsy is recommended for postmenopausal women with uterine bleeding 4
• Women with sonographic endometrial thickness > 4 mm using tamoxifen should undergo hysteroscopic endometrial biopsy 4

Diagnostic Accuracy of Endometrial Biopsy

• Endometrial biopsy is 90% sensitive for endometrial cancer and 82% sensitive for atypical hyperplasia, with specificity of 100% for postmenopausal patients 3
• Hysteroscopy is the targeted-biopsy method with the highest diagnostic accuracy and cost-effectiveness 4

Further Workup with Pelvic MRI

• Pelvic MRI is recommended to exclude ovarian malignancy in cases with suspicious ovarian lesions 5
• MRI has high sensitivity and specificity in determining the origin of the primary endometrial versus cervical tumors when endometrial/endocervical curettage is inconclusive 5