From the Guidelines
For a 51-year-old perimenopausal woman with daily spotting for 1 year and an endometrial stripe of 8mm, endometrial biopsy is recommended to rule out endometrial hyperplasia or cancer. This can be performed in the office setting using a Pipelle or similar sampling device, as it has been shown to be a very sensitive technique for the detection of endometrial carcinoma, with a sensitivity of 99.6% 1. Given her age, perimenopausal status, and endometrial thickness exceeding 4-5mm, tissue sampling is necessary as the risk of endometrial pathology increases with age and persistent bleeding.
The diagnostic approach for abnormal uterine bleeding, as outlined in the ACR Appropriateness Criteria, supports the use of endometrial sampling in patients with increased risk for endometrial hyperplasia or cancer 1. The measurement of endometrial thickness using a cut-off point of 3 or 4 mm, followed by endometrial sampling, is a recommended diagnostic strategy 1.
If the biopsy is negative for hyperplasia or malignancy, hormonal management options include:
- Cyclic progesterone therapy (medroxyprogesterone acetate 10mg daily for 10-14 days each month or norethindrone acetate 5mg daily)
- Combined hormonal contraceptives if not contraindicated
- A levonorgestrel intrauterine system (Mirena) If the patient has other perimenopausal symptoms, systemic hormone therapy could be considered.
Transvaginal ultrasound should be repeated in 3-6 months to ensure stability of the endometrial stripe. If the bleeding persists despite negative biopsy and medical management, or if the endometrial stripe increases in thickness, hysteroscopy with directed biopsy should be considered for more comprehensive evaluation, as it is highly accurate and clinically useful in diagnosing endometrial cancer 1.
From the Research
Management of Abnormal Uterine Bleeding
The management of a 51-year-old perimenopausal woman with daily spotting for 1 year and an endometrial stripe measuring 8mm involves several steps:
- Evaluation of abnormal uterine bleeding (AUB) using the PALM-COEIN classification system to determine the cause of bleeding 2
- Transvaginal ultrasound as an initial screening evaluation to assess endometrial thickness and detect any abnormalities 3, 4
- Endometrial sampling, such as endometrial biopsy or hysteroscopy, may be necessary to rule out endometrial hyperplasia or cancer, especially if the endometrial stripe is thickened or if there are other risk factors 3, 5
Role of Transvaginal Ultrasound
Transvaginal ultrasound is a cost-effective and sensitive method for evaluating AUB in perimenopausal women:
- It can detect endometrial thickness and abnormalities, such as polyps or hyperplasia 3, 4
- An endometrial thickness of less than or equal to 4mm has a low risk of malignancy, and biopsy may not be necessary in postmenopausal women with bleeding 5
- However, in perimenopausal women, the significance of endometrial thickness is less clear, and other factors, such as clinical symptoms and risk factors, should be considered 4
Endometrial Sampling
Endometrial sampling, such as endometrial biopsy or hysteroscopy, is necessary to diagnose endometrial hyperplasia or cancer:
- It can be performed in an outpatient setting and is generally well-tolerated 3
- The decision to perform endometrial sampling should be based on individual risk factors, clinical symptoms, and ultrasound findings 2, 4
- Hysteroscopy may become the new gold standard for evaluating AUB due to its ability to visualize the endometrium and perform directed biopsies 3