When should an endometrial biopsy be performed in a perimenopausal woman?

From the Guidelines

An endometrial biopsy should be performed in a perimenopausal woman who experiences abnormal uterine bleeding, particularly when there are risk factors for endometrial hyperplasia or cancer. Abnormal bleeding patterns warranting investigation include heavy menstrual bleeding, intermenstrual bleeding, postcoital bleeding, or any bleeding that represents a significant change from the woman's normal pattern. Risk factors that should lower the threshold for biopsy include obesity, diabetes, hypertension, nulliparity, late menopause, family history of endometrial or colon cancer, and use of unopposed estrogen therapy 1.

Key Considerations

• The biopsy is especially indicated in women over 45 years old with abnormal bleeding or in younger women with persistent bleeding and risk factors.
• Endometrial sampling can be performed in an office setting using a pipelle or similar device, causing minimal discomfort and requiring no anesthesia.
• If the biopsy is non-diagnostic or symptoms persist despite normal findings, further evaluation with hysteroscopy may be necessary 1.

Diagnostic Approach

• The evaluation of endometrial histology with the endometrial biopsy is still the standard for determining the status of the endometrium 1.
• Women at very high risk for endometrial cancer because of known Lynch syndrome genetic mutation carrier status, a substantial likelihood of being a mutation carrier, or families with suspected autosomal-dominant predisposition to colon cancer should consider beginning annual testing for early endometrial cancer detection at age 35 years 1.

Clinical Guidelines

• The American Cancer Society recommends that women at average and increased risk should be informed about the risks and symptoms of endometrial cancer at the onset of menopause and should be strongly encouraged to immediately report these symptoms to their physicians 1.
• The National Comprehensive Cancer Network (NCCN) guidelines recommend office endometrial biopsy as the initial diagnostic step for women with abnormal vaginal bleeding, with further evaluation using hysteroscopy or dilation and curettage as needed 1.

From the Research

Indications for Endometrial Biopsy in Perimenopausal Women

• Abnormal Uterine Bleeding (AUB) is a common health problem in perimenopausal women, and endometrial biopsy is an essential diagnostic tool to rule out endometrial cancer or hyperplasia 2.
• The American College of Obstetricians and Gynecologists (ACOG) recommends endometrial biopsy for perimenopausal women with AUB, especially those with risk factors such as obesity, diabetes, or family history of endometrial, ovarian, or breast cancer 3.
• Transvaginal ultrasound is an ideal first step for evaluating perimenopausal AUB, and endometrial biopsy can be planned based on ultrasound findings 3.

Diagnostic Approaches

• Hysteroscopy and directed biopsy are considered the gold standard for evaluating the endometrium in perimenopausal women with AUB 2.
• Blind endometrial biopsies should not be performed as the sole diagnostic strategy in perimenopausal women with AUB 2.
• A single-stop approach combining office hysteroscopy, directed biopsy, and vacuum sampling of the endometrium can be an accurate and minimally invasive approach for diagnosing AUB in perimenopausal women 2.

Risk Factors and Considerations

• Perimenopausal women with risk factors such as obesity, diabetes, or family history of endometrial, ovarian, or breast cancer should undergo endometrial biopsy to rule out endometrial cancer or hyperplasia 3.
• Endometrial volume calculation can be useful in evaluating postmenopausal uterine bleeding, and endometrial biopsy should be performed to exclude endometrial hyperplasia and carcinoma in women with endometrial volume ≥ 3 mL 4.
• Women with an initial biopsy of limited, benign, surface endometrium may require subsequent pathologic diagnosis, especially if they have increased endometrial thickness or other risk factors 5.