What is the treatment for abnormal uterus thickness?

Treatment for Abnormal Uterine Thickness

For abnormal uterine thickness, the treatment approach should be guided by transvaginal ultrasound findings, with endometrial sampling recommended for postmenopausal women with endometrial thickness ≥5 mm or for premenopausal women with thickness >8 mm, followed by appropriate medical or surgical interventions based on the underlying pathology. 1, 2

Diagnostic Evaluation

• Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study for evaluating abnormal uterine thickness 1
• In postmenopausal women, endometrial thickness ≥5 mm generally prompts endometrial tissue sampling as it may indicate underlying pathology 1, 2
• In premenopausal women, endometrial thickness of 8 mm shows optimal sensitivity (83.9%) and specificity (58.8%) for detecting abnormal endometrium 3
• If initial ultrasound is inconclusive, sonohysterography can be performed to further characterize endometrial abnormalities, particularly if a polyp is suspected 1
• When the uterus is incompletely visualized by ultrasound or findings are indeterminate, MRI with contrast should be considered due to its multiplanar capabilities and excellent tissue contrast 1

Treatment Algorithm Based on Menopausal Status

For Postmenopausal Women:

• If endometrial thickness <4 mm: Observation may be appropriate as negative predictive value for cancer approaches 100% 1, 2
• If endometrial thickness ≥5 mm: Endometrial sampling is recommended 1, 2
• If endometrial hyperplasia is found: Treatment with progesterone is indicated to reduce the risk of endometrial cancer 4
  • Progesterone capsules 200 mg daily at bedtime for 12 continuous days per 28-day cycle in women taking estrogen therapy 4
• If endometrial cancer is detected: Referral for gynecologic oncology evaluation 1

For Premenopausal Women:

• If endometrial thickness ≤8 mm: Less likely to be associated with malignant pathologies 3
• If endometrial thickness >8 mm: Endometrial sampling is recommended 3
• For idiopathic abnormal uterine bleeding: First-line treatment is medical 5
  • Levonorgestrel IUD (most effective) 5
  • Tranexamic acid 5
  • Oral contraceptives (estrogen and progestin or progestin-only) 5
  • NSAIDs 5
• For secondary amenorrhea: Progesterone capsules 400 mg at bedtime for 10 days 4
• If medical treatment fails: Consider conservative surgical techniques such as endometrial ablation 5

Treatment Based on Specific Pathology

• Endometrial polyps: Hysteroscopic polypectomy 1, 6
• Submucous fibroids: Hysteroscopic myomectomy or medical management 1
• Adenomyosis: Levonorgestrel IUD, hormonal therapy, or, in severe cases, hysterectomy 1
• Endometrial hyperplasia: Progestin therapy to prevent progression to endometrial cancer 4
  • In a clinical trial, progesterone capsules plus estrogen reduced hyperplasia rates to 6% versus 64% with estrogen alone 4
• Endometrial cancer: Surgical management with hysterectomy and staging 1

Important Considerations and Pitfalls

• Normal endometrial thickness varies throughout the menstrual cycle in premenopausal women, making interpretation more challenging than in postmenopausal women 1, 2
• Abnormal echogenicity and texture of the endometrium correlates with underlying uterine pathology regardless of thickness and should not be ignored 1, 2
• Endometrial thickness measurement alone cannot reliably determine the etiology of endometrial thickening, necessitating tissue sampling in suspicious cases 1, 2
• First-line hysterectomy is not recommended for functional bleeding; conservative medical and surgical options should be tried first 5
• When progesterone therapy is prescribed, patients should be warned about potential side effects including dizziness, drowsiness, and breast tenderness 4