What is the next step if a focal area is found in the endometrium after menopause?

Management of Focal Endometrial Abnormality in Postmenopausal Women

When a focal area is found in the endometrium of a postmenopausal woman, the next step should be endometrial tissue sampling, preferably with hysteroscopy to visualize and target the focal lesion. 1

Diagnostic Algorithm for Focal Endometrial Abnormalities

Initial Assessment

• Transvaginal ultrasound (TVUS) should be the first imaging study performed to assess endometrial thickness and characterize the focal abnormality 1
• An endometrial thickness of ≤4 mm in a postmenopausal woman has a negative predictive value for endometrial cancer of nearly 100% 2
• When endometrial thickness is ≥5 mm or a focal abnormality is identified, further evaluation is necessary regardless of thickness 2, 3

Recommended Next Steps for Focal Abnormalities

• Endometrial sampling is mandatory for focal endometrial abnormalities in postmenopausal women to rule out malignancy 1
• Hysteroscopy with directed biopsy is preferred over blind endometrial sampling for focal lesions as it allows visualization and targeted sampling 1, 4
• Blind endometrial sampling techniques (Pipelle or Vabra) are highly sensitive for detecting diffuse endometrial carcinoma (99.6% and 97.1% respectively) but may miss focal lesions 1, 2

Additional Imaging Considerations

• If initial TVUS is inconclusive, sonohysterography (saline infusion sonography) can help distinguish between focal and diffuse pathology 1, 5
• MRI with contrast may be considered when ultrasound is inconclusive or further characterization is needed 1
• Diffusion-weighted MRI sequences improve sensitivity and specificity for diagnosing uterine pathology, particularly endometrial cancer 1

Clinical Significance and Pitfalls

• Focal endometrial lesions in postmenopausal women may represent polyps, hyperplasia, or malignancy, with endometrial cancer being the most serious concern 1
• Atrophic endometrium is often incorrectly attributed as a cause of postmenopausal bleeding; focal lesions are frequently the true source and may harbor malignancy 6
• The risk of malignancy increases significantly when endometrial thickness is ≥10 mm in asymptomatic postmenopausal women 3
• Approximately 90% of asymptomatic postmenopausal women with endometrial thickness <7 mm have atrophic endometrium, but focal lesions can still be present 7

Important Caveats

• Blind endometrial sampling may miss focal lesions, leading to false-negative results and delayed diagnosis 4, 6
• Dilatation and curettage (D&C) has largely been replaced by office-based endometrial sampling and hysteroscopy 1
• Even with normal endometrial thickness, abnormal echogenicity or texture may indicate significant underlying pathology requiring evaluation 2
• Endometrial cancer is the most common gynecologic malignancy, with more than 90% of cases occurring in women older than 50 years 1

Remember that early diagnosis of endometrial pathology is crucial as endometrial cancer diagnosed at early stages has excellent survival rates 1.