From the Guidelines
The best next step in management for this 56-year-old postmenopausal woman with endometrial cells on her Pap test is to perform endometrial sampling, such as an endometrial biopsy. The presence of endometrial cells on a Pap test in a postmenopausal woman is abnormal and warrants further evaluation to rule out endometrial hyperplasia or endometrial cancer, as supported by the American Family Physician guidelines 1. This finding is particularly concerning given her risk factors for endometrial cancer, including obesity (BMI 38 kg/m²), postmenopausal status, and hypertension. Some key points to consider in this patient's management include:
- The prevalence of endometrial cells on Pap tests in women 40 years and older is between 0.5 to 1.8 percent, but the significance of this finding differs between premenopausal and postmenopausal women 1.
- For asymptomatic premenopausal women, benign endometrial cells do not require evaluation because they are rarely associated with underlying pathology, but endometrial assessment is recommended for postmenopausal women with benign endometrial cells, as 7 percent will have significant endometrial pathology 1.
- Endometrial biopsy is an office-based procedure that can be performed with minimal discomfort using a small suction catheter inserted through the cervix to obtain tissue samples from the endometrium.
- If the endometrial biopsy is inadequate or inconclusive, or if symptoms persist despite negative findings, a more comprehensive evaluation with transvaginal ultrasound to measure endometrial thickness or hysteroscopy with directed biopsies may be necessary. Early detection of endometrial abnormalities is important as endometrial cancer, when caught early, has excellent treatment outcomes.
From the Research
Patient Management
The patient is a 56-year-old postmenopausal woman with a history of well-controlled hypertension and hyperlipidemia, and a BMI of 38 kg/m2. Her Pap test shows endometrial cells and no cervical intraepithelial lesions.
- The presence of endometrial cells on a Pap test in a postmenopausal woman is abnormal and requires further evaluation 2, 3.
- Endometrial biopsy is a safe and efficient method to evaluate the endometrium for a variety of indications, including postmenopausal bleeding and abnormal uterine bleeding 2, 4.
- The sensitivity of endometrial biopsy for endometrial cancer is 90% and for atypical hyperplasia is 82%, with a specificity of 100% for postmenopausal patients 4.
Next Steps
- Given the patient's age and the presence of endometrial cells on her Pap test, an endometrial biopsy is recommended to rule out endometrial hyperplasia or malignancy 2, 3, 5.
- The biopsy should be performed using a blind suction technique or hysteroscopic biopsy, depending on the availability of resources and the patient's individual needs 5.
- If the biopsy is inadequate or the patient has persistent or recurrent symptoms, further evaluation with imaging studies such as ultrasound or MRI may be necessary 3, 5.
- The patient should be informed of the risks and benefits of the procedure, and her questions and concerns should be addressed before proceeding with the biopsy 2, 4.