From the Guidelines
A 30mm endometrial stripe in a 49-year-old woman with an IUD and abnormal uterine bleeding requires immediate evaluation for endometrial hyperplasia or cancer, and an endometrial biopsy should be performed as soon as possible, ideally within 1-2 weeks, as the first step in the workup. The patient's symptoms and the significant endometrial thickening suggest a high risk of malignancy, and the presence of an IUD does not negate the need for thorough investigation 1. The biopsy can be performed as an office procedure using a Pipelle or similar sampling device.
Causes of Endometrial Thickening
The causes of such significant endometrial thickening include:
- Endometrial hyperplasia with or without atypia
- Endometrial polyps
- Submucosal fibroids
- Endometrial carcinoma The risk of endometrial cancer increases significantly when the endometrial stripe exceeds 15mm, and at 30mm, malignancy must be ruled out urgently 1.
Diagnostic Approach
In addition to the endometrial biopsy, a transvaginal ultrasound should be performed if not already done to further characterize the endometrial thickening and assess for other pelvic pathology 1. The IUD should be removed prior to or during the biopsy procedure. If the biopsy is non-diagnostic or insufficient, hysteroscopy with directed biopsy or dilation and curettage (D&C) should be performed 1. The patient should be counseled about the possibility of needing surgical management depending on the biopsy results.
Additional Imaging Considerations
While transvaginal ultrasound is the initial imaging modality of choice, MRI can also be considered for the assessment of the endometrium, particularly if the endometrium cannot be completely evaluated by ultrasound 1. Diffusion-weighted imaging has been shown to improve the sensitivity and specificity of MRI for the accurate diagnosis of uterine pathology 1. However, the initial step in the workup should focus on endometrial biopsy and transvaginal ultrasound.
From the Research
Cause of Thick Endometrial Stripe
- A thick endometrial stripe of 30mm in a 49-year-old woman with an IUD and abnormal uterine bleeding can be caused by various factors, including endometrial hyperplasia or cancer 2.
- The presence of an IUD, particularly a progesterone-containing IUD, can decrease the risk of endometrial hyperplasia 2.
- However, abnormal uterine bleeding remains a hallmark of endometrial pathology, and immediate evaluation is necessary 2.
Workup of Thick Endometrial Stripe
- Endometrial biopsy is a safe and efficient method to evaluate the endometrium for abnormal uterine bleeding and can be performed in an office setting 3, 4.
- The biopsy can be performed using an endometrial biopsy catheter, and topical lidocaine or nonsteroidal anti-inflammatory drugs can be used to reduce procedure-associated pain 3, 4.
- Hysteroscopy with biopsy is a targeted-biopsy method with high diagnostic accuracy and cost-effectiveness, especially in patients with suspected endometrial malignancy 5.
- In patients with a thick endometrial stripe, hysteroscopic biopsy is recommended to obtain a tissue sample for histopathological examination 6, 5.
Diagnostic Considerations
- Endometrial biopsy has high sensitivity for detecting intrauterine pathologies, including endometrial cancer and atypical hyperplasia 4, 5.
- However, blind suction techniques may not be reliable for diagnosing endometrial polyps, and hysteroscopic biopsy is preferred 5.
- The diagnostic accuracy of endometrial biopsy can be improved by using hysteroscopy with biopsy, especially in patients with suspected endometrial malignancy 6, 5.