In a woman who is not perimenopausal, does a normal‑appearing endometrial stripe on ultrasound require any further work‑up?

Normal Endometrial Stripe in Premenopausal Women

In premenopausal women who are not perimenopausal, a normal-appearing endometrial stripe on ultrasound requires no further workup if the patient is asymptomatic. 1, 2

Key Management Principle

• Asymptomatic premenopausal women with benign-appearing endometrium do not require any evaluation or follow-up imaging. 1, 2
• The presence of normal endometrial cells or a normal endometrial stripe in this population is rarely associated with significant underlying pathology. 1
• Endometrial thickness varies physiologically throughout the menstrual cycle in premenopausal women, and there is no validated absolute upper limit cutoff for endometrial thickness in this population. 3

When Further Evaluation IS Indicated

Further workup should be pursued only in specific clinical scenarios:

• Premenopausal women with abnormal uterine bleeding should undergo endometrial assessment regardless of endometrial stripe appearance. 1, 4
• Women with conditions suggesting chronic anovulation (such as PCOS, obesity, or irregular cycles) warrant consideration of endometrial assessment even if asymptomatic. 1
• If initial transvaginal ultrasound shows a focal endometrial abnormality or irregular echogenicity/texture, sonohysterography should be considered for further characterization. 3

Critical Pitfall to Avoid

Do not rely on endometrial stripe thickness cutoffs in premenopausal women with abnormal bleeding. 4

• A study of 200 premenopausal women with abnormal uterine bleeding found that using an endometrial stripe cutoff of <5 mm would miss 20% of endometrial polyps and submucosal fibroids. 4
• The sensitivity of endometrial stripe <5 mm for excluding pathology was only 74%, with a negative predictive value of 80%. 4
• Symptomatic premenopausal women should undergo sonohysterography or equivalent testing regardless of endometrial stripe thickness. 4

Contrast with Postmenopausal Women

This recommendation differs dramatically from postmenopausal management:

• Postmenopausal women with benign-appearing endometrial cells require endometrial assessment regardless of symptoms, as approximately 7% harbor significant endometrial pathology. 1, 5
• In postmenopausal women, an endometrial thickness ≤4 mm has a negative predictive value for endometrial cancer of nearly 100%. 3, 5