Ability to successfully image endometrium on transvaginal ultrasound in asymptomatic postmenopausal women

Abstract

Objectives Numerous studies indicate that endometrial thickness of ≤ 4 mm on transvaginal ultrasound (TVS) is a reliable test to exclude endometrial cancer in women with postmenopausal bleeding (PMB), such that biopsy is not needed. However, not all postmenopausal women have anatomy that allows reliable measurement of endometrial thickness. This study was undertaken to evaluate the frequency of, and the reasons for, an inability to adequately visualize the endometrium on TVS. Methods A total of 472 consecutive asymptomatic postmenopausal women underwent TVS as part of their routine gynecological care. Their charts and TVS images were reviewed, and, if possible, endometrial thickness was recorded. If the endometrium was not adequately visualized, the reason for inadequacy was recorded, as judged by the examiner. Other demographic characteristics recorded included the number of years since menopause, body mass index (BMI) and current use of hormone replacement therapy. Results Of the 472 women, 292 (61.9%) had an endometrium that was well visualized, in whom endometrial thickness could be measured reliably (mean, 3.0 (range, 1.0–28.0) mm). In the other 180 postmenopausal women (38.1%), a distinct endometrium was not adequately visualized. The reasons for non‐visualization were fibroids (n = 95, 20.1% of the overall cohort), adenomyosis (n = 35, 7.4% of the overall cohort) and an axial uterus (n = 50, 10.6% of the overall cohort). Mean interval from menopause was 14.0 (range, 1–50) years and 14.1 (range, 1–40) years in the visualized and non‐visualized cohorts, respectively (P = 0.83). Mean BMI was 23.9 (range, 16.3–41.5) kg/m2 in the visualized cohort and 25.4 (range, 18.0–39.9) kg/m2 in the non‐visualized cohort (P = 0.015). Conclusions TVS has become an accepted first step in the evaluation of PMB. However, in our cohort, 38.1% of women had anatomical reasons for non‐visualization of the endometrium and lack of a reliable endometrial thickness measurement, including fibroids, adenomyosis or an axial uterus. There was no significant difference between groups in the interval from menopause or current use of hormone replacement therapy, but the mean BMI of the non‐visualized group was significantly higher than in the visualized group. Clinicians should be cognizant of these potential limitations of TVS in the initial evaluation of women with PMB. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

New Light on Endometrial Thickness as a Risk Factor of Cancer: What Do Clinicians Need to Know?

“…Many studies have underlined the inability to complete a meaningful TVUS examination with a reliable measurement of ET in all postmenopausal patients. 25 , 42–44 The ACOG guidelines underlined that the presence of uterine pathology, such as fibroids, adenomyosis, or previous uterine surgery, can increase the difficulty of obtaining a measurement of the endometrial echo. In these cases, failure to adequately evaluate the endometrium by US investigation should always be followed by an alternative method of evaluation like saline or gel-infused sonohysterography and office hysteroscopy.…”

Efficacy of transrectal ultrasound in assessing endometrium of postmenopausal women with axial uterus

“…In a recent study by Goldstein and Khafaga 2 , TVS failed to visualize the endometrium in 38% of asymptomatic postmenopausal women. The main reasons for non‐visualization were uterine fibroids (53%), axial uterus (28%) and adenomyosis (19%).…”

“…Endometrial assessment is an integral part of gynecological ultrasound examination. However, factors such as an axial uterus, fibroids, adenomyosis, obesity or previous uterine surgery may complicate visualization of the endometrium on transvaginal ultrasound (TVS) 1,2 . For example, in a prospective study of women with postmenopausal bleeding (PMB), endometrial thickness (ET) could not be measured in around one in eight women 3 .…”