No. 249-Asymptomatic Endometrial Thickening

ObjectiveTo formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding.OutcomesEnsure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately.EvidencePublished literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., “asymptomatic endometrial thickness,” “endometrial cancer,” “postmenopausal bleeding,” “transvaginal ultrasonography,” “endometrial biopsy” and “endometrial polyp”). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.ValuesThe level of evidence was determined according to the criteria established by the Canadian Task Force on Preventive Health Care (Table 1). Recommendations are ranked according to this method.Benefits, harms, and costsIt is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions.Recommendations1.Transvaginal ultrasound should not be used as screening for endometrial cancer (II-1E).2.Endometrial sampling in a postmenopausal woman without bleeding should not be routinely performed (II-1E).3.Indications for tissue sampling of the endometrium in bleeding postmenopausal women with an endometrial thickness of greater than 4 to 5 mm should not be extrapolated to asymptomatic women (II-2E).4.A woman who has endometrial thickening and other positive findings on ultrasound, such as increased vascularity, inhomogeneity of endometrium, particulate fluid, or thickened endometrium over 11 mm, should be referred to a gynaecologist for further investigations (II-1A).5.Decisions about further investigations should be made on a case-by-case basis in asymptomatic women with increased endometrial thickening and risk factors for endometrial cancer such as obesity, hypertension, and late menopause (II-1B).6.In asymptomatic women on tamoxifen, a routine ultrasound for endometrial thickening should not be performed (II-2E).7.Not all postmenopausal women who have asymptomatic endometrial polyps require surgery. Women found to have asymptomatic polyps on ultrasound should be triaged for intervention according to size of the polyp, age, and other risk factors (II-1A).