Modern evaluation of the endometrium

Abnormal uterine bleeding in women older than age 35 years, and certainly in menopausal patients, mandates evaluation, mainly to exclude cancer and hyperplasia, but also to better diagnose the source of the bleeding to appropriately manage the patient. In the past, dilation and curettage was the mainstay of diagnosis. This gave way to in-office suction pump-generated biopsies. Most recently, disposable biopsy instruments with their own internal piston to generate suction have become the standard of care. Rarely has such a technique received such widespread acceptance with such limited validation. Transvaginal ultrasonography, when technically feasible, is a noninvasive way to image the endometrial cavity. Saline-infusion sonohysterography is a subset of transvaginal ultrasonography reserved for patients in whom an adequate endometrial echo is not seen or when an endometrial echo is seen but not sufficiently thin. Appropriate understanding and use of transvaginal ultrasonography and addition of sonohysterography when necessary can allow a clinical algorithm that can triage patients with abnormal uterine bleeding to 1) no anatomic pathology best treated expectantly; 2) a global endometrial process, in which case random blind endometrial sampling is appropriate; or 3) a focal endometrial abnormality in which case endometrial sampling should be done with the visualization offered by hysteroscopy. Finally, the incidence of thick endometrial echo found incidentally in postmenopausal women with no bleeding is extremely high (10-17%) and should not trigger invasive endometrial sampling automatically.