Modern evaluation of the endometrium.

Area of Science:

• Gynecology
• Diagnostic Imaging
• Pathology

Background:

• Abnormal uterine bleeding (AUB) in women over 35, especially postmenopausal patients, necessitates evaluation to rule out malignancy and hyperplasia.
• Historically, dilation and curettage was standard; it has been replaced by suction biopsies, with newer disposable instruments now common.
• Limited validation exists for current biopsy techniques, highlighting the need for improved diagnostic algorithms.

Purpose of the Study:

• To present a clinical algorithm for evaluating abnormal uterine bleeding (AUB) in women over 35.
• To emphasize the role of transvaginal ultrasonography (TVUS) and saline-infusion sonohysterography (SIS) in diagnosing AUB.
• To guide appropriate management based on imaging and biopsy findings.

Main Methods:

• Utilizing transvaginal ultrasonography (TVUS) for noninvasive imaging of the endometrial cavity.
• Employing saline-infusion sonohysterography (SIS) when TVUS provides inadequate visualization of the endometrium.
• Developing a triage algorithm based on imaging findings to guide endometrial sampling.

Main Results:

• TVUS and SIS can effectively differentiate between no anatomic pathology, global endometrial processes, and focal endometrial abnormalities.
• A clinical algorithm incorporating these imaging techniques allows for targeted endometrial sampling (blind or hysteroscopy-guided).
• Incidental thick endometrial echoes in asymptomatic postmenopausal women (10-17%) do not warrant automatic invasive sampling.

Conclusions:

• An integrated approach using TVUS and SIS can optimize the diagnostic pathway for abnormal uterine bleeding.
• This algorithm aids in selecting appropriate management, including expectant treatment, blind biopsy, or hysteroscopy-guided sampling.
• It is crucial to avoid unnecessary invasive procedures based on incidental findings in asymptomatic postmenopausal women.