Diagnosing Endometrial Carcinoma in a Patient With Atrophic Endometrium and Postmenopausal Bleeding

Endometrial carcinoma is the leading cause of gynecologic malignancies in the United States. Unlike other malignancies, endometrial carcinoma presents early with the most common clinical symptom being uterine bleeding (including irregular menses, inter-menstrual bleeding, and postmenopausal bleeding, or PMB). Hence, the evaluation of PMB should have efficient and effective strategies to prevent a missed diagnosis of malignancy and to facilitate an early diagnosis for potentially curative treatment. Transvaginal ultrasound is appropriate to evaluate PMB initially. If imaging reveals an endometrial thickness of ≤4 mm, endometrial sampling is not warranted, given the high negative predictive value (>99%) of this finding for endometrial carcinoma. In women with persistent or recurrent bleeding, if blind endometrial sampling does not show endometrial hyperplasia or malignancy, further testing with hysteroscopy with dilation and curettage is indicated. However, in cases of PMB with an endometrial thickness of ≤4 mm on transvaginal ultrasound, little information can be gained from endometrial sampling alone as the chance of getting an adequate sample is low and malignancy is rare. For such patients, outpatient hysteroscopy has become a convenient and cost-effective procedure that may be done before an endometrial sampling.