Thickened endometrial stripe and/or endometrial fluid as a marker of pathology: fact or fancy?

To evaluate the implication of a thickened endometrial stripe (ES) and endometrial fluid (EF) in postmenopausal women.

Between 1991 and 1995, 897 consecutive postmenopausal patients underwent pelvic ultrasound at our institution. Clinical and ultrasound data were reviewed for the 624 patients in whom a comprehensive evaluation of the uterus and adnexae was performed. Of this study group, 495 had normal ES thickness. Nine patients with a thickened ES were excluded due to immediate hysterectomy or history of cervical cancer. This resulted in 120 subjects comprising the group with EF, or a thickened ES > or = 5 mm for patients not on hormone replacement therapy (HR-) and > or = 8 mm in patients receiving hormone replacement therapy (HR+)]. Symptoms were defined as bleeding. Statistical analysis was performed by use of Fisher's exact test.

184/ 495 patients with normal ES thickness underwent biopsy. In this group, 7 cases of simple hyperplasia, 4 cases of atypical hyperplasia (AH), and 4 cases of endometrial cancer (CA) were detected. All of these subjects who were found to have either AH or CA were symptomatic. Of the subjects with a thickened ES, 54 had symptoms and 66 were asymptomatic with 51/54 and 52/66 undergoing endometrial sampling, respectively. Initial sampling in the symptomatic group with thickened ES revealed 7 cases of simple hyperplasia and 2 cases of AH. There were 6 cases of simple hyperplasia in the asymptomatic group (P = NS). Initial biopsy results were either negative or nondiagnostic in 42 symptomatic patients and 46 asymptomatic patients with 40/42 and 19/46 undergoing repeat sampling, respectively. Repeat sampling further identified 9 cases of endometrial hyperplasia or cancer in the symptomatic group while in the asymptomatic group, 2 cases of simple hyperplasia were detected. For symptomatic and asymptomatic patients, analysis of combined initial and second biopsies performed within 1 year was undertaken. This combined analysis revealed a significantly greater rate of detection of endometrial hyperplasia or carcinoma in the symptomatic group vs the asymptomatic group (P = 0.0229, Fishers exact test, [Mantel-Haenszel odds ratio 3.094, confidence interval 0.4799-25.7]). Indeed, the observed detection of hyperplasia or cancer doubled in the symptomatic group, increasing from 9 to 18%, but did not increase significantly in the asymptomatic group. A subpopulation of 21 patients with a thickened ES were HR+ and underwent biopsy, while 72 patients with a thickened ES who were HR- underwent biopsy. 43% of HR+ patients manifested endometrial hyperplasia vs 8% in the HR- group (P = 0.0022). Endometrial fluid was present in 23 patients. The one patient with EF who was determined to have endometrial hyperplasia also had a thickened ES, was symptomatic and HR+.

In the absence of symptoms, repeat sampling is not warranted in patients with a thickened ES and negative findings at initial abnormal biopsy. The presence of symptoms with a thickened ES warrants further diagnostic evaluation to determine an etiology. There was an association with hyperplasia in patients with a thickened ES who were HR+.