A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer

Objective:  To evaluate postmenopausal bleeding (PMB) and transvaginal sonographic (TVS) measurement of endometrial thickness (ET) as predictors of endometrial cancer (EC) and atypical hyperplasia (AH) in women during a >10-year period following a PMB. Study design:  Women presented with a PMB from November 1987 to October 1990 were included in this study (n = 394). The women underwent TVS with measurement of ET and a dilation and curettage (D & C). It was possible to assess the medical records of 339 of the 394 women (86%) >10 years after referral for PMB. During the follow up period the recurrence of a PMB, the development of EC and mortality were assessed. Results:  After the primary investigation, 39 of the 339 women were diagnosed as having EC (11.5%) and 5 women had AH (1.5%). The relative risk (RR) of diagnosing an EC in women referred for a PMB was 63.9 (CI 46.0 Ð 88.8) and the corresponding RR for EC and AH together was 72.1 (CI 52.8 Ð 98.5) compared to women of the same age from the same region of Sweden. The reliability of PMB as a diagnostic test for EC was assessed: sensitivity 18%; specificity 100%; positive predictive value 12%; and negative predictive value 100%. None of the women with an ET of 2 × 4 mm were diagnosed as having EC. The reliability of ET (cut-off 2 × 4 mm) as a diagnostic test for EC was assessed: sensitivity 100%; specificity 60%; positive predictive value 25% and negative predictive value 100%. The incidence of EC or AH in women with an intact uterus followed 3 × 10 years was 5.8%. The corresponding figure for women who had 3 × 1 recurrent bleeding during follow up was 22.7%. No EC was diagnosed in women with a recurrent PMB who had an ET of 2 × 4 mm at the initial scan. No EC was diagnosed in the absence of a recurrent bleeding. Conclusion:  PMB incurs a 64-fold increase risk for EC. No EC was missed when ET measurement (cut-off 2 × 4 mm) was used even if the women were followed 3 × 10 years. About 5.8% of the women referred for a PMB later developed EC or atypia during the 10-year observation period. There was no increased risk of EC or AH in women who did not have recurrent bleedings whereas women with a recurrent bleeding were a high risk group. A thick endometrium, with histopathological diagnosis of atrophy or insufficient for diagnosis, should be taken seriously and a guided biopsy should be taken or saline instillation sonography performed with ultrasound-guided biopsy.