Version May 2024
INTRODUCTION — Evaluation of the endometrium is the key component in the diagnostic evaluation of patients suspected of endometrial carcinoma or a premalignant endometrial lesion (ie, endometrial hyperplasia with or without atypia). Evaluation methods typically include endometrial sampling procedures (eg, endometrial biopsy, dilation and curettage [D&C] with or without hysteroscopy) and/or transvaginal ultrasound [TVUS].
This topic will provide an overview of the evaluation of the endometrium for premalignant and malignant disease. Detailed descriptions of the performance of the procedures themselves and the diagnosis of endometrial hyperplasia or carcinoma are available separately.
●(See "Endometrial sampling procedures".)
●(See "Saline infusion sonohysterography".)
●(See "Dilation and curettage".)
●(See "Overview of hysteroscopy" and "Hysteroscopy: Managing fluid and gas distending media".)
HOW TO CHOOSE THE METHOD
Postmenopausal patients with bleeding — For postmenopausal patients with uterine bleeding, the American College of Obstetricians and Gynecologists and the Society of Radiologists in Ultrasound advises that either endometrial sampling or transvaginal ultrasound (TVUS) can be used as the first diagnostic step for evaluating the endometrium [1,2]. The choice of procedure is often driven by the specialty of the physician caring for the patient.
●For those in gynecologic practices, endometrial biopsy is often performed as the initial diagnostic test due to its high sensitivity, low complication rate, and low cost (see 'Endometrial biopsy' below). If a cause for the bleeding is determined, then further management depends on the clinical diagnosis.
Additional endometrial assessment (with TVUS, repeat endometrial biopsy, or dilation and curettage [D&C] with hysteroscopy) should be performed:
•In patients in whom postmenopausal bleeding continues despite a "benign" endometrial biopsy [3]. Benign endometrial histology includes atrophy (absence of a hormonal effect), proliferative endometrium (estrogen effect), secretory endometrium (progestin effect), disordered or dyssynchronous endometrium (implies irregular shedding of the endometrium secondary to unopposed estrogen), and endometritis. (See "Endometrial hyperplasia: Management and prognosis", section on 'Proliferative endometrium' and "Endometritis unrelated to pregnancy".)
•When the endometrial biopsy is nondiagnostic, but a high suspicion of cancer remains [4]. Nondiagnostic biopsies may be associated with polyps, fibroids, endometrial carcinoma, or other lesions occupying an area of the uterus that was not sampled.
●For those in practices where office endometrial biopsy is not performed, TVUS examination is a reasonable initial test. TVUS can also be used for postmenopausal patients in whom office biopsy cannot be performed, structural uterine pathology (eg, polyp, leiomyoma) is suspected, or evaluation of the adnexa is needed.
•Endometrial carcinoma can reasonably be excluded by TVUS in postmenopausal patients with a thin (≤4 mm), homogeneous endometrium on initial evaluation (image 1) [5,6]. (See 'Transvaginal ultrasound' below.)
However, the diagnostic efficacy of TVUS may be lower in Black patients compared with White patients [7]; the greater prevalence of fibroids (which can limit assessment of the endometrium) in Black patients may contribute to this disparity. The diagnostic efficacy of TVUS is also lower in patients with serous and clear cell endometrial cancers [8]. (See "Endometrial carcinoma: Serous and clear cell histologies", section on 'Limited role of transvaginal ultrasound'.)
•Further evaluation with endometrial sampling is required if:
-The endometrial lining is >4 mm (image 2). Endometrial carcinoma becomes increasingly more frequent relative to benign disease as the endometrial thickness approaches 20 mm, which was the mean endometrial thickness in 759 patients with endometrial carcinoma in one study [6].
-The endometrium is not adequately visualized or shows diffuse or focal heterogeneity.
-The patient has persistent bleeding. Persistent bleeding can be a sign of endometrial carcinoma even when the endometrial thickness is ≤4 mm since a thin or indistinct endometrial stripe does not reliably exclude all cancers, particularly those that are of nonendometrioid histology [9,10].
Evaluation of postmenopausal patients with bleeding on hormone therapy and postmenopausal patients without bleeding are discussed below. (See 'Patients on hormone therapy' below and 'Incidental finding on TVUS for another indication' below.)
Premenopausal patients with abnormal bleeding — For premenopausal patients with abnormal uterine bleeding (AUB), evaluation of the endometrium with endometrial sampling or TVUS is determined by the bleeding pattern (eg, heavy menstrual bleeding, intermenstrual bleeding, irregular bleeding) and risk factors for endometrial carcinoma (table 1). This is discussed in detail separately. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis", section on 'Secondary evaluation'.)
In contrast with postmenopausal patients, there is no standard threshold for abnormal endometrial thickness in premenopausal patients and the utility of TVUS for excluding endometrial carcinoma in premenopausal patients has not been established [11,12]. If TVUS is performed, it should be performed on days 4, 5, or 6 of the menstrual cycle, ideally when the patient is no longer bleeding. At this early phase of the menstrual cycle, the endometrium is expected to be thin. In reproductive-age patients, normal endometrial thickness in the proliferative phase is 4 to 8 mm and in the secretory phase 8 to 14 mm, but higher values (eg, up to 24 mm) have been reported (image 3) [4,13]. If a patient is found to have a thick, heterogenous echogenic endometrium in the late secretory phase of the menstrual cycle, a follow-up ultrasound early in the next menstrual cycle (after the patient completes their menses) is helpful to reassess the endometrium; the endometrium will frequently appear thin and normal on follow-up. Further evaluation should be based on the clinical situation, including persistent AUB not responsive to medical management or suspicion of a structural abnormality, such as a polyp, which may require removal.
Patients on hormone therapy
Continuous combined hormone therapy — For pre- and postmenopausal patients on continuous combined estrogen and progestin therapy, the endometrial lining is expected to be thin and atrophic, and in such patients, the initial evaluation of the endometrium is similar to postmenopausal patients with bleeding. (See 'Postmenopausal patients with bleeding' above.)
Cyclic progesterone — For postmenopausal patients on cyclic progesterone, the endometrium can have a varied appearance and endometrial thickness thresholds are not well established for such patients. TVUS or endometrial sampling may be used for initial evaluation. If ultrasound is used, it is best to perform the ultrasound early in the cycle, when the endometrium is expected to be thin [14]. A homogenous endometrium that is <8 mm is considered normal. However, persistent bleeding always requires endometrial sampling regardless of ultrasound findings. We tell patients that bleeding is common when hormone replacement therapy is initiated and should decrease over time. If it does not, and if it becomes heavier, or bleeding occurs after a long period of no bleeding, or at an abnormal time of the cycle, then endometrial sampling is indicated. (See "Treatment of menopausal symptoms with hormone therapy", section on 'Endometrial monitoring'.)
Unopposed estrogen — Unopposed estrogen is contraindicated in patients with a uterus; the risk of endometrial carcinoma is sufficiently high in such patients. In the rare event that a patient with a uterus is on unopposed estrogen, endometrial biopsy should be performed at least yearly. TVUS may also be useful when a focal endometrial lesion is suspected or when fibroids complicate endometrial assessment.
Tamoxifen — For patients on tamoxifen therapy (for the treatment and prevention of breast cancer), routine endometrial assessment is not performed. However, endometrial assessment should be performed if any abnormal bleeding occurs, as tamoxifen confers a slight increase in endometrial carcinoma risk. (See "Abnormal uterine bleeding and uterine pathology in patients on tamoxifen therapy".)
The choice of procedure (ie, endometrial sampling, TVUS) is discussed in detail separately. (See "Abnormal uterine bleeding and uterine pathology in patients on tamoxifen therapy", section on 'Pelvic ultrasound and endometrial sampling'.)
METHODS OF EVALUATION
Endometrial sampling procedures
Endometrial biopsy — The development of equipment and techniques for office-based endometrial biopsy has generally replaced the need for diagnostic dilation and curettage (D&C) performed in the operating room [15].
Advantages of office biopsy include:
●Minimal to no cervical dilation is required.
●May be performed without anesthesia or with only local anesthesia.
●Procedure time is brief; actual sampling time is approximately 5 to 15 seconds.
●Risk of uterine perforation, while low for either procedure, is lower than with D&C. (See "Endometrial sampling procedures", section on 'Side effects and complications' and "Uterine perforation during gynecologic procedures", section on 'Uterine perforation'.)
●Less expensive than a procedure in the operating room.
Disadvantages of office biopsy include:
●It is a "blind procedure," and the operator may (unintentionally) not enter the uterine cavity or sample only the lower uterine segment.
●May yield a scant specimen, not reflective of the underlying pathology.
●May only sample a portion of the endometrium, particularly in patients with a large uterus, intracavitary fibroids, or uterine anomalies.
●Is usually performed without anesthesia, and patient discomfort may limit the ability to obtain an adequate sample.
There is an excellent correlation between the histopathology of endometrial specimens taken by biopsy instruments in the office and D&C [16-18]. However, since less than half of the endometrium is sampled, malignancy can be missed (table 2).
In a meta-analysis including 39 studies (7914 patients) comparing the results of endometrial biopsy with histopathology at D&C, hysteroscopy, and/or hysterectomy, the Pipelle device was more sensitive for the detection of endometrial carcinoma and hyperplasia with atypia than all other sampling devices; however, the specificity for all devices was high (>98 percent) [19]. In addition, the sensitivity for the diagnosis of endometrial carcinoma (by Pipelle) was higher in postmenopausal compared with premenopausal patients (99.6 versus 91 percent, respectively). Fewer than 5 percent of patients had an insufficient or no sample. In a subsequent meta-analysis assessing the accuracy of outpatient endometrial biopsy in the diagnosis of endometrial carcinoma, the post-test probability of endometrial carcinoma after a positive biopsy was 82 percent (95% CI 60-93 percent) and, after a negative test, was 0.9 percent (95% CI 0.4-2.4 percent) [20]. In this analysis, 15 percent (138 of 945) of specimens were inadequate (no sample or insufficient tissue for assessment), and one case of cancer was subsequently found among these patients.
All sampling devices perform better when pathology is global rather than focal; this has been demonstrated repeatedly in multiple studies. In a prospective study including 65 patients with known endometrial carcinoma undergoing Pipelle biopsy prior to hysterectomy, endometrial sampling was most reliable when at least one-half of the endometrium was affected by disease [21].
Dilation and curettage — As discussed above, endometrial biopsy in the office has generally replaced diagnostic D&C, but there is still a role for this procedure for some patients.
Indications for diagnostic D&C include (see "Dilation and curettage"):
●When an office endometrial biopsy cannot be performed (eg, cervical stenosis, patient anxiety or pain). (See "Endometrial sampling procedures", section on 'Preprocedure preparation'.)
●After a nondiagnostic (eg, insufficient tissue) office biopsy.
●When transvaginal ultrasound (TVUS) identifies a focal lesion or multiple lesions, which may not be adequately sampled by office biopsy.
●Patients with persistent abnormal bleeding, even if benign histology was demonstrated on a prior office biopsy.
●When a concomitant operative procedure, such as laparoscopy, is deemed necessary.
Role of hysteroscopy — For patients undergoing D&C and in whom the risk for endometrial carcinoma is increased (table 1), we advise also performing a diagnostic hysteroscopy; however, hysteroscopy should not be performed instead of D&C. This approach is consistent with guidelines from the Society of Gynecologic Oncology [22]. Hysteroscopy provides direct visualization of the endometrial cavity, thereby allowing targeted biopsy or excision of lesions prior to curettage of the background endometrium [22].
Multiple studies have shown that diagnostic hysteroscopy can aid in the detection of focal lesions of the endometrial lining that may be missed by D&C alone (approximately 60 percent of curettage specimens sample less than half of the uterine cavity [23]) [24,25]. However, hysteroscopy can also miss endometrial carcinoma. In one descriptive study including 29 patients with endometrial carcinoma, the diagnosis was missed in 10 patients (34.5 percent) using hysteroscopy alone (without biopsies) [26].
Hysteroscopy with biopsies requires more skill and is more costly and invasive than most other modalities of endometrial assessment [4]. (See "Overview of hysteroscopy".)
Risk of tumor dissemination — One concern with hysteroscopy is the risk of possible cancer dissemination due to the intraperitoneal spillage of endometrial cells (some of which remain viable) through the fallopian tubes [27-39].
The clinical significance of the transport of these cells is not known, nor does it necessarily result in implantation and/or persistence of disease. While peritoneal washings are not part of the staging of endometrial carcinoma (table 3 and table 4), they were in the past, and the presence of cancer cells in the peritoneal cavity may affect prognosis (see "Endometrial carcinoma: Staging and surgical treatment", section on 'Staging system'). However, in a meta-analysis of observational studies including patients with endometrial carcinoma, patients who had or had not undergone diagnostic hysteroscopy had similar rates of positive peritoneal cytology [39]. In addition, in a subsequent retrospective study that reported on long-term follow-up (median 25 months), prestaging hysteroscopy was not associated with worse survival [40].
Transvaginal ultrasound — TVUS is an acceptable alternative to endometrial sampling in some patients, and also allows for evaluation of the adnexa and structural lesions of the endometrium (eg, polyp, leiomyoma), if present. Sonographic measurement of endometrial thickness is performed by scanning the uterus in a sagittal view. The result reported is the double layer endometrial thickness measured in an anteroposterior dimension from one basalis layer to the other, excluding any fluid within the cavity.
The use of TVUS as an alternative to endometrial sampling is supported by a meta-analysis of 35 prospective studies that included data from almost 6000 patients with postmenopausal bleeding [41]. The sensitivity of TVUS for detection of endometrial carcinoma at a thickness of 4 and 5 mm was 96 percent; the specificity was 53 and 61 percent, respectively. The authors of this analysis calculated that the probability of endometrial carcinoma (based on the average risk associated with postmenopausal bleeding) following a normal (<5 mm endometrial thickness) TVUS was 1 percent.
However, subsequent meta-analyses have reached different conclusions.
●In a meta-analysis using individual patient data from 13 studies including almost 3000 patients, the sensitivity of TVUS for detection of endometrial carcinoma at 5 mm, 4 mm, and 3 mm, was 90, 95, and 98 percent, respectively [42]. A limitation of this analysis was that many studies were excluded because individual patient data were not available.
●Another meta-analysis consisted of 57 studies with 9031 patients [43]. The four highest quality studies used an endometrial thickness threshold of ≤5 mm. Using the pooled estimates from these four studies only, a positive test result raised the probability of cancer from 14 to 31 percent, while a negative test reduced it to 2.5 percent. The authors concluded that while a negative result (≤5 mm) usually excluded endometrial neoplasia, the measurement of endometrial thickness alone could not be used to reliably exclude cancer.
●A meta-analysis of nine studies (3483 patients without endometrial carcinoma and 330 with the disease) found that when the detection rate for endometrial carcinoma was 63 percent (95% CI 58-69 percent), the false-positive rate was 10 percent; by contrast, when the detection rate increased to 96 percent (95% CI 94-98 percent), the false-positive rate increased to 50 percent [44]. The authors concluded that even at this latter threshold, 4 percent of endometrial carcinomas would be missed; thus, further invasive diagnostic testing was indicated in all symptomatic patients with a "thin" endometrial thickness.
For patients in whom TVUS visualization of the endometrium is limited (eg, large, fibroid uterus), additional methods of evaluation may be needed.
Other
●Saline infusion sonography – Saline infusion sonography (SIS; also called sonohysterography) is generally not used for the primary evaluation of the endometrium; rather, SIS may be used as subsequent evaluation to help detect small lesions (eg, polyps, small submucous fibroids) that may be missed on TVUS or by blind endometrial sampling. One of the main disadvantages of SIS is that no tissue is obtained for histologic diagnosis. (See "Saline infusion sonohysterography", section on 'Indications'.)
The combined technique of endometrial biopsy and SIS helps diagnose the cause of abnormal uterine bleeding (AUB) in most patients without the need for more invasive procedures such as hysteroscopy with D&C [45,46]. In a prospective study including 113 patients ages 25 to 69 years with AUB evaluated with endometrial biopsy and SIS and then subsequently with hysteroscopy/curettage or hysterectomy, the sensitivity, specificity, and positive and negative predictive values of biopsy plus SIS were 97, 70, 82, and 94 percent, respectively [45]. False-positive results were due to intrauterine debris, blood clot, thickened endometrial folds, and misidentified endometrial fragments. A subsequent meta-analysis showed similar results [47]. The combined technique is most useful in patients with a symmetrically thickened endometrium. If SIS shows a focal lesion, hysteroscopy with targeted biopsies should be considered. (See 'Role of hysteroscopy' above.)
As with hysteroscopy, dissemination of cancer is a theoretical concern, but the clinical significance is not known. This is discussed in detail separately. (See 'Risk of tumor dissemination' above and "Saline infusion sonohysterography", section on 'Dissemination of carcinoma'.)
●Computed tomography (CT) or magnetic resonance imaging (MRI) – CT and MRI are also not routinely used for the primary evaluation of the endometrium. Normal endometrial thickness on CT for a postmenopausal patient is not well established and abnormalities of the endometrium noted on CT should be further evaluated with TVUS (see 'Transvaginal ultrasound' above). By contrast, the normal postmenopausal endometrium on MRI should be hyperintense on T2-weighted images and <5 mm thick [48], with the exception of patients on hormonal therapy. Abnormalities of the endometrium on MRI should be further evaluated with endometrial sampling. (See 'Endometrial sampling procedures' above.).
●Investigational methods – Methylated DNA, obtained from a tampon, vaginal fluid, or cervical sample, has been proposed as an initial method to detect endometrial cancers in patients with abnormal uterine or postmenopausal bleeding [49,50]. This method of evaluation is considered investigational. Other investigational methods are mentioned separately. (See "Endometrial sampling procedures", section on 'Investigational approaches'.)
SPECIAL CONSIDERATIONS
Incidental finding on TVUS for another indication
●Postmenopausal patients – In a postmenopausal patient without bleeding in whom an ultrasound examination was performed for another indication other than evaluation of the endometrium, the finding of a thickened endometrium, a focal endometrial mass, or fluid within the endometrial cavity may require further evaluation. While most patients with endometrial carcinoma present with abnormal uterine bleeding (AUB), approximately 5 to 20 percent patients without bleeding will be diagnosed with cancer [51].
•Endometrial thickness >4 mm – In our practice, we sample the endometrium for postmenopausal patients without uterine bleeding in whom the endometrial thickness is >4 mm. However, expert opinion varies, and higher thresholds have been described. Many patients with an endometrial thickness of >4 mm will have benign pathology (eg, endometrial polyp, submucosal fibroid) and other findings on transvaginal ultrasound (TVUS) may provide reassurance. For example, a single feeding vessel (which may arborize) may be visualized with Doppler, which is reassuring for an endometrial polyp, or the endometrium may "wrap" around a submucosal fibroid, resulting in a thickened appearance.
Endometrial thickness is less predictive of endometrial neoplasia in asymptomatic patients (those without postmenopausal uterine bleeding [including red, pink, or brown spotting or staining]). In a meta-analysis of 32 studies including over 11,000 asymptomatic postmenopausal patients who were not using hormone therapy, mean endometrial thickness was 2.9 mm [52]. The sensitivity and specificity for detecting endometrial carcinoma at an endometrial thickness of ≥5 mm was 83 and 72 percent, respectively; this is lower than in patients with bleeding. There were few data for an endometrial thickness >5 mm. A well-designed decision analysis calculated that postmenopausal patients without uterine bleeding who had an endometrial thickness >11 mm had an endometrial carcinoma risk of 6.7 percent; this risk is similar to postmenopausal patients with bleeding and an endometrial thickness >5 mm [51]. However, lower thresholds have been described. In a meta-analysis of 18 studies evaluating the diagnostic accuracy of TVUS in over 10,300 postmenopausal patients without bleeding, a threshold of 3 to 5.9 mm had the highest sensitivity (0.81, 95% CI, 0.49-0.85; eight studies) for detecting atypical endometrial hyperplasia and endometrial carcinoma, while a threshold of ≥14 mm had the highest specificity (0.86, 95% CI 0.71-0.94; five studies) [53]. The overall incidence of endometrial pathology was low for both groups. While less pathology was missed in the lower threshold group, more patients had false-positive results which may lead to unnecessary procedures (ie, endometrial sampling), increased cost, and unfavorable patient experiences.
•Endometrial fluid – We also sample selected postmenopausal patients without uterine bleeding if endometrial fluid is visualized on ultrasound. In patients with cervical stenosis, a patient might be bleeding into the endometrial cavity, but the blood and/or tissue is unable to pass through the cervical os. Such patients are at increased risk of endometrial carcinoma [54-58]. The surrounding endometrium should be assessed for focal lesions, and the two layers of endometrium combined into a single endometrial thickness. (See 'Transvaginal ultrasound' above.)
In our practice, we typically perform endometrial sampling in postmenopausal patients with endometrial fluid and an endometrial thickness >4 mm. While a "sliver" of fluid within the endometrial cavity is a normal finding [54,55,59], more than this is concerning for bleeding (with the blood not able to pass through a stenotic cervix), especially in a patient using an anticoagulant. By contrast, a thin (≤4 mm) atrophic endometrium (without any focal lesions) surrounding the endometrial fluid is a reassuring finding.
Postmenopausal patients without bleeding on hormone therapy are managed similarly to postmenopausal patients with bleeding on hormone therapy and are described in detail above. (See 'Patients on hormone therapy' above.)
●Premenopausal patients – In asymptomatic premenopausal patients without AUB, endometrial thickness alone is not an indication for biopsy. Endometrial evaluation should be based on a combination of factors (table 5), including cervical cytology results showing glandular abnormalities or endometrial cells, a chronic history of estrogen excess or anovulation (polycystic ovary syndrome), focal endometrial lesions, as well as endometrial thickness.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Uterine cancer".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)" and "Patient education: Abnormal uterine bleeding (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Overview – Evaluation of the endometrium (with endometrial sampling and/or transvaginal ultrasound [TVUS]) is the key component in the diagnostic evaluation of patients suspected of endometrial carcinoma or a premalignant endometrial lesion. (See 'Introduction' above.)
●Postmenopausal patients with bleeding and patients (pre- and postmenopausal) on hormone therapy with abnormal bleeding (see 'Postmenopausal patients with bleeding' above and 'Patients on hormone therapy' above)
•For such patients evaluated in a gynecologic practice, endometrial biopsy is often performed as the initial diagnostic test due to its high sensitivity, low complication rate, and low cost.
Additional endometrial assessment (with TVUS, repeat endometrial biopsy, or dilation and curettage [D&C] with hysteroscopy) is performed in patients with persistent bleeding despite a "benign" endometrial biopsy and in patients with a nondiagnostic endometrial biopsy but in whom a high suspicion of cancer remains.
•For such patients evaluated in a practice where office endometrial biopsy is not performed, TVUS examination is a reasonable initial test. TVUS can also be used as an initial test for patients in whom office biopsy cannot be performed, structural uterine pathology (eg, polyp, leiomyoma) is suspected, or evaluation of the adnexa is needed.
Further evaluation with endometrial sampling is required if the endometrial lining is >4 mm (postmenopausal patients), the endometrium is not adequately visualized or shows diffuse or focal heterogeneity, or in patients with persistent bleeding.
●Premenopausal patients with abnormal bleeding – Premenopausal patients with abnormal bleeding are evaluated with endometrial sampling or TVUS; the choice of method is determined by the bleeding pattern (eg, heavy menstrual bleeding, intermenstrual bleeding, irregular bleeding) and risk factors for endometrial carcinoma (table 1). (See 'Premenopausal patients with abnormal bleeding' above.)
●Methods of evaluation
•Endometrial sampling has generally replaced the need for diagnostic D&C in the operating room; there is an excellent correlation between the histopathology of endometrial specimens taken by these methods [16-18]. However, since less than half of the endometrium is sampled, malignancy can be missed. (See 'Endometrial biopsy' above.)
•For patients undergoing D&C and in whom the risk for endometrial carcinoma is increased (table 1), we advise also performing a diagnostic hysteroscopy to aid in the detection of focal lesions of the endometrial lining that may be missed by D&C alone. (See 'Role of hysteroscopy' above.)
•TVUS also allows for evaluation of the adnexa and structural lesions of the endometrium (eg, polyp, leiomyoma), if present. However, the diagnostic efficacy of TVUS may be lower in Black patients compared with White patients; greater prevalence of fibroids in Black patients may contribute to this disparity. (See 'Transvaginal ultrasound' above and 'Postmenopausal patients with bleeding' above.)
•Other methods, such as saline infusion sonography (SIS; also called sonohysterography), computed tomography (CT), and magnetic resonance imaging (MRI) are generally not used for the primary evaluation of the endometrium. (See 'Other' above.)
●Patients without bleeding – In postmenopausal patients without bleeding in whom an ultrasound examination was performed for another indication other than evaluation of the endometrium, the finding of a thickened endometrium or fluid within the endometrial cavity may require further evaluation. In premenopausal patients without abnormal bleeding, endometrial thickness alone is not an indication for biopsy. (See 'Incidental finding on TVUS for another indication' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Deborah Levine, MD, who contributed to earlier versions of this topic review.
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