RCOG World Congress 2023

Introduction

v Endometrial cancer (EC) is the most common gynaecological malignancy in developed countries.

v Transvaginal ultrasound (TVUS) represents an accurate and non-invasive technique for screening

v No consensus on the cut-off value for normal ET in post-menopausal asymptomatic women.

v Up to 15% of EC occurs in women without vaginal bleeding.

Objectives

Review Hysteroscopic outcomes of asymptomatic postmenopausal women with incidental finding of thickened endometrium for

v Cost-benefit analysis

v Assessment of pathological outcomes

v To establish endometrial thickness cut-off for our cohort based on the evidence available in studies.

Method

v Study Design:- Retrospective Review

v Data were collected retrospectively for Postmenopausal women referred to the

PMB clinic from 1st Jan– 30th Jun 22 with incidental findings of thickened

endometrium and PMB.

Results

60 cases were reviewed with a median age of 65.5 years & a median BMI of 30.5.

22 (37%) were hypertensive. None had Diabetes & One patient was on Tamoxifen.

Endometrial thickness ranged between 2mm - 40 mm . 22 patients had endometrial thickness >10mm & 10 women had fluid in the cavity with ET < 4mm

The most common indication for ultrasound scan was abdominal pain (30 patients)

53 of 60 patients had benign histopathology out of which 5 patients had endometrial hyperplasia without atypia. 7 patients (11.6%) had endometrial Cancer (4 x G1 endometrial adenocarcinoma, 2 x mixed serous & endometroid carcinoma, 1 x G3 endometrial Adenocarcinoma)

All women with Endometrial Cancer were >60 years of age, and BMI > 35. More than 50% had chronic HTN, all had ET >9mm.

Impact on resources

v Single out-patient procedure - 58%
v Out-patient hysteroscopy Twice - 5%
v Out-patient Hysteroscopy then GA hysteroscopy - 30% v Failed procedure requiring GA hysteroscopy – 6%
v Multiple radiological investigations (CT & USS) - 25%

Literature Review

v́ The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines state, ET >4–5 mm No tissue biopsy is needed & ET >11 mm or other positive ultrasonographic findings (such as increased vascularity, inhomogeneous endometrium, or particulate fluid), she should be further investigated

v ́ The ACOG has stated: ET >4 mm, no evidence to recommend other investigation, although an individualized assessment based on patient characteristics and risk factors is appropriate.

v The risk of EC in women with ET ≥11 mm was almost threefold that of those with ET 5–10 mm.

v A significant risk of cancer only for values of ET starting from 11 mm, with 100% sensitivity and 80% specificity for EC detection.

Conclusions & Recommendation

v Watchful waiting is reasonable for the majority of patients. Refer if bleeding occurs.

v Effective triage considering pre-existing risk factors and additional scan findings

v Adopting endometrial cut-off of 10mm for this cohort. This has been incorporated into locally developed outpatient hysteroscopy guidelines for OUH.

v It is anticipated that the adoption of these recommendations would spare women unnecessary anxiety, pain, and possible procedural complication. There are also cost savings to the health system by eliminating unnecessary interventions

RCOG World Congress 2023

OVER INVESTIGATING THE POSTMENOPAUSAL PATIENT (I)

Poster Presenter

Authors

Affiliations

Part of Topic