Abstract
BackgroundEven in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology.MethodsRetrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results.ResultsThe charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution.ConclusionsThe probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.
Highlights
Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment
The purpose of this study was to determine the probability of finding significant endometrial pathology on aspiration of women with different risk factors who present with what their clinicians categorize as “abnormal bleeding”
In 14.7 % cases, a history of diabetes was recorded; 5.3 % had thyroid dysfunction; 1.9 % provided a history of breast cancer and 1.1 % volunteered a history of prior endometrial hyperplasia
Summary
Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology. ACOG has recommended endometrial sampling for women as young as age 19–39 years who do not respond to medical therapy or who have prolonged periods of unopposed estrogen stimulation. The Canadian Society of Obstetricians and Gynecologists recommends endometrial sampling in women presenting with abnormal uterine bleeding and age over 40 or weighing more than 90 kg [28]. In all of these cases, the definitions of “irregular”, “abnormal” and “heavy” bleeding are not standardized. There are multiple well established risk factors in the development of endometrial cancer including diabetes, unopposed estrogen stimulation and nulliparity [29], rarely are risk factors other than age and weight considered in the guidelines
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