Ultrasound, hysteroscopy and endometrial biopsy in the investigation of endometrial cancer

Abstract

Dilation and curettage without hysteroscopy should no longer be used as first line investigation for endometrial carcinoma. Outpatient endometrial sampling and uterine cytology are not sensitive enough to be used alone to exclude endometrial carcinoma but may be a useful tool in combination with ultrasound or if a positive result is obtained. Outpatient hysteroscopy is more cost-effective and equally acceptable to patients as inpatient investigation. The quality of histopathological samples obtained from the endometrium is as good as that obtained from dilation and curettage. However, up to 30% of patients will need to undergo a second surgical procedure. Both transvaginal ultrasound (TVS) and outpatient hysteroscopy have a high degree of sensitivity for endometrial carcinoma although about 50% of postmenopausal women assessed by TVS will also require hysteroscopy. TVS is less invasive and allows assessment of the adnexae at the same time. The specificity of TVS is reduced in women who are pre-menopausal or taking Tamoxifen or HRT. In these cases it may be more cost-effective to use hysteroscopy and endometrial biopsy as the first line investigation. TVS will miss a higher proportion of cancers in women over the age of 70. Any woman with recurrent episodes of postmenopausal bleeding should be investigated with both TVS and hysteroscopy to exclude endometrial and ovarian disease.