Policy Statement Diagnosis of Endometrial Cancer in the Assessment of Endometrial Bleeding

CLINICAL

PRACTICE

GUIDELINES

POLICY STATEMENT* DIAGNOSIS OF ENDOMETRIAL CANCER IN THE ASSESSMENT OF ENDOMETRIAL BLEEDING This document has been reviewed and approved by the SOGC/GOC/SCC Policy and Practice Guidelines Committee and approved by the Council of the Society of Obstetricians and Gynaecologists of Canada as a Policy Statement in March 1996.

SOGC/GOC/SCC POLICY AND PRACTICE GUIDELINES COMMITTEE MEMBERS:

methods, while transvaginal ultrasound will yield an indirect assessment.! The hysteroscope can give direct visual assessment of the endometrial cavity.2

Chair Robert J. Lotocki, MD, FRCSC Members: Valerie Anne Capstick, MD, FRCSC Mark Carey, MD, FRCSC A. Dennis DePetrillo, MD, FRCSC Josee Dubuc-Lissoir, MD, FRCSC Robert Grimshaw, MD, FRCSC Cecil Wright, MD, FRCSC

ENDOMETRIAL SUCTION ASPIRATION

(Winnipeg, MB)

Historically, dilatation and fractional curettage has been the definitive procedure to exclude endometrial carcinoma. 1 A variety of out-patient procedures has been suggested for several decades as alternatives to dilatation and fractional curettage. Some of these have yielded histologic samples and other cytologic specimens. Unfortunately, cytopathologists were often unable to interpret cytologic samples and the final correlation was poor. Currently, direct histologic sampling of the endometrium can be obtained in the office with a variety of flexible aspiration devices. These are tolerated well by the patient and yield accurate results. The presence of cervical stenosis may prevent successful endometrial sampling but is relatively infrequent. 4

(Edmonton, AB) (London, ON) (Toronto, ON) (Montreal, QC) (Halifax, NS) (London, ON)

INTRODUCTION

There are three methods of assessing the endometrium: dilatation and curettage, endometrial suction biopsy, and transvaginal ultrasound. A blind endometrial assessment can be obtained by the first two

* Policy Statements: this policy reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.

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AUGUST 1996

, , , The accuracy of endometrial sampling is in the order of 90 percent or greater. 5 In the post-menopausal women with abnormal bleeding, insufficient tissue obtained for diagnosis is common. However, this qualifies as a successful procedure. If bleeding persists, individuals can be evaluated further with such imaging techniques as transvaginal ultrasound or direct visualization using the hysteroscope.

FIGURE 1 ALGORITHM FOR THE MANAGEMENT OF ABNORMAL VAGINAL BLEEDING ABNORMAL VAGINAL BLEEDING

y ASPIRATION SUCTION BIOPSY

•

TRANSVAGINAL ULTRASOUND

POSITIVE

Transvaginal ultrasound has a good correlation with pathologic endometrial findings. Using an endometrial thickness from myometrium to myometrium of five mm (considered the upper limit of normal), sensitivity is 91 percent and specificity is 96 percent. 6 There is a high rate of false positive transvaginal ultrasounds in patients treated with tamoxifen because of the high frequency of endometrial thickening.

.... NEGATW£ NEGATW£ NO FURTHER SYMPTOMS CONTINUED SYMPTOMS

/ APPROPRIA le MANAGEMENT

FOLLOW

TRANSVAGINAL ULTRASOUND

VS.

HYSTEROSCOPV AND BIOPSY ~

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NEGATIVE

SUSPICIOUS

FRACTIONAL D&C

Produced by the SOGe, 1996.

HYSTEROSCOPY REFERENCES

Several studies have demonstrated the value of hysteroscopy and directed biopsies in the diagnosis of anatomical lesions within the endometrial cavity in women with post-menopausal bleeding.

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ASSESSMENT OF THE PATIENT WITH THE DIAGNOSIS OF ENDOMETRIAL CARCINOMA

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Most patients (75%) with endometrial carcinoma, will present with post-menopausal bleeding. Our threshold for defining post-menopausal bleeding has decreased. Most patients with post-menopausal bleeding have atrophic genital tract features responsible for their symptoms. Endometrial suction aspiration should be the initial investigation in the assessment of the patient with abnormal vaginal bleeding. As an office procedure it is economical and yields accurate results. Hence, endometrial suction aspiration can replace dilatation and fractional curettage. If the patient continues to have symptoms which cause the physician to suspect endometrial cancer, then further assessment is imperative. Two methods are available. On the one hand, transvaginal ultrasound can rule out, with reliability, significant disease if the thickness of the endometrium is less than five mm. However, if an abnormality is suggested with ultrasound, a tissue diagnosis is necessary, and hysteroscopy may be indicated (Figure 1). J SOGe 1996;18:814-15

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Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding . Am J Obstet Gynecol1990; 16:119-24. Siegler AM, Lindermann HJ. Hysteroscopy, principles and practice, Philadelphia, J.B. Lippincott Company, 1984. Berek JS, Hacker NF. Practical Gynecologic Oncology, Second Edition, Baltimore, Williams and Wilkins, 1994. Creasman WT, Morrow CP, Bundy BN et al. Surgical pathologic spread patterns of endometrial cancer. 1987; 60:2035-41. Hofmeister FJ. Endometrial biopsy: another look. Am J ObstetGynecol1974; 118:773-7. Bourne TH, Campbell S, Steer CV et al. Detection of endometrial cancer by transvaginal ultrasonography with color flow imaging and blood flow analysis: a preliminary report. Gynecol On col 1991; 40:253-9.

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