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PRACTICE: A Sahdev Imaging the endometrium in postmenopausal bleeding BMJ 2007; 334: 635-636 [Full text]

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Don't be ridiculous

James Currie   (23 March 2007)

Authors Response

A Sahdev   (26 March 2007)

The endometrial thickness on TVS

Suresh Pai   (26 March 2007)

Imaging the endometrium in postmenopausal bleeding

Patrick Neven, Patrick Neven, Frederic Amant, Dirk Timmerman, Thierry Van den Bosch and Ignace Vergote   (14 May 2007)

Don't be ridiculous 23 March 2007
James Currie, Consultant Gyneacologist Calgary Health Region Chronic Pain Centre, 2210-2nd Street SW, Calgary AB, T2S 3C3 Send response to journal: Re: Don't be ridiculous	Be honest. If you were a woman with an epidemiological background and history as presented, would you be satisfied with any radiological diagnosis or non- diagnosis. An endometrial biopsy is minimally invasive with a very low rate of discomfort or complication (zero complication in my experience, and I don't claim a special talent). Forgive me, I go back to 'Parachute' evidence. I don't need positive or negative predictive values in simple matters. And I know, my anecdotes are not enough, but what would you say to a 35 year old parous patient with a normal endometrial echo, who did turn out to have a carcinoma. Let's get some common sense! BMJ Sept 2006; 333:701-703 Competing interests: None declared
Authors Response 26 March 2007
A Sahdev, Consultant Radiologist Barts and the London NHS Trust Send response to journal: Re: Authors Response	I would like to clarify the purpose of the article was not to propose imaging as the sole diagnostic tool in the diagnosis of endometrial cancer. It is a guide to select the appropriate imaging in postmenopausal bleeding. Competing interests: None declared
The endometrial thickness on TVS 26 March 2007
Suresh Pai, Assocate specialist in Obstetrics and Gynecology Nobles Hospital, Isle of Man IM44RJ Send response to journal: Re: The endometrial thickness on TVS	The exact cut off threshold of endometrial thickness on transvaginal scan for biopsy might depend on the specific group of women presenting with postmenopausal bleeding. Meta analysis does suggest a cut off of 3 mm in women with PMB who never had any HRT, not had HRT in the preceding one year or those who are on combined HRT. In these women the risk of endometrial cancer may be significantly more. A cutoff of 5 mm is recommended for women on sequential HRT having unscheduled bleeding. Ref: SIGN publication No.61, Sept 2002 Competing interests: None declared
Imaging the endometrium in postmenopausal bleeding 14 May 2007
Patrick Neven, MD PhD Gyn Oncol University Hospitals Leuven, B-3000 Leuven, Belgium, Patrick Neven, Frederic Amant, Dirk Timmerman, Thierry Van den Bosch and Ignace Vergote Send response to journal: Re: Imaging the endometrium in postmenopausal bleeding	Dear Editor, Sahdev reports on imaging of the endometrium in a postmenopausal patient with vaginal bleeding using 1999 guidelines.1 This 72 year old lady was for 3 years on tamoxifen for breast cancer, was obese, and had diabetes and hypertension. We present some critical remarks regarding this case in particular and the proposed management of postmenopausal vaginal bleeding in general. 1. Obesity, diabetes, age, breast cancer and tamoxifen are independent risk factors for endometrial cancer in women with postmenopausal vaginal bleeding, whereas hypertension is not.2 2. When the likelihood of endometrial cancer is over 15% - as might be in this case - it is cost-effective to start with an endometrial biopsy, but in all other cases, we agree the first step should be a transvaginal ultrasound imaging in addition to the uterus also ovaries and the pouch of Douglas.3 3. We agree with the authors that endometrial polyps may manifest as focal areas of endometrial thickening and that the stalk of the polyp might be visible if sufficient fluid is present in the endometrial cavity. However, a more efficient way to visualise focal endometrial lesions is by using colour Doppler imaging (‘pedicle artery sign’).4 4. We disagree with the proposal to perform a hysteroscopy prior to an endometrial biopsy in this patient with abnormal endometrial ultrasound imaging. Hysteroscopy should only be performed if pathologic examination of the endometrial biopsy excludes endometrial cancer because hysteroscopy and saline infusion sonography (SIS) result in a higher incidence of malignant cells in the peritoneal fluid.2 If a hysteroscopy is performed, one should always aim to use the lowest possible intrauterine pressure. 5. Some prudence is advised when a 5 mm cut off for endometrial thickness (ET) is used as the only discriminator for endometrial pathology in case of postmenopausal vaginal bleeding. Apart from ET, the regularity of the endometrial lining is also important to exclude malignancy. Some endometrial cancers like the serous ones have a tendency for transperitoneal spread even in the absence of myometrial invasion. Following comprehensive surgical staging, 37% of such cases without myometrial invasion appeared as stage III or IV disease.5 Therefore, a thin and regular endometrial lining is more likely to be benign. If bleeding continues despite normal ultrasound findings or a Pipelle biopsy, additional imaging with SIS or hysteroscopy remain the standard of care.2 6. Neither MRI nor ultrasound are diagnostic tests for endometrial cancer. The wording ‘MRI demonstrated a FIGO 1a stage carcinoma’ should have been ‘MRI suggested a FIGO 1a stage carcinoma’. Histopathology of endometrium and myometrium remains the golden standard especially in long term tamoxifen users where the false positive rate of imaging is extremely high and where thickening of tamoxifen-exposed endometrium is unlikely to be related to endometrial hyperplasia or cancer, but most commonly represents a cystic atrophic endometrium with supepithelial formation of cysts.6 In addition, the use of MRI in staging endometrial cancer is costly and should be limited to the rare cases where ultrasound is unsatisfactory for preoperative estimation of myometrial invasion..2 application of MRI in a relatively frequent disease will unnecessary burden the health budget. 7. The rationale for the pelvic lymphadenectomy is unclear in this case as it is a low-risk endometrial cancer.2 Neven P, Amant F, Timmerman D, Van den Bosch T, Vergote I References 1.Sahdev A. Imaging the endometrium in postmenopausal bleeding. BMJ 2007; 334: 635-6. 2.Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. Lancet 2005; 366: 491-505. 3.Clark TJ, Barton PM, Coomarasamy A, Gupta JK, Khan KS. Investigating postmenopausal bleeding for endometrial cancer: cost- effectiveness of initial diagnostic strategies. BJOG 2006; 113: 502-10. 4.Timmerman D, Verguts J, Konstantinovic ML et al. The pedicle artery sign based on sonography with color Doppler imaging can replace second-stage tests in women with abnormal vaginal bleeding. Ultrasound Obstet Gynecol 2003;22:166-71. 5.Slomovitz BM, Burke TW, Eifel PJ et al. Uterine papillary serous carcinoma (UPSC): a single institution review of 129 cases. Gynecol Oncol 2003; 91: 463-9. 6.Timmerman D, Vergote I. Tamoxifen-induced endometrial polyp. N Engl J Med 1996; 335: 1650. Competing interests: None declared