No. 249-Asymptomatic Endometrial Thickening



      To formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding.


      Ensure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately.


      Published literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., “asymptomatic endometrial thickness,” “endometrial cancer,” “postmenopausal bleeding,” “transvaginal ultrasonography,” “endometrial biopsy” and “endometrial polyp”). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.


      The level of evidence was determined according to the criteria established by the Canadian Task Force on Preventive Health Care (Table 1). Recommendations are ranked according to this method.

      Benefits, harms, and costs

      It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions.


      • 1.
        Transvaginal ultrasound should not be used as screening for endometrial cancer (II-1E).
      • 2.
        Endometrial sampling in a postmenopausal woman without bleeding should not be routinely performed (II-1E).
      • 3.
        Indications for tissue sampling of the endometrium in bleeding postmenopausal women with an endometrial thickness of greater than 4 to 5 mm should not be extrapolated to asymptomatic women (II-2E).
      • 4.
        A woman who has endometrial thickening and other positive findings on ultrasound, such as increased vascularity, inhomogeneity of endometrium, particulate fluid, or thickened endometrium over 11 mm, should be referred to a gynaecologist for further investigations (II-1A).
      • 5.
        Decisions about further investigations should be made on a case-by-case basis in asymptomatic women with increased endometrial thickening and risk factors for endometrial cancer such as obesity, hypertension, and late menopause (II-1B).
      • 6.
        In asymptomatic women on tamoxifen, a routine ultrasound for endometrial thickening should not be performed (II-2E).
      • 7.
        Not all postmenopausal women who have asymptomatic endometrial polyps require surgery. Women found to have asymptomatic polyps on ultrasound should be triaged for intervention according to size of the polyp, age, and other risk factors (II-1A).

      Key Words


      HT (hormone therapy), TVUS (transvaginal ultrasound)
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        • Gambacciani M.
        • Monteleone P.
        • Ciaponi M.
        • et al.
        Clinical usefulness of endometrial screening by ultrasound in asymptomatic postmenopausal women.
        Maturitas. 2004; 48: 4221-4224
        • Koss L.
        • Schreiber K.
        • Oberlander S.
        • et al.
        Screening of asymptomatic women for endometrial cancer.
        CA Cancer J Clin. 1981; 31: 300-317
        • Vuento M.H.
        • Pirhonen J.P.
        • Mäkinen J.I.
        • et al.
        Screening for endometrial cancer in asymptomatic postmenopausal women with conventional and colour Doppler sonography.
        Br J Obstet Gynaecol. 1999; 106: 14-20
        • Smith-Bindman R.
        • Weiss E.
        • Feldstein V.
        How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding.
        Ultrasound Obstet Gynecol. 2004; 24: 558-565
        • Levine D.
        • Gosink B.B.
        • Johnson L.A.
        Change in endometrial thickness In postmenopausal women undergoing hormone replacement therapy.
        Radiology. 1995; 197: 603-608
        • Shipley 3rd, C.F.
        • Simmons C.L.
        • Nelson G.H.
        Comparison of transvaginal sonography with endometrial biopsy in asymptomatic postmenopausal women.
        J Ultrasound Med. 1994; 13: 99-104
        • Lin M.C.
        • Gosink B.B.
        • Wolf S.I.
        • et al.
        Endometrial thickness after menopause: effect of hormone replacement.
        Radiology. 1991; 180: 427-432
        • Aleem F.
        • Predanic M.
        • Calame R.
        • et al.
        Transvaginal color and pulsed Doppler sonography of the endometrium: a possible role in reducing the number of dilatation and curettage procedures.
        J Ultrasound Med. 1995; 14: 139-145
        • Varner R.E.
        • Sparks J.M.
        • Cameron C.D.
        • et al.
        Transvaginal sonography of the endometrium in postmenopausal women.
        Obstet Gynecol. 1991; 78: 195-199
        • Hänggi W.
        • Bersinger N.
        • Altermatt H.J.
        • et al.
        Comparison of transvaginal ultrasonography and endometrial biopsy in surveillance in postmenopausal HRT users.
        Maturitas. 1997; 27: 133-143
        • Tsuda H.
        • Kawabata M.
        • Kawabata K.
        • et al.
        Improvement of diagnostic accuracy of transvaginal ultrasound for identification of endometrial malignancies by using cutoff level of endometrial thickness based on length of time since menopause.
        Gynecol Oncol. 1997; 64: 35-37
        • Archer D.
        • McIntyre-Seltman K.
        • Wilborn W.
        • et al.
        Endometrial morphology in asymptomatic postmenopausal women.
        Am J Obstet Gynecol. 1991; 165: 317-320
        • Gull B.
        • Karlsson B.
        • Milsom I.
        • et al.
        Transvaginal sonography of the endometrium in a representative sample of postmenopausal women.
        Ultrasound Obstet Gynecol. 1996; 7: 322-327
        • Koss L.G.
        • Schreiber K.
        • Oberlander S.G.
        • et al.
        Detection of endometrial carcinoma and hyperplasia in asymptomatic women.
        Obstet Gynecol. 1984; 64: 1-11
        • American Cancer Society
        Cancer Facts & Figures 2009.
        (Atlanta, GA : American Cancer Society)2009
        • Canadian Cancer Society/National Cancer Institute of Canada
        Canadian Cancer Statistics 2008.
        (Toronto : Canadian Cancer Society)2008
        • Goldstein R.B.
        • Bree R.L.
        • Benson C.B.
        • et al.
        Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-sponsored consensus conference statement.
        J Ultrasound Med. 2001; 20: 1025-1036
        • American College of Obstetricians and Gyneoclogists
        The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. ACOG Committee Opinion No. 426.
        Obstet Gynecol. 2009; 113: 462-464
        • Goldstein S.R.
        Modern evaluation of the endometrium.
        Obstet Gynecol. 2010; 116: 168-176
        • Jemal A.
        • Siegel R.
        • Ward E.
        • et al.
        Cancer Statistics.
        CA Cancer J Clin. 2008; 58: 71-96
        • Gallup D.G.
        • Stock R.J.
        Adenocarcinoma of the endometrium in women 40 years of age or younger.
        Obstet Gynecol. 1984; 64: 417-420
        • American College of Obstetricians and Gynecologists
        ACOG practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer.
        Obstet Gynecol. 2005; 106: 413-417
        • Linkov F.
        • Edwards R.
        • Balk J.
        • et al.
        Endometrial hyperplasia, endometrial cancer and prevention: gaps in existing research of modifiable risk factors.
        Eur J Cancer. 2008; 44: 1632-1644
        • American College of Obstetricians and Gynecologists Committee on Gynecologic Practice
        ACOG Committee Opinion No. 336: tamoxifen and uterine cancer.
        Obstet Gynecol. 2006; 107: 1475-1478
        • Meyer L.A.
        • Broaddus R.R.
        • Lu K.H.
        Endometrial cancer and Lynch syndrome: clinical and pathologic considerations.
        Cancer Control. 2009; 16: 14-22
        • Schmeler K.M.
        • Lu K.H.
        Gynecologic cancers associated with Lynch syndrome/HNPCC.
        Clin Trans Oncol. 2008; 10: 313-317
        • Allard J.E.
        • Maxwell G.L.
        Race disparities between black and white women in the incidence, treatment, and prognosis of endometrial cancer.
        Cancer Control. 2009; 16: 53-56
        • Karlsson B.
        • Granberg S.
        • Wikland M.
        • et al.
        Endovaginal scanning of the endometrium compared to cytology and histology in women with postmenopausal bleeding.
        Gynecol Oncol. 1993; 50: 173-178
        • Karlsson B.
        • Granberg S.
        • Wikland M.
        • et al.
        Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding—a Nordic multicenter study.
        Am J Obstet Gynecol. 1995; 172: 1488-1494
        • Smith-Bindman R.
        • Kerlikowske K.
        • Feldstein V.
        • et al.
        Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities.
        JAMA. 1998; 280: 1510-1517
        • Korhonen M.O.
        • Symons J.P.
        • Hyde B.M.
        • et al.
        Histologic classification and pathologic findings for endometrial biopsy specimens obtained from 2964 perimenopausal and postmenopausal women undergoing screening for continuous hormones as replacement therapy (CHART 2 Study).
        Am J Obstet Gynecol. 1997; 176: 377-380
        • Horwitz R.I.
        • Horwitz S.M.
        • Feinstein R.
        • et al.
        Necropsy diagnosis of endometrial cancer and detection-bias in case/control studies.
        Lancet. 1981; 2: 66-68
        • Alcazar J.L.
        • Galvan R.
        Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium.
        Am J Obstet Gynecol. 2009; 200 (e1–6. Epub; 30 octobre 2008): 44
        • Opolskiene G.
        • Sladkevicius P.
        • Valentin L.
        Ultrasound assessment of endometrial morphology and vascularity to predict endometrial malignancy in women with postmenopausal bleeding and sonographic endometrial thickness > 4.5 mm.
        Ultrasound Obstet Gynecol. 2007; 30: 332-340
        • Ciatto S.
        • Cecchini S.
        • Bonardi R.
        • et al.
        A feasibility study of screening for endometrial carcinoma in postmenopausal women by ultrasonography.
        Tumori. 1995; 81: 334-337
        • Fleischer A.C.
        • Wheeler J.E.
        • Lindsay I.
        • et al.
        An assessment of the value of ultrasonographic screening for endometrial disease in postmenopausal women without symptoms.
        Am J Obstet Gynecol. 2001; 184: 70-75
        • Smith R.A.
        • Cokkinides V.
        • Brawley O.W.
        Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues, 2008.
        CA Cancer J Clin. 2008; 58: 161-179
        • Gerber B.
        • Krause A.
        • Mueller H.
        • et al.
        Ultrasonographic detection of asymptomatic endometrial cancer in postmenopausal patients offers no prognostic advantage over symptomatic disease discovered by uterine bleeding.
        Eur J Cancer. 2001; 37: 64-71
        • Tsuda H.
        • Nakamura H.
        • Inoue T.
        • et al.
        Transvaginal ultrasonography of the endometrium in postmenopausal Japanese women.
        Gynecol Obstet Invest. 2005; 60: 218-223
        • Maatela J.
        • Aromaa A.
        • Salmi T.
        • et al.
        The risk of endometrial cancer in diabetic and hypertensive patients: a nationwide record-linkage study in Finland.
        Ann Chir Gynaecol Suppl. 1994; 208: 20-24
        • Andolf E.
        • Dahlander K.
        • Aspenberg P.
        Ultrasound thickness of the endometrium correlated to body weight in asymptomatic postmenopausal women.
        Obstet Gynecol. 1993; 82: 936-940
        • Anderson G.L.
        • Judd H.L.
        • Kaunitz A.M.
        • et al.
        Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women's Health Initiative Randomized Trial.
        JAMA. 2003; 290: 1739-1748
        • Martinez Rubio M.
        • Alcazar J.
        Ultrasonographic and pathological endometrial findings in asymptomatic postmenopausal women taking antihypertensive drugs.
        Maturitas. 2003; 46: 27-32
        • Sit A.S.
        • Modugno F.
        • Hill L.M.
        • et al.
        Transvaginal ultrasound measurement of endometrial thickness as a biomarker for estrogen exposure.
        Cancer Epidemiol Biomarkers Prev. 2004; 13: 1459-1465
        • Langer R.D.
        • Pierce J.J.
        • O'Hanlan K.A.
        • et al.
        Transvaginal ultrasonography compared with endometrial biopsy for the detection of endometrial disease. Postmenopausal Estrogen/Progestin Intervention Trial.
        N Engl J Med. 1997; 337: 1792-1798
        • Gull B.
        • Karlsson B.
        • Milsom I.
        • et al.
        Can ultrasound replace dilation and curettage: a longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer.
        Am J Obstet Gynecol. 2003; 188: 401-408
        • Kurtay G.
        • Berker B.
        • Demirel C.
        Transvaginal ultrasonographic assessment of the endometrium in asymptomatic, postmenopausal women using different HRT regimens containing tibolone or estrogen.
        J Reprod Med. 2004; 49: 893-898
        • Mossa B.
        • Imperato F.
        • Marziani R.
        • et al.
        Hormonal replacement therapy and evaluation of intrauterine pathology in postmenopausal women: a ten-year study.
        Eur J Gynaecol Oncol. 2003; 24: 507-512
        • Tjarks M.
        • Van Voorhis B.J.
        Treatment of endometrial polyps.
        Obstet Gynecol. 2000; 96: 886-889
        • Bakour S.H.
        • Khan K.S.
        • Gupta J.K.
        The risk of premalignant and malignant pathology in endometrial polyps.
        Acta Obstet Gynecol Scand. 2000; 79: 317-320
        • Savelli L.
        • De Iaco P.
        • Santini D.
        • et al.
        Histopathological features and risk factors for benignity, hyperplasia and cancer in endometrial polyps.
        Am J Obstet Gynecol. 2003; 188: 927-931
        • Domingues A.P.
        • Lopes H.
        • Dias I.
        • et al.
        Endometrial polyps in postmenopausal women.
        Acta Obstet Gynecol Scand. 2009; 88: 618-620
        • Antunes A.
        • Costa-Paiva L.
        • Arthuso M.
        • et al.
        Endometrial polyps in pre- and postmenopausal women: factors associated with malignancy.
        Maturitas. 2007; 57: 415-421
        • Ferrazzi E.
        • Zupi E.
        • Leone F.P.
        • et al.
        How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study.
        Am J Obstet Gynecol. 2009; 200: 1-6
        • Fernández-Parra J.
        • Rodríguez Oliver A.
        • López Criado S.
        • et al.
        Hysteroscopic evaluation of endometrial polyps.
        Int J Gynaecol Obstet. 2006; 95: 144-148
        • Gregoriou O.
        • Konidaris S.
        • Vrachnis N.
        • et al.
        Clinical parameters linked with malignancy in endometrial polyps.
        Climacteric. 2009; 12: 454-458
        • Baiocchi G.
        • Manci N.
        • Pazzaglia M.
        • et al.
        Malignancy in endometrial polyps: a 12-year experience.
        Am J Obstet Gynecol. 2009; 201: e1-e4
        • Bernstein L.
        • Deapen D.
        • Cerhan J.R.
        • et al.
        Tamoxifen therapy for breast cancer and endometrial cancer risk.
        Natl Cancer Inst. 1999; 91: 1654-1662
        • Fishman M.
        • Mona B.
        • Sheiner E.
        • et al.
        Changes in the sonographic appearance of the uterus after discontinuation of tamoxifen therapy.
        J Ultrasound Med. 2006; 25: 469-473
        • Gerber B.
        • Krause A.
        • Reimer T.
        • et al.
        Anastrozole versus tamoxifen treatment in postmenopausal women with endocrine-responsive breast cancer and tamoxifen-induced endometrial pathology.
        Clin Cancer Res. 2006; 12: 1245-1250
        • Berlière M.
        • Radikov G.
        • Galant C.
        • et al.
        Identification of women at high risk of developing endometrial cancer on tamoxifen.
        Eur J Cancer. 2000; 36: S35-S36
        • Garuti G.
        • Cellani F.
        • Centinaio G.
        • et al.
        Baseline endometrial assessment before tamoxifen for breast cancer in asymptomatic menopausal women.
        Gynecol Oncol. 2005; : 63-67
        • Gull B.
        • Carlsson S.A.
        • Karlsson B.
        • et al.
        Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?.
        Am J Obstet Gynecol. 2000; 182: 509-515
        • Goldstein S.
        • Nachtigall M.
        • Snyder J.
        Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding.
        Am J Obstet Gynecol. 1990; 163: 119-123
        • Goldstein S.
        The endometrial echo revisited: have we created a monster?.
        Am J Obstet Gynecol. 2004; 191: 1092-1096
        • Goldstein S.R.
        Postmenopausal endometrial fluid collections revisited: look at the doughnut rather than the hole.
        Obstet Gynecol. 1994; 83: 738-740
        • Critchley H.O.
        • Warner P.
        • Lee A.J.
        • et al.
        Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status.
        Health Technol Assess. 2004; 8 (iii-iv): 1-139
        • Shushan A.
        • Revel A.
        • Rojansky N.
        How often are endometrial polyps malignant?.
        Gynecol Obstet Invest. 2004; 58: 212-215
        • Lev-Sagie A.
        • Hamani Y.
        • Imbar T.
        • et al.
        The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients.
        BJOG. 2005; 112: 379-381
        • Lieng M.
        • Qvigstad E.
        • Sandvik L.
        • et al.
        Hysteroscopic resection of symptomatic and asymptomatic endometrial polyps.
        J Min Invas Gynecol. 2007; 14: 189-194

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