Dr. S. K. Giri is a former Professor, Dept. Gynaecologic Oncology, A.H. Postgraduate Institute of Cancer (A.H.PGIC), Cuttack and former director of the same institute. He has been the President of the Association of Gynaecologic Oncologists of India, 2007–2009. He has more than 40 publications in national and international journals and contributed chapters in Gynaecologic Oncology in different books including FOGSI publications. He has delivered Dr. Subodh Mitra Memorial oration at Bengal Obstetrics and Gynaecological society in 2015 and ICOG oration at Thrissur Obst. and Gyn. Society in 2016. He is also MCh examiner in Gynaecologic Oncology at TMH, Mumbai under Homi Bhabha National Institute, KMIO and St. John’s Medical College Banglore under Rajiv Gandhi University of Health Sciences, Karnataka, Gujarat Cancer Research Institute under Gujarat University, CMC, Vellore under MGR, Medical University, Chennai. He is a peer reviewer in Indian Journal of Gynaecologic Oncology and Indian Journal of Surgical Oncology
The endometrium is a dynamic target organ in a woman’s reproductive life. It undergoes cyclical change regulated by the fine balance between oestrogen and progesterone. The endometrial thickness (ET) varies according to the phases of the menstrual cycle. Endometrium contains both oestrogen and progesterone receptors, which respond to above hormones, irrespective of whether the woman is in reproductive or menopausal phase. Abundance of oestrogen leads to endometrial hyperplasia, and paucity causes endometrial atrophy. The initial best modality of assessing ET or aberration is high resolution transvaginal ultrasonogram. Thickened endometrium is always a clinical conundrum. Dilemma does remain as to the thickness of endometrium which requires intervention, mostly in symptomatic pre and perimenopausal women. In post-menopausal women with bleeding, the cut-off of ET that warrants investigation is almost defined. However, the cut-off value of ET in asymptomatic postmenopausal women; beyond which intervention is required, is still debated. Dilemma also exists about the cut-off of ET in both symptomatic and asymptomatic women on HRT and Tamoxifen. This article will discuss the above issues and reach at some consensus about the cut-off of ET after critical analysis of evidence and experience and will help clinicians in arriving at a proper decision in dealing with such clinically confounding situations.
Keywords : Endometrial thickness · TVS · AUB · Perimenopause/menopause · Intervention
In the reproductive years of women’s life, the endometrium is a dynamic target organ, regulated by the hypothalamicpituitary- ovarian axis leading to its cyclical changes mediated through oestrogen and progesterone. Endometrium contains both oestrogen and progesterone receptors, which bind and respond to the above hormones respectively, irrespective of whether the woman is in reproductive or menopausal phase of her life. In post-menopausal women with bleeding, the cut-off of endometrial thickness (ET) that warrants investigation is almost defined. However, there is no consensus as to the cut-off value of endometrial thickness in asymptomatic postmenopausal women. This article will discuss about the cut-off of endometrial thickness (ET) in symptomatic premenopausal and perimenopausal women, postmenopausal women with or without bleeding episode(s), and women under HRT and Tamoxifen. This will help to reach at some consensus, when to intervene, so that the diagnosis of endometrial hyperplasia (EH) and endometrial carcinoma (EC) is not delayed or missed.
Transvaginal ultrasonography (TVS) is preferred as the first modality of imaging, to assess endometrial milieu. Other imaging modalities like, Saline Infusion Sonohysterography (SIS), sonohysterography, hysterosalpingography, Computerized Tomography and Magnetic Resonance Imaging are sometimes used to confirm or add-on the findings of USG when deemed necessary. To avoid overestimation of endometrial thickness, the measurement should be made by USG on midline sagittal image, not oblique image or too close to uterine cornua. To ascertain that the imaging plane is midline, the endometrial echo should be seen continuous with the edocervical canal. Typically, endometrial thickness is measured and reported as the sum of the two adjacent layers of the endometrium, a measurement called the endometrial echo complex (EEC). If the complex is indistinct, heterogeneous or focally thickened, the double thickness measurement of the thickest segment of EEC should be measured. It is pertinent to know about patient’s age, day of menstrual cycle and any history of drug intake like HRT, Tamoxifen etc., in addition to clinical history and physical examination. Ideally, ultrasound scan should be performed after cessation of period or in periovulatory period as focal endometrial pathology can easily be detected during this period [1].
Conflict of interest None of the authors have any conflicts of interest to declare.
Ethical Approval This article does not contain any studies with human participants performed by any of the authors.
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