Evaluation of the Woman With Postmenopausal Bleeding Society of Radiologists in Ultrasound–Sponsored Consensus Conference Statement Ruth B. Goldstein, MD, Moderator, Robert L. Bree, MD, Carol B. Benson, MD, Beryl R. Benacerraf, MD, Jeffrey D. Bloss, MD, Ruth Carlos, MD, Arthur C. Fleischer, MD, Steven R. Goldstein, MD, Robert B. Hunt, MD, Robert J. Kurman, MD, Alfred B. Kurtz, MD, Faye C. Laing, MD, Anna K. Parsons, MD, Rebecca Smith-Bindman, MD, Joan Walker, MD

Abbreviations D&C, dilation and curettage; EMB, endometrial biopsy; HRT, hormone replacement therapy; PMB, postmenopausal bleeding; SIS, saline infusion sonohysterography; SRU, Society of Radiologists in Ultrasound; TVS, transvaginal sonography

A complete list of presenters and panelists appears in “Appendix.” Address correspondence and reprint requests to Ruth B. Goldstein, MD, Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Room M-396, Box 0628, San Francisco, CA 94143-0628.

Objectives. A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects. Setting. October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference. Procedure. Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators? Conclusions. Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician’s assessment of patient risk, the nature of the physician’s practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when “sufficient” tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects. Key words: postmenopausal bleeding; menopause; sonography; ultrasound; transvaginal sonography; endometrium; endometrial cancer.

© 2001 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 20:1025–1036, 2001 • 0278-4297/01/$3.50

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Definition The term postmenopausal bleeding (PMB) refers to any vaginal bleeding in a postmenopausal woman other than expected cyclic bleeding that occurs with sequential hormone replacement therapy (HRT).

Summary of Issues Addressed by the Panel The consensus panel addressed the role of transvaginal sonography (TVS) in the evaluation of women with PMB. The majority of the debate and discussion focused on 3 issues: whether TVS can be used safely as the initial diagnostic test in women with PMB; whether a thin endometrium can be used to obviate the need for additional attempts at tissue sampling (in women in whom office endometrial biopsy [EMB] is nondiagnostic); and formulation of recommendations for an appropriate threshold of endometrial thickness, measured sonographically, below which the sonographic findings can safely be interpreted as “negative.” The panel also discussed the clinical importance of detecting other benign uterine abnormalities that may be the cause of PMB. The potential role of saline infusion sonohysterography (SIS) and hysteroscopy was discussed.

Background and Summary of Literature Endometrial cancer may be found in 1% to 25% (typically quoted as 10%) of women with unexpected PMB, depending on age and risk factors.1–3 Endometrial cancer is the most common gynecologic malignancy.4 More than 90% of cases occur in women older than 50 years, and abnormal bleeding is the most common presenting symptom. Vaginal bleeding, however, may be due to many causes other than cancer3,5 and is a common problem in postmenopausal women, occurring in as many as 1 per 10 women older than 55 years.6,7 Although PMB is often due to other conditions, endometrial cancer is the most serious. Thus, accepted practice in the United States includes further evaluation to exclude endometrial carcinoma in women with PMB.8 Before 1982, diagnostic evaluation was routinely accomplished by surgical dilation and curettage (D&C) of the endometrium. More 1026

recently, a suction catheter technique for endometrial tissue sampling, performed in an office setting, has been shown to be more than 85% sensitive for the detection of endometrial carcinoma7,9,10 and is more convenient and less costly. Unlike surgical D&C, EMB can easily be performed in the office with minimal or no analgesia. Transvaginal sonography has also become an increasingly popular tool for endometrial assessment and, in comparison with office EMB, has similar (or slightly lower) falsenegative rates for cancer detection.7 Although tissue is not obtained during sonography, sonographic imaging of the endometrium can be extremely helpful, because endometrial cancer is nearly always associated with thickening and heterogeneity of the endometrium6,11 and is rarely present when the endometrium is thin. In fact, the positive predictive value for cancer on a sonogram increases with the thickness of the endometrium.6,7,12–14 Furthermore, a large number of studies from the United States and Europe have confirmed that a very thin endometrial lining almost never harbors carcinoma.7,15 To determine how thin an endometrium should be to reasonably exclude cancer, many large studies have been performed. These studies have shown that when an endometrial thickness threshold of 4 or 5 mm is used, the sensitivity for detecting endometrial carcinoma approaches 95%.6,7 Furthermore, in part because the prevalence of endometrial cancer is low, the negative predictive value of a thin endometrium is very high. Thus, the presence of a thin endometrium can be used reliably to exclude cancer. These observations, in combination with evidence that TVS assessment of endometrial thickness is highly reproducible,16 have fueled interest in using TVS in 2 important settings. The first is to assess the endometrium with TVS as the initial diagnostic test (after history and physical examination) in women with PMB. Some physicians and patients may elect to begin the evaluation with TVS because office EMB may be uncomfortable.17 In comparison with EMB, TVS is better tolerated and has a higher rate (>95%) of diagnostic results.7,14 Furthermore, in some patients, office EMB cannot be adequately performed because of cervical stenosis or patient intolerance or, as occurs in 5% to 15% of patients, because the J Ultrasound Med 20:1025–1036, 2001

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specimen may not provide sufficient information to exclude endometrial cancer.2,3,14,18,19 The second setting in which TVS can be extremely helpful is in the group of women in whom EMB has been attempted but has not been diagnostic. In this setting, the high negative predictive value of a thin, homogeneous endometrium can be used to obviate the need for a more invasive procedure such as surgical D&C.

Panel Discussion The consensus panel addressed the following 5 questions: 1. What are the relative effectiveness and costeffectiveness of using sonography versus blind EMB as the initial test for PMB? The panelists concluded that, after a history and physical examination, either TVS or EMB would be effective and diagnostic as the first step in the evaluation of women with PMB. The relative cost-effectiveness of using EMB versus TVS as the first diagnostic procedure has not been determined by prospective testing. The choice will depend on the physician’s practice and expertise and the availability of high-quality sonography. Some of the panelists thought that in women considered to be at high risk for endometrial cancer (e.g., women older than 60 years, not receiving HRT or treatment with unopposed estrogen, or women with obesity or diabetes), EMB may be preferred as the first step in this evaluation, although the efficacy of using a 5-mm endometrial threshold in this particular subset of patients has not been carefully studied. Using published data on sensitivities and cost projected onto varying algorithms, Weber et al14 addressed theoretical considerations to assess cost-effectiveness, but some of the assumptions used by these authors may not be universally applicable (i.e., costs and outcomes may vary). They concluded that the costs are reasonably comparable for either approach. The panel speculated that if a study were done prospectively, the false-positive rates and patient referral patterns would likely have the greatest influence on cost.

formed according to the following standards. The sonography should be performed transvaginally with a 5- to 10-MHz transducer and an empty bladder, for resolution of the endometrial echotexture, margins, and double-layer thickness measurement. In the majority of patients, the TVS will provide diagnostic information for assessing the endometrium. Transverse/coronal (short-axis) and longitudinal/sagittal (long-axis) images of the uterus should be obtained in each examination and should also include images of the cervix and fundal and cornual portions of the endometrium (Fig. 1). The uterus and adnexa should be imaged in each examination, although it is understood that the ovaries may not be visible in all postmenopausal women. Transabdominal sonography alone is not sufficient in a woman with PMB because of suboptimal resolution of the endometrium and its borders (Fig. 2). Many panelists thought that the transabdominal portion of the sonographic examination, however, should be included to ensure that a large mass or fluid collection is not missed (owing to the limited field of view of TVS). Most agreed that the transabdominal scan could be performed with either a full or an empty bladder. Endometrial thickness should be measured on a sagittal (long-axis) image of the uterus, and the measurement should be performed on the thickest portion of the endometrium, excluding the Figure 1. Complete endometrial imaging has been accomplished on this sagittal image of the uterus using TVS. A small amount of fluid is shown in the endometrial canal. In the postmenopausal woman, this is not necessarily pathologic. The endometrium is visualized in its entirety, including the cervix (arrow). An incidentally observed nabothian cyst is seen in the cervix (arrowhead). Image courtesy of Peter M. Doubilet, MD, PhD (Brigham and Women’s Hospital, Boston, MA).

2. What are the sonographic standards for evaluating a woman with PMB? To use sonography to exclude cancer in a woman with PMB, sonography must be perJ Ultrasound Med 20:1025–1036, 2001

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A

B

Figure 2. Endometrial polyp shown to better advantage with TVS than transabdominal sonography. A, Transabdominal sonogram (4-MHz transducer). The endometrium is not adequately visualized, although there is a vague abnormality of the endometrium (arrows). Calipers mark the margins of the uterus. B, Transvaginal sonogram performed with an 8-MHz transducer in same patient as in A. A cystic and solid endometrial polyp (arrows) is resolved better with TVS.

hypoechoic inner myometrium (Figs. 3 and 4). The endometrial thickness should be reported as the “double-thickness” measurement. A small amount of fluid will be found in the endometrial canal of some postmenopausal women without abnormalities. This fluid should not be included in the endometrial measurement. In these cases, the reported endometrial thickness should be the sum of the thickness of the 2 endometrial layers, excluding the fluid (Fig. 5). The endometrium should be visualized completely. If the entire endometrium cannot be imaged because of obscuration by fibroids, or if

the endometrial margins are indistinct such that the borders of the endometrium cannot be delineated to measure the double wall thickness, the study should be considered inadequate, and other means of evaluating the endometrium should be used (Fig. 6). Practitioners are reminded that nondiagnostic findings may occur more commonly in women with invasive carcinoma because of indistinct endometrial margins. With recognition of the potentially pivotal role of TVS in the diagnostic evaluation of these patients, a statement should be included in the report regarding the technical adequacy of the sonogram.

Figure 3. Measuring the endometrium. Endometrial measurement should include the double thickness (arrows) excluding the hypoechoic myometrium (asterisks).

3. What are the abnormal sonographic findings in a woman with PMB? A. The sonogram should be interpreted as abnormal if the double thickness of the endometrium is greater than 5 mm. This conclusion is based on 2 important observations: (1) nearly all patients with proven endometrial cancer had an endometrial thickness of greater than 5 mm; and (2) when this threshold is used, the sensitivity of detecting endometrial cancer with TVS is comparable with that of EMB.6,7,15,20 A meta-analysis of 85 published studies that included 5892 women showed that an endometrial thickness of greater than 5 mm identified 96% of endometrial cancer.7 These sensitivities did not vary with the use of HRT (see question 5). The panel discussed whether 4 mm might be a

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A

B

Figure 4. Focal endometrial mass. Care should be taken to scrutinize the entire endometrium carefully in real time. The thickest portion of the endometrium should be reported as the double-thickness measurement. A, A portion of the endometrium appears homogeneous and thin (calipers). B, Further evaluation discloses a focal abnormality, which was an endometrial polyp (calipers).

more sensitive and, therefore, a better threshold. They noted, however, that Smith-Bindman and coworkers7 found that decreasing the threshold to 4 mm negligibly alters the sensitivity for cancer detection but substantially decreases the specificity (more false-positive results). As a result, most panelists favored using a threshold of 5 mm. The panel agreed that it is important to emphasize that this threshold does not apply to an asymptomatic woman with an incidentally observed endometrium of greater than 5 mm. Among these postmenopausal women, a normal maximal endometrial thickness measurement has not yet been established. B. The sonogram should be interpreted as nondiagnostic if the endometrium cannot be visualized in its entirety. This observation, found in approximately 5% to 10% of patients,15,21,22 is not specific for disease, but an incompletely visualized endometrium cannot be interpreted as benign or reassuring. Because this appearance can occur with endometrial cancer, a nondiagnostic sonogram should lead to the further evaluation, similar to positive sonographic findings (Fig. 6). C. The sonographic findings are abnormal if a focal endometrial abnormality is detected. Among women with PMB, endometrial cancer is found in approximately 10%, but polyps, hyperplasia, and fibroids will be found in as many as J Ultrasound Med 20:1025–1036, 2001

Figure 5. Transvaginal sonogram of a postmenopausal woman with a small volume of fluid in the central canal. Fluid should not be included in the endometrial thickness measurement. In this case, each endometrial wall should be measured separately (lines) and summed for the reported double-thickness measurement. Image courtesy of Peter M. Doubilet, MD, PhD.

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endometrium can also be seen in benign conditions, such as adenomyosis. 4. When should SIS or hysteroscopy be used in the evaluation of PMB?

Figure 6. Inadequate transvaginal sonogram. Despite the placement of calipers, the endometrium could not be examined in its entirety; therefore, endometrial carcinoma cannot be safely excluded.

40%. A focal area of thickening, a mass, or inhomogeneity on TVS warrants further evaluation in a woman with PMB. Tissue sampling, SIS, or hysteroscopy with D&C should be performed. D. The sonographic findings are abnormal if the margins of the endometrium are indistinct. Endometrial cancer often expands the endometrial cavity and, in addition to thickening, may result in an indistinct appearance of the endometrial lining (Fig. 7). An indistinct Figure 7. Endometrial cancer. A transabdominal sonogram shows an indistinct and thickened endometrium.

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Consensus was uniform among panelists that either SIS or hysteroscopy is appropriate when a focal abnormality is suspected on the transvaginal sonogram. One advantage of hysteroscopy is that it permits biopsy of a focal mass. Most panelists favored surgical hysteroscopy compared with office hysteroscopy, although this requires considerable anesthesia and expense. Saline infusion sonohysterography is a relatively new imaging procedure during which TVS is performed while sterile saline is infused into the endometrial cavity via a transcervically placed catheter. Saline infusion sonohysterography can be performed safely and easily as an outpatient procedure. Anesthesia is not required, and detection rates for focal abnormalities are comparable with those of hysteroscopy.23 Thus, many on the panel favored SIS when a focal endometrial abnormality is suspected on the transvaginal sonogram to confirm that a focal abnormality is indeed present (Figs. 2 and 8) and to define the nature of the focal abnormality better (e.g., polyp versus fibroid). Subsequent hysteroscopy could then be used to remove the focal abnormality, if appropriate. Saline infusion sonohysterography may also be helpful when a thickened endometrium has been identified on the sonogram to allow more efficient triaging of patients.24 The SIS will show whether the endometrium is diffusely thickened, in which case EMB or D&C would be the next step, or focally thickened, in which case hysteroscopy would be the next step (Fig. 8). Saline infusion sonohysterography is also helpful if there is a discrepancy between the findings on the transvaginal sonogram and the EMB (Fig. 9). An issue is the clinical importance of finding benign endometrial abnormalities in women with PMB. The majority agreed that in patients in whom a focal abnormality was suspected on TVS, SIS might be helpful to characterize the abnormality more fully. The panelists agreed that there is good evidence that SIS is more sensitive than TVS alone to detect focal abnormalities in women with PMB. The important but as yet unanswered question is whether finding and treating these benign conditions improve the patient’s quality of life, morbidity, and survival. J Ultrasound Med 20:1025–1036, 2001

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The panelists concluded that further investigation into this issue is warranted. A minority of panelists thought that all women with PMB should undergo SIS. The opinion of these panelists is a reflection of recent published evidence that suggests that SIS is more sensitive for detecting focal endometrial abnormalities than either TVS or EMB.22,23 It is becoming apparent that focal endometrial abnormalities are more common than previously thought. Many of these abnormalities are benign polyps and fibroids, and these may account for abnormal bleeding. In a multicenter study investigating the utility of SIS, Bree et al23 reported polyps in 47% and endometrial hyperplasia in 4% of women with PMB. These results should be considered, however, in light of a recent study published by Neale et al,22 who found that nearly 35% of asymptomatic postmenopausal women had endometrial abnormalities detected with SIS. 5. Should the diagnostic approach be modified for patients taking HRT medications, tamoxifen, or other selective estrogen receptor modulators? Women taking sequential regimens of HRT may have cyclic alterations in endometrial thickness. For these women, the TVS should be performed 4 to 5 days after completion of the cyclic bleeding. For those taking continuous regimens of HRT, including unopposed estrogen, or no HRT, sonography can be performed any time during the monthly cycle. Sensitivities for the detection of cancer do not differ for women taking HRT compared with those not taking HRT.7 In considering cost-effectiveness, the rate of false-positive sonographic findings among hormone users is considerably higher than that among those who do not take HRT.7 Although the rate of cancer detection does not differ, if TVS is the first diagnostic test, a greater rate of “positive” sonographic findings is likely to lead to more additional testing and higher cost for a complete evaluation for patients taking HRT. The panelists acknowledged that treatment with tamoxifen (used in adjuvant therapy for breast cancer) is associated with increased risk of endometrial proliferation, including polyp formation, endometrial hyperplasia, and endometrial cancer (Fig. 10).25 This is especially true with increasing durations and dosages of this medication. Panelists thought there was insufficient evidence to warrant recommendaJ Ultrasound Med 20:1025–1036, 2001

Figure 8. Saline infusion sonohysterogram showing that there is focal thickening of the endometrium in several places (arrows). This patient might benefit from hysteroscopy and biopsy.

tion of routine evaluation of asymptomatic women treated in this way. The panel recommended that bleeding women treated with tamoxifen or other selective estrogen receptor modulator therapy be evaluated in a fashion similar to that of other women with PMB (use an endometrial thickness threshold of 5 mm, and sonography can be performed anytime during the month). Figure 9. Discordant sonographic findings and EMB result. Transvaginal sonogram in a postmenopausal woman with bleeding shows a markedly thickened endometrium (arrows) containing numerous small cysts. Office EMB showed a normal endometrium. This patient should undergo further evaluation, which might include SIS.

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3. Further investigation into the relative effectiveness of using TVS versus EMB as the initial test in women with PMB is suggested. This would ideally represent a prospective trial with end points of not only cancer detection but also quality-of-life measures (e.g., patient preference, risk of additional tests, and tolerance of the need for additional testing). 4. Quality control of TVS in the community should be studied further. If TVS may replace EMB as the first diagnostic step in the evaluation of PMB, reproducibility of endometrial measurements in the community setting should be investigated. The Society of Radiologists in Ultrasound (SRU) has funded an educational program to provide standards for performing TVS in this setting.

Figure 10. Tamoxifen effect. Transvaginal sonogram shows marked endometrial thickening. This appearance is nonspecific and may represent endometrial hyperplasia, polyp, or carcinoma.

Research Agenda 1. The prevalence of benign endometrial abnormalities in women with PMB is higher than previously thought. Further investigation into the clinical significance of benign endometrial abnormalities associated with PMB is warranted. This might include better documentation of the rate of malignancy in polyps detected in patients with PMB and investigation into the impact of detecting, treating, and removing these benign abnormalities on outcome. 2. Hormone replacement therapy appears to influence the specificity of TVS. More falsepositive sonographic results (by definition abnormal) are found in women taking HRT. The panelists suggested studies to determine how HRT affects the cost-effectiveness of doing TVS or EMB first for the detection of cancer.

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5. Because TVS has become an acceptable means of commencing the evaluation of PMB, methods of standardizing the sonographic evaluation may be useful. The value of an educational program for improving the quality of TVS in the community should be investigated. 6. Some think that the causes of PMB in women taking HRT or tamoxifen are present before the commencement of therapy. Whether it would be beneficial to perform pretreatment TVS on women before commencement of tamoxifen or HRT should be investigated

Conclusions Conclusions from the panel discussion are summarized in algorithms 1 and 2 (Figs. 11 and 12) and include the following: 1. Transvaginal sonography can be used safely as the initial diagnostic test to evaluate the endometrial lining in a woman with PMB. 2. If the sonogram shows a normal-appearing endometrium with a double-thickness measurement of less than 5 mm, the test can be considered negative for endometrial cancer. 3. In women in whom office EMB is nondiagnostic, a thin endometrium can be used safely to obviate additional attempts at tissue sampling.

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Figure 11. Proposed algorithm for evaluating PMB commencing with EMB. ET indicates endometrium; and

Figure 12. Proposed algorithm for evaluating PMB commencing with TVS. ET indicates endometrium; and

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*, physician preference.

*, physician preference. 1033

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4. Both office EMB and TVS may miss benign causes of vaginal bleeding. However, whether cost or clinical benefit results from their detection is not known at this time. Further investigation of this issue would be helpful.

Appendix: Summary of Conference Activities Preconference Activities The conference directors (R.B.G. and R.L.B.) and consultants (The Lewin Group, Falls Church, VA [Sean Tunis, MD, MS, Senior Research Scientist]) together determined the key topics and identified experts to participate in the conference. A literature search was performed on the topic of PMB and reviewed for content and authorship. Our intention was to assemble a panel of experts with representatives from general gynecology, gynecologic oncology, hysteroscopy, radiology, pathology, and epidemiology. The consultants and Drs Goldstein and Bree wrote the objectives and formulated 5 questions to the panelists. These were distributed to them before the conference. Several months before the conference, the consensus conference presenters were asked to identify 4 or 5 key references. These were distributed to the participants before the conference. A general announcement of the conference was placed in the SRU newsletter, and a number of organizations and journal editors were invited to send representatives to participate in the audience. These included the American Academy of Family Physicians, American College of Physicians–American Society of Internal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, National Cancer Institute, National Institutes of Health, Office of Women’s Health, Health Care Financing Administration, and the editors of Radiology, American Journal of Roentgenology, Journal of Ultrasound in Medicine, and Journal of Women’s Imaging. Conference Activities The consensus conference, sponsored by the SRU, was held on October 24 and 25, 2000, at L’Enfant Plaza Hotel (Washington, DC). A series of presentations (each ≈30 minutes) were made from 8 AM until 5 PM with two 30-minute discussion sessions. Questions were taken during the presentations so that discussion was ongoing during the day. 1034

Topics of the presentations included Clinical Summary of Postmenopausal Bleeding; Pathology of the Endometrium in Postmenopausal Women; American College of Obstetricians and Gynecologists Guidelines for the Evaluation of Postmenopausal Bleeding; Nonimaging Means of Assessing the Endometrium in Women With Postmenopausal Bleeding (Pipelle, D&C, etc); Transvaginal Sonography; Sonohysterography; Hysteroscopy—Office and Operative; The Effects of Tamoxifen; and Summary of Cost of Transvaginal Sonography, Pipelle, Sonohysterography, D&C, Office Hysteroscopy, and Operative Hysteroscopy. The consensus panel members met in the evening after the day of presentations and discussions to outline the salient features and conclusions reached during the conference. The next day, all participants met to further refine the consensus outline. Dr Goldstein presented this material at the plenary session of the annual meeting of the SRU, held on October 27, 2000. Presenters and Panelists Presenters Jeffrey D. Bloss, MD, Vice-Chairman of Obstetrics and Gynecology, Director and Assistant Professor of Gynecologic Oncology, University of Missouri Health Sciences Center, Columbia, Missouri; Robert L. Bree, MD, Professor and Chair, Department of Radiology, University of Missouri Health Sciences Center, Columbia, Missouri; Ruth Carlos, MD, Lecturer, Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan; Arthur C. Fleischer, MD, Professor of Radiology and Radiological Sciences, Professor of Obstetrics and Gynecology, Chief of Diagnostic Ultrasound, Vanderbilt University Medical Center, Nashville, Tennessee; Steven R. Goldstein, MD, Professor of Obstetrics and Gynecology, New York University School of Medicine, Director of Gynecologic Ultrasound, Codirector of Bone Densitometry, New York University Medical Center, New York, New York; Robert B. Hunt, MD, Assistant Clinical Professor, Harvard Medical School, Boston, Massachusetts; Robert J. Kurman, MD, Richard TeLinde Distinguished Professor of Gynecologic Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland; Anna K. Parsons, MD, Associate Professor and Director of Image-Based J Ultrasound Med 20:1025–1036, 2001

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Gynecology, University of South Florida, Tampa, Florida; Rebecca Smith-Bindman, MD, Assistant Professor of Radiology, Epidemiology, and Biostatistics, University of California San Francisco–Mount Zion Medical Center, San Francisco, California; and Joan Walker, MD, Associate Professor and Chief, Section of Gynecologic Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

menopausal uterine bleeding. Acta Obstet Gynecol Scand 1986; 65:41–43. 3.

Reid PC, Brown VA, Fothergill DJ. Outpatient investigation of postmenopausal bleeding. Br J Obstet Gynaecol 1993; 100:498.

4.

Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics, 1996 [see comment]. CA Cancer J Clin 1996; 46:5–27.

5.

Van den Bosch T, Vandendael A, Van Schoubroeck D, Wranz PA, Lombard CJ. Combining vaginal ultrasonography and office endometrial sampling in the diagnosis of endometrial disease in postmenopausal women [comment appears in Obstet Gynecol 1995; 86:317–318]. Obstet Gynecol 1995; 85:349–352.

6.

Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: a Nordic multicenter study [comment appears in Am J Obstet Gynecol 1995; 173:1637–1638]. Am J Obstet Gynecol 1995; 172:1488–1494.

7.

Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities [comments appear in JAMA 1998; 280:1529–1530, 1999; 281:1693–1694]. JAMA 1998; 280: 1510– 1517.

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American College of Obstetricians and Gynecologists. Guidelines for Women’s Health. Washington, DC: American College of Obstetricians and Gynecologists; 1995. Technical Bulletin.

9.

Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. J Reprod Med 1995; 40:553–555.

Panelists Ruth B. Goldstein, MD (Moderator), Professor of Radiology and Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California; Beryl R. Benacerraf, MD, Clinical Professor of Radiology, Obstetrics, and Gynecology, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts; Carol B. Benson, MD, Associate Professor of Radiology, Harvard Medical School, Director of Ultrasound, Brigham and Women’s Hospital, Boston, Massachusetts; Robert L. Bree, MD; Alfred B. Kurtz, MD, Professor and Vice Chair, Thomas Jefferson University Hospital, Jefferson Medical College, Philadelphia, Pennsylvania; Faye C. Laing, MD, Professor of Radiology, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts; Anna K. Parsons, MD; Rebecca Smith-Bindman, MD; and Joan Walker, MD. Postconference Activities In addition to the outline generated and presented on the final day of the conference, all handouts, slides, and notes taken during the conference were reviewed and summarized by the conference codirectors. This summary was sent to each conference participant, who was asked to contribute comments and suggestions. This article represents the culmination and summary of those activities.

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Rose PG. Endometrial carcinoma [comment appears in N Engl J Med 1997; 336:1388; published erratum appears in N Engl J Med 1997; 336:1335]. N Engl J Med 1996; 335:640–649.

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10. Stovall TG, Ling FW, Morgan PL. A prospective, randomized comparison of the Pipelle endometrial sampling device with the Novak curette. Am J Obstet Gynecol 1991; 165:1287–1290. 11. Ferrazzi E, Torri V, Trio D, Zannoni E, Filiberto S, Dordoni D. Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal bleeding. An Italian multicenter study. Ultrasound Obstet Gynecol 1996; 7:315–321. 12. Taipale P, Tarjanne H, Heinonen UM. The diagnostic value of transvaginal sonography in the diagnosis of endometrial malignancy in women with peri- and

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postmenopausal bleeding [published erratum appears in Acta Obstet Gynecol Scand 1995; 74:324]. Acta Obstet Gynecol Scand 1994; 73: 819–823.

asymptomatic early post-menopausal women: saline infusion sonohysterography versus transvaginal ultrasound. Ultrasound Obstet Gynecol 2000; 16:254–259.

13. Malinova M, Pehlivanov B. Transvaginal sonography and endometrial thickness in patients with postmenopausal uterine bleeding. Eur J Obstet Gynecol Reprod Biol 1995; 58:161–165.

23. Bree RL, Bowerman RA, Bohm-Velez M, et al. US evaluation of the uterus in patients with postmenopausal bleeding: a positive effect on diagnostic decision making. Radiology 2000; 216:260–264.

14. Weber AM, Belinson JL, Bradley LD, Piedmonte MR. Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. Am J Obstet Gynecol 1997; 177:924–929.

24. Goldstein SR, Zeltser I, Horan CK, Snyder JR, Schwartz LB. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997; 177:102–108.

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