Clinician misinterpretation of transvaginal ultrasound results was the most common reason for delayed or absent follow-up among patients with postmenopausal bleeding.
Abstract
OBJECTIVE:
To characterize guideline-adherent follow-up in patients evaluated with transvaginal ultrasonography (TVUS) for postmenopausal bleeding.
METHODS:
We conducted a retrospective study of patients with an intact uterus and postmenopausal bleeding who presented to a single academic institution and underwent TVUS between January 2013 and December 2022. Primary outcome measures were prompt follow-up, defined as receipt of endometrial sampling within 3 months of a finding of thickened or inadequately visualized endometrium, diagnosis of endometrial cancer, cancer stage at diagnosis, and rates of tissue sampling. Associations between sociodemographic variables and prompt follow-up were assessed. A Pareto analysis was performed to describe reasons for lack of prompt follow-up.
RESULTS:
Of 1,671 patients with thickened endometrium, 307 (18.4%) did not receive prompt follow-up; of 389 patients with inadequately visualized endometrium, 128 (33.0%) did not receive prompt follow-up. Sociodemographic variables were not associated with prompt follow-up. Clinician-related factors, including misinterpretation of ultrasound results, accounted for 46.1% of delayed or absent follow-up for thickened endometrium and 58.4% of inadequately visualized endometrium. The rates of diagnosing endometrial cancer within 1 year were similar after findings of thickened endometrium (8.8%; 95% CI, 7.5–10.3%) compared with inadequately visualized (7.7%; 95% CI, 5.3–10.9%) endometrium.
CONCLUSION:
Clinician misinterpretation of TVUS performed for postmenopausal bleeding was the most common reason for delayed or absent follow-up. Given observed suboptimal rates of prompt follow-up after findings of thickened or inadequately visualized endometrium on ultrasonography and similar rates of an eventual cancer diagnosis in these cohorts, efforts should be focused on clinician understanding of ultrasonographic endometrial evaluation. To simplify the diagnostic process and reduce the risk of missing a cancer diagnosis, universal endometrial sampling for patients with postmenopausal bleeding could be considered.
Postmenopausal bleeding is the most common presentation of endometrial cancer.1 Since 2009, the American College of Obstetricians and Gynecologists (ACOG) has recommended either ultrasonography or biopsy-based evaluation of postmenopausal bleeding to rule out endometrial cancer.2–4 Under an ultrasound-based strategy, transvaginal ultrasonography (TVUS) is used to determine the endometrial thickness, followed by endometrial sampling if the endometrium exceeds 4 mm. Compared with a biopsy-first strategy, this approach minimizes patient discomfort and procedural risk in patients with normal endometrial thickness.5–7
Black patients are, on average, diagnosed with higher grade and later stage endometrial cancer compared with White patients; this has been attributed to more aggressive histopathologic subtypes in Black patients and is further compounded by socioeconomic, cultural, and treatment-related differences in the United States.8–13 Previous studies also suggest that TVUS may be less effective for evaluating the endometrium in Black patients due to factors such as leiomyomas, adenomyosis, and elevated body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), which disproportionately affect this population.14–21 However, neither associations between sociodemographic characteristics and prompt evaluation of nonreassuring ultrasound findings, nor factors contributing to delayed endometrial sampling have previously been characterized.
We sought to identify whether race, ethnicity, language, or insurance status were associated with delayed endometrial sampling after findings of thickened or inadequately visualized endometrium on ultrasound examination for postmenopausal bleeding. Additionally, we analyzed whether delayed sampling was associated with differences in subsequent diagnosis and stage of endometrial cancer. For patients with delayed or absent follow-up after TVUS, we sought to identify the most common reasons for guideline nonadherence.
METHODS
The PUMBA (Performance of Ultrasound in Postmenopausal Bleeding Assessment) study is an ongoing multisite collaborative retrospective cohort study whose primary objective is to calculate the performance of ultrasound-measured endometrial stripe thickness cutoffs to exclude the diagnosis of endometrial cancer across different racial and ethnic backgrounds. We describe a prospectively defined hypothesis-driven substudy of PUMBA, driven by our observation of imperfect rates of endometrial sampling after nonreassuring endometrial ultrasound examination at our institution. We conducted an institutional review board-approved (Pro00111807) retrospective observational study at a single academic institution to characterize rates of prompt endometrial sampling among patients presenting with an initial episode of postmenopausal bleeding who were found to have thickened or inadequately visualized endometrium on TVUS, and to investigate factors and outcomes related to prompt follow-up. This study conformed to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist for observational cohort studies.22,23 Our primary study hypothesis was that racial, ethnic, and socioeconomic barriers that often lead to health care disparities may also affect the receipt of appropriate follow-up care when the endometrium is thickened or inadequately visualized.
We defined three study aims. Our first aim was to evaluate the association of sociodemographic factors (race, ethnicity, primary language, insurance status) with receipt of endometrial sampling within 3 months of initial ultrasound examination performed for postmenopausal bleeding showing thickened or inadequately visualized endometrium. Our second aim was to evaluate and characterize incidence and stage of endometrial cancer at diagnosis among patients who received prompt sampling within 3 months, compared with those who underwent sampling between 3 months and 1 year after findings of thickened or inadequately visualized endometrium. We chose less than 3 months as a clinically reasonable timeframe to achieve biopsy after the abnormal index ultrasound result and up to 1 year as a timeframe during which we would track and quantify any additional biopsies. Our third aim was to use the descriptive documentation of the clinician interpreting the ultrasonogram and the clinical notes to characterize reasons for delayed follow-up among patients who did not receive appropriate endometrial sampling when indicated.
An Epic Caboodle database was used to identify patients from the electronic medical record (EMR) at a single academic institution who were older than age 45 years and received a TVUS with a coded indication of postmenopausal bleeding (International Classification of Diseases, Tenth Revision, Clinical Modification codes N95.0, N95.1, N95.8, N95.9) from January 2013 to December 2022. Patients were excluded from this study if they did not have an intact uterus or had received a prior TVUS for the indication of postmenopausal bleeding.
Demographic data imported from the EMR included age, BMI, self-reported race and ethnicity, insurance status, and preferred language. Data from ultrasound and pathology reports were collected manually and included endometrial thickness, ability to visualize the endometrium, radiologist or clinician interpretation, receipt of endometrial sampling, date of sampling, and histologic diagnosis. A single obstetrician–gynecologist with experience interpreting gynecologic ultrasonograms reviewed electronic images of all ultrasonograms to classify endometrial visualization as adequate or inadequate based on the 2001 Society for Radiologists in Ultrasound guidelines.24 Cancer stage was calculated based on pathologic results after hysterectomy using the 2009 International Federation of Gynecology and Obstetrics endometrial cancer staging system.25 All data were collected and stored within our institution's Protected Analytics Computing Environment, a secure research server designed for protected health information, with deidentified data later exported to REDCap for further statistical analysis.26,27
Endometrial evaluation by TVUS was characterized as normal (endometrial thickness 4 mm or less), thickened (endometrial thickness greater than 4 mm), or inadequate (endometrium not fully visualized).28 These criteria were used to create two cohorts for further analysis, based on endometrial ultrasound findings: cohort 1, thickened endometrium; and cohort 2, inadequately visualized endometrium. Prompt follow-up was defined as sampling (endometrial biopsy, dilation and curettage, or hysterectomy) with endometrial pathology available within 3 months before or after a TVUS finding of thickened or incompletely visualized endometrium. The inclusion of hysterectomy was not considered a standard of care sampling method but was intended to identify all cases with a definitive histologic diagnosis. As part of the PUMBA study criteria and to account for differences in scheduling and clinical workflows, we included endometrial sampling that occurred up to 3 months before an ultrasound examination. These criteria were used to create two subcohorts: subcohort 1, thickened endometrium without prompt sampling; and subcohort 2, inadequately visualized endometrium without prompt sampling.
Logistic regression models were used to analyze associations between sociodemographic variables (race, ethnicity, primary language, insurance status) and receipt of endometrial sampling within 3 months for patients in cohorts 1 and 2. Two separate analyses were conducted using this model: the first included sampling that occurred within 3 months before and after the ultrasound examination, and the second included only sampling that occurred within 3 months after the ultrasound examination. The latter analysis specifically aimed to characterize adherence to an ultrasound-first strategy for patients with inadequately visualized or thickened endometrium. Receipt of endometrial sampling within 3 months of TVUS was categorized as a binary outcome. Descriptive statistics were used to characterize rates of endometrial cancer diagnosis and cancer stage at diagnosis by endometrial sampling timing (within 3 months, between 3 and 6 months, and between 6 and 12 months) for the thickened and inadequately visualized endometrium cohorts. Cancer staging was analyzed as stage IA compared with stage IB compared with stages II–IV using 2009 International Federation of Gynecology and Obstetrics cancer staging criteria.25 With the limitation that some patients never received documented sampling, we calculated the observed rate of endometrial cancer in cohorts 1 and 2 by dividing the number of observed malignancies during the first year after ultrasound examination by the cohort total, reported with Clopper-Pearson CIs.
A Pareto analysis, a method used to visualize the most common contributors to an outcome of interest, was performed to further characterize and quantify reasons for lack of prompt follow-up in patients with thickened or inadequately visualized endometrium.29 Full EMR review was performed for this subset; individual patient encounter notes were analyzed to identify documented reasons that patients did not receive sampling. This analysis excluded patients who had undergone a biopsy within 3 months before or after an ultrasound examination to ensure that patients who had recently received a biopsy before their TVUS were not misclassified as having inadequate follow-up. To further exclude clinically appropriate lack of sampling, individuals who were determined by full chart review to be premenopausal or perimenopausal at the time of ultrasound examination were excluded, with premenopausal or perimenopausal status defined as having had a menstrual period within the previous 12 months. Pareto charts were created to describe the distribution of identified reasons for nonreceipt of prompt follow-up after findings of thickened or inadequately visualized endometrium.
RESULTS
From 5,573 patients identified by our initial search query, 3,369 eligible patients ultimately formed our study cohort after exclusionary criteria were applied (Fig. 1). Across the entire cohort, the mean age was 60 years and the mean BMI was 32. Most patients were White (1,889/3,369, 56.1%), not Hispanic or Latina (3,090/3,369, 91.7%), had private insurance (1,979/3,369, 58.7%), and had English as their preferred language (3,226/3,369, 95.8%). The age, BMI, race, ethnicity, preferred language, and insurance status of the patients in the normal, thickened, and inadequately visualized endometrium cohorts are further described in Table 1.
Fig. 1. Clinical cohort flowchart describing data extraction and creation of the cohorts and subcohorts analyzed in this study. *Aims 1 and 2. †Aim 3. TVUS, transvaginal ultrasonography; PMB, postmenopausal bleeding.
Atkins. Timely Evaluation of Postmenopausal Bleeding. O&G Open 2025.
Table 1.
Patient Demographics and Clinical Characteristics
| Demographic Variable | Total (N=3,369) | Normal Endometrium (n=1,309) | Thickened Endometrium (n=1,671) | Inadequately Visualized Endometrium (n=389) |
| Age (y) | 60.3±8.9 | 60.1±9.2 | 60.4±8.8 | 60.5±8.8 |
| 58.0 | 58.0 | 58.0 | 58.0 | |
| 54.0, 66.0 | 53.0, 66.0 | 54.0, 66.0 | 54.0, 66.0 | |
| 45.0–100 | 45.0–95.0 | 45.0–100 | 45.0–90.0 | |
| BMI (kg/m2) | 32.3±8.9 | 29.5±7.4 | 34.1±9.2 | 34.3±9.8 |
| 30.7 | 27.9 | 32.7 | 32.9 | |
| 25.5, 37.7 | 23.8, 34.2 | 27.1, 39.7 | 27.4, 39.6 | |
| 14.5–82.4 | 14.5–68.6 | 16.1–72.5 | 18.4–82.4 | |
| Race | ||||
| American Indian or Alaskan Native | 7 (0.2) | 3 (0.2) | 4 (0.2) | 0 (0) |
| Asian | 126 (3.7) | 67 (5.1) | 49 (2.9) | 10 (2.6) |
| Black or African American | 1,136 (33.7) | 352 (26.9) | 576 (34.5) | 208 (53.5) |
| Native Hawaiian or other Pacific Islander | 2 (0.1) | 1 (0.1) | 0 (0) | 1 (0.3) |
| White | 1,889 (56.1) | 806 (61.6) | 946 (56.6) | 137 (35.2) |
| None of the above | 95 (2.8) | 35 (2.7) | 45 (2.7) | 15 (3.9) |
| Not reported or declined | 93 (2.8) | 36 (2.8) | 44 (2.6) | 13 (3.3) |
| Two or more races | 21 (0.6) | 9 (0.7) | 7 (0.4) | 5 (1.3) |
| Ethnicity | ||||
| Hispanic | 177 (5.3) | 67 (5.1) | 82 (4.9) | 28 (7.2) |
| Not Hispanic or Latina | 3,090 (91.7) | 1,203 (91.9) | 1,543 (92.3) | 344 (88.4) |
| Not reported or declined | 102 (3.0) | 39 (3.0) | 46 (2.8) | 17 (4.4) |
| Insurance status | ||||
| Private | 1,979 (58.7) | 787 (60.1) | 1,000 (59.8) | 192 (49.4) |
| Medicare | 1,107 (32.9) | 426 (32.5) | 546 (32.7) | 135 (34.7) |
| Medicaid | 104 (3.1) | 27 (2.1) | 54 (3.2) | 23 (5.9) |
| Uninsured | 111 (3.3) | 42 (3.2) | 45 (2.7) | 24 (6.2) |
| Unknown | 68 (2.0) | 27 (2.1) | 26 (1.6) | 15 (3.9) |
| Patient preferred language | ||||
| English | 3,226 (95.8) | 1,251 (95.6) | 1,611 (96.4) | 364 (93.6) |
| Spanish | 98 (2.9) | 39 (3.0) | 41 (2.5) | 18 (4.6) |
| Mandarin | 6 (0.2) | 2 (0.2) | 3 (0.2) | 1 (0.3) |
| Arabic | 5 (0.1) | 2 (0.2) | 2 (0.1) | 1 (0.3) |
| None of the above | 34 (1.0) | 15 (1.1) | 14 (0.8) | 5 (1.3) |
BMI, body mass index.
Data are mean±SD; median; quartile 1, quartile 3; range; or n (%).
Among 3,369 patients meeting inclusion criteria, 1,671 (49.6%) had thickened endometrium and 389 (11.5%) had inadequately visualized endometrium. Of the 1,671 patients with thickened endometrium, 307 (18.4%) did not receive endometrial sampling within 3 months before or after ultrasound examination; the remainder received sampling: 206 (12.3%) within 3 months preceding the ultrasound examination, 1,015 (60.7%) within 3 months after the ultrasound examination, and 143 (8.6%) both before and after the ultrasound examination. Of the 389 patients with inadequately visualized endometrium, 128 (32.9%) did not receive sampling within 3 months before or after the ultrasound examination; the remainder received sampling: 75 (19.3%) within 3 months preceding the ultrasound examination, 163 (41.9%) within 3 months after the ultrasound examination, and 23 (5.9%) both before and after the ultrasound examination.
Neither race nor ethnicity was significantly associated with prompt receipt of endometrial sampling within 3 months of the ultrasound examination demonstrating thickened endometrium (odds ratio [OR] 1.03, 95% CI, 0.79–1.35 for Black vs White; OR 1.1, 95% CI, 0.54–2.27 for Hispanic vs not Hispanic or Latina). Race and ethnicity were also not significantly associated with receipt of prompt sampling within 3 months of inadequately visualized endometrium (OR 1.13, 95% CI, 0.71–1.8 for Black vs White; OR 1.1, 95% CI, 0.37–3.22 for Hispanic vs not Hispanic or Latina). Other associations are displayed in Table 2. In a sensitivity analysis excluding patients who underwent endometrial sampling performed within 3 months before the index TVUS (n=2,683), prompt sampling was missed in 128 of 290 (44%) with inadequately visualized endometrium and in 307 of 1,317 (23.3%) with thickened endometrium. No statistically significant differences in prompt follow-up were identified based on race, ethnicity, preferred language, or insurance status (Appendix 1, available online at http://links.lww.com/AOG/D979).
Table 2.
Association Between Patient Characteristics and Receipt of Endometrial Sampling Within 3 Months of Findings of Thickened or Inadequately Visualized Endometrium on Transvaginal Ultrasonography
| Demographic Variable | Inadequately Visualized Endometrium | Thickened Endometrium | ||
| OR (95% CI) | P | OR (95% CI) | P | |
| Race and ethnicity | ||||
| Hispanic vs not Hispanic or Latina | 1.1 (0.37–3.22) | .87 | 1.1 (0.54–2.27) | .79 |
| Black vs White | 1.13 (0.71–1.8) | .61 | 1.03 (0.79–1.35) | .83 |
| Additional races and ethnicities vs White* | 1.36 (0.49–3.76) | .55 | 1.15 (0.64–2.07) | .65 |
| Insurance status | ||||
| Medicaid vs Private† | 1.6 (0.57–4.5) | .38 | 1.7 (0.76–3.83) | .20 |
| Medicare vs Private† | 0.7 (0.33–1.47) | .35 | 1.16 (0.73–1.82) | .53 |
| Uninsured vs Private† | 0.62 (0.26–1.48) | .28 | 0.61 (0.32–1.19) | .15 |
| Preferred language | ||||
| Not English vs English | 0.86 (0.37–2.01) | .73 | 0.9 (0.47–1.71) | .74 |
OR, odds ratio.
Includes American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, and two or more races.
Age adjusted.
The observed rate of cancer diagnosis at 1 year, regardless of sampling timing, was 8.8% (95% CI, 7.5–10.3%) among patients with thickened endometrium and was 7.7% (95% CI, 5.3–10.9%) among those with inadequately visualized endometrium (Appendix 2, available online at http://links.lww.com/AOG/D979). Among patients with thickened endometrium, 143 of 1,165 (12.3%) endometrial cancers were diagnosed after prompt sampling and 4 of 62 (6.5%) were diagnosed after sampling was performed between 3 and 12 months after the ultrasound examination. The stage distribution for endometrial cancers diagnosed after prompt sampling of thickened endometrium was stage IA or IB in 107 of 133 (80.5%) and stage II–IV in 26 of 133 (19.5%), compared with stage IA in two of four (50%) and stage II–IV in two of four (50%) after delayed sampling. The stage distribution for endometrial cancers diagnosed after prompt sampling of inadequately visualized endometrium was stage IA or IB in 16 of 24 (66.7%) and stage II–IV in 8 of 24 (33.3%), with 0 of 17 (0%) cancer diagnoses occurring after delayed sampling (Appendix 3, available online at http://links.lww.com/AOG/D979).
After extensive chart review, 42 of 307 (13.7%) patients with thickened endometrium and 5 of 128 (3.9%) patients with inadequately visualized endometrium and without prompt sampling were excluded due to premenopausal or perimenopausal status at the time of ultrasound examination. Of the remaining postmenopausal patients without prompt sampling, reasons were identified in 217 individuals with thickened endometrium and in 106 individuals with inadequately visualized endometrium. Lack of prompt follow-up for thickened endometrium was most commonly due to incorrect clinician interpretation of ultrasound results for which thickened endometrium was considered normal (72/217, 33.2%), patient-related delays (46/217, 21.2%), patient-declined biopsy (25/217, 11.5%), incorrect radiographic interpretation of ultrasound results for which thickened endometrium was considered normal (21/217, 9.7%), loss to follow-up after gynecologic referral from primary care clinician (16/217, 7.4%), failed biopsy attempts (14/217, 6.5%), scheduling-related delays (9/217, 4.1%), and other reasons ([including clinician delay, patient moved away, and prior reassuring biopsies] 16/217, 7.4%) (Fig. 2). Of the 21 incorrect radiographic interpretations, 19 were interpreted by radiologists and two were interpreted by an obstetrician–gynecologist. Of the 19 ultrasonograms that were interpreted by a radiologist, 17 cases could be attributed to guideline discordance between the Society for Radiologists in Ultrasound (5-mm cutoff) and ACOG (4-mm cutoff) during the study period. After inadequately visualized endometrium, reasons for lack of follow-up were as follows: the identified portion of the endometrium appeared normal (44/106, 41.5%); patient-related delays (22/106, 20.8%); patient declined biopsy (14/106, 13.2%); no endometrium visualized but patient was offered reassurance (11/106, 10.4%); failed biopsy attempts (6/106, 5.7%); endometrium was both inadequately visualized and the thickness was greater than 4 mm in the visualized portion, but the clinician interpreted the ultrasonogram as normal (4/106, 3.8%); clinician delay (3/106, 2.8%); and other (including prior reassuring biopsy and scheduling delay; 2/106, 1.9%) (Fig. 3). Clinician-related factors, which included misinterpretation of ultrasound results and clinician delay, contributed to 46.1% of delayed or absent follow-up in patients with thickened endometrium and contributed to 58.4% of delayed or absent follow-up in those with inadequately visualized endometrium. Reasons for delayed or absent follow-up by race, ethnicity and insurance status are presented in Appendices 4 and 5, available online at http://links.lww.com/AOG/D979.
Fig. 2. Pareto chart analysis of patients who did not receive prompt endometrial sampling after thickened endometrium was identified on ultrasound examination for postmenopausal bleeding (n=265). “Other” includes clinician delay, patient moved away, and previous reassuring biopsies.
Atkins. Timely Evaluation of Postmenopausal Bleeding. O&G Open 2025.
Fig. 3. Pareto chart analysis of patients who did not receive prompt endometrial sampling after inadequately visualized endometrium on ultrasound examination for postmenopausal bleeding (n=123). “Other” includes previous reassuring biopsy and scheduling delay. ES, endometrial stripe.
Atkins. Timely Evaluation of Postmenopausal Bleeding. O&G Open 2025.
DISCUSSION
In this single-institution retrospective analysis of more than 3,300 patients, one-fifth of patients with thickened endometrium and one-third with inadequately visualized endometrium failed to receive endometrial sampling within 3 months of an ultrasound examination performed for postmenopausal bleeding. Incorrect clinician interpretation was the most common reason for delayed or absent sampling after an ultrasonogram showing thickened endometrium. When combined with discrepancies in radiographic interpretation guidelines and documentation errors, practitioner-related factors accounted for 46.1% of cases that did not receive prompt sampling of thickened endometrium. The ACOG postmenopausal bleeding guidance first put forth in 2009 recommend sampling if the endometrial thickness exceeds 4 mm; however, it appears there may be clinician variability in the adherence to this specific cutoff.2–4 Additionally, between 2001 and 2020 there were guideline discrepancies between ACOG and the Society for Radiologists in Ultrasound, with conflicting endometrial thickness cutoffs of 4 and 5 mm, respectively, in the setting of postmenopausal bleeding.2–4,24 These discrepancies could explain 17 of the 19 observed cases of nonconcordant radiographic interpretation by radiologists.
The most common reason for lack of sampling of findings of inadequately visualized endometrium was that clinicians were reassured when the identified portion of the endometrium was less than 4 mm. Joint practice parameters recommend further evaluation if the entire endometrium is not fully identified.3,4,24,28 Notably, our analysis showed no significant difference in the minimum rate of endometrial cancer diagnosis after findings of thickened or inadequately visualized endometrium. As many as 9% of patients in each cohort received a diagnosis of endometrial cancer within 1 year after the index ultrasound examination. No disparities were identified in the receipt of endometrial sampling across patient race, ethnicity, language, or insurance status in either cohort when analyzed individually.
Our study has the limitations inherent to a retrospective observational study. Although it includes a racially diverse population with 33.7% Black patients, its demographics do not replicate those of the U.S. population, and, as such, our results may be difficult to generalize. A particular limitation was the use of coding to identify our large study cohort with postmenopausal bleeding, such that we were unable to review each patient's medical record individually to confirm their postmenopausal status. Although we selected only patients older than age 45 years, we were also reliant on the accuracy of clinician's coded diagnosis of postmenopausal bleeding. Given the coding-based data set of more than 5,500 individuals, we were not able to assess specific menstrual patterns or other risk factors such as obesity and hormone replacement exposures. Additionally, our independent investigator review of ultrasound images was used to judge the adequacy of endometrial visualization; this judgment was concordant with EMR-based ultrasound reports in 121 of 128 (94.5%) of inadequately visualized cases without prompt sampling. The 5.5% discrepancy between investigator-assessed and EMR ultrasound reports has a small potential to influence our reported results. Individual chart review was only feasible for the Pareto analysis; among the 435 patients who received manual chart review, approximately 11% were found to be premenopausal or perimenopausal at index ultrasound examination. Given the lack of sampling of every individual, our reported endometrial cancer rates of up to 9% in cohorts 1 and 2 may be either underestimates or overestimates of the true endometrial cancer rate in the study population; however, this is a clinically meaningful rate that supports the need for prompt endometrial biopsy. Finally, some patients may have been incorrectly categorized as not receiving prompt follow-up if they received care by a clinician or facility outside the reach of the EMR system used at our institution; this was an inherent limitation to our data-collection method. We are able to view many, but not all, outside records with our current EMR system.
Given these findings, advocating for universal endometrial sampling in patients who present with postmenopausal bleeding may be a reasonable approach. Forgoing the ultrasound-first strategy could mitigate delayed or absent follow-up after a nonreassuring ultrasound result. However, given that a substantial number of patients declined biopsy even with thickened endometrium, strategies to improve shared decision making as well as minimize the discomfort of biopsy are needed. Alternatively, enhanced clinician familiarity with and adherence to established guidelines could reduce instances of inadequate follow-up in the evaluation of postmenopausal bleeding. For patients with inadequately visualized endometrium on ultrasonography, our results support that sampling is advisable due to the similar rate of cancer diagnosis as in those with a clearly thickened endometrium in our study. Future studies may include identifying interventions to increase clinician awareness of guideline-specific endometrial thickness limits to promote adequate and timely evaluation of postmenopausal bleeding.
Footnotes
The Duke BERD Methods Core's support of this project was made possible in part by CTSA Grant (UL1TR002553) from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NCATS or NIH. SA acknowledges the support of the Kirkpatrick Family to fund this research.
Financial Disclosure The authors did not report any potential conflicts of interest.
Presented at the NC Obstetrical & Gynecological Society Annual Meeting, March 8–10 2024, Charlotte, North Carolina; and at the American Society of Clinical Oncology Annual Meeting, May 31–June 4, 2024, Chicago, Illinois.
Each author has confirmed compliance with the journal's requirements for authorship.
Peer reviews and author correspondence are available at http://links.lww.com/AOG/D980.
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