Thickened Endometrial Stripe and/or Endometrial Fluid as a Marker of Pathology: Fact or Fancy?

Abstract Objective: To evaluate the implication of a thickened endometrial stripe (ES) and endometrial fluid (EF) in postmenopausal women. Methods: Between 1991 and 1995, 897 consecutive postmenopausal patients underwent pelvic ultrasound at our institution. Clinical and ultrasound data were reviewed for the 624 patients in whom a comprehensive evaluation of the uterus and adnexae was performed. Of this study group, 495 had normal ES thickness. Nine patients with a thickened ES were excluded due to immediate hysterectomy or history of cervical cancer. This resulted in 120 subjects comprising the group with EF, or a thickened ES [≥5 mm for patients not on hormone replacement therapy (HR−) and ≥8 mm in patients receiving hormone replacement therapy (HR+)]. Symptoms were defined as bleeding. Statistical analysis was performed by use of Fisher's exact test. Results: 184/495 patients with normal ES thickness underwent biopsy. In this group, 7 cases of simple hyperplasia, 4 cases of atypical hyperplasia (AH), and 4 cases of endometrial cancer (CA) were detected. All of these subjects who were found to have either AH or CA were symptomatic. Of the subjects with a thickened ES, 54 had symptoms and 66 were asymptomatic with 51/54 and 52/66 undergoing endometrial sampling, respectively. Initial sampling in the symptomatic group with thickened ES revealed 7 cases of simple hyperplasia and 2 cases of AH. There were 6 cases of simple hyperplasia in the asymptomatic group ( P = NS). Initial biopsy results were either negative or nondiagnostic in 42 symptomatic patients and 46 asymptomatic patients with 40/42 and 19/46 undergoing repeat sampling, respectively. Repeat sampling further identified 9 cases of endometrial hyperplasia or cancer in the symptomatic group while in the asymptomatic group, 2 cases of simple hyperplasia were detected. For symptomatic and asymptomatic patients, analysis of combined initial and second biopsies performed within 1 year was undertaken. This combined analysis revealed a significantly greater rate of detection of endometrial hyperplasia or carcinoma in the symptomatic group vs the asymptomatic group ( P = 0.0229, Fishers exact test, [Mantel–Haenszel odds ratio 3.094, confidence interval 0.4799–25.7]). Indeed, the observed detection of hyperplasia or cancer doubled in the symptomatic group, increasing from 9 to 18%, but did not increase significantly in the asymptomatic group. A subpopulation of 21 patients with a thickened ES were HR+ and underwent biopsy, while 72 patients with a thickened ES who were HR− underwent biopsy. 43% of HR+ patients manifested endometrial hyperplasia vs 8% in the HR− group ( P = 0.0022). Endometrial fluid was present in 23 patients. The one patient with EF who was determined to have endometrial hyperplasia also had a thickened ES, was symptomatic and HR+. Conclusions: In the absence of symptoms, repeat sampling is not warranted in patients with a thickened ES and negative findings at initial abnormal biopsy. The presence of symptoms with a thickened ES warrants further diagnostic evaluation to determine an etiology. There was an association with hyperplasia in patients with a thickened ES who were HR+.