The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding
The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding
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DOI：
10.1097/aog.0000000000002631
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发表时间：
2018-05-01
影响因子：
7.2
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子宫内膜癌是美国最常见的妇科癌症类型。阴道出血是 90% 以上患有子宫内膜癌的绝经后妇女的症状。在评估绝经后出血时，还应考虑子宫内膜癌的临床危险因素，包括但不限于年龄、肥胖、使用非对抗性雌激素、特定的医学合并症（例如多囊卵巢综合征、2型糖尿病、宫颈细胞学筛查中的非典型腺细胞）以及妇科恶性肿瘤家族史。绝经后出血的临床方法需要及时有效的评估，以排除或诊断子宫内膜癌和子宫内膜上皮内瘤变。如果超声图像显示薄的子宫内膜回声（小于或等于 4 毫米），经阴道超声检查通常足以对绝经后出血进行初步评估，因为子宫内膜厚度为 4 毫米或以下，对子宫内膜癌的阴性预测值大于 99%。经阴道超声检查是子宫内膜取样的合理替代方案，是评估初次出血的绝经后妇女的首选方法。如果盲检未发现子宫内膜增生或恶性肿瘤，则在评估持续或复发性出血的女性时，需要进行进一步的检查，例如宫腔镜扩张和刮宫术。尽管根据患者特征和危险因素进行个体化评估是适当的，但在无出血的绝经后患者中偶然发现的子宫内膜测量值大于 4 毫米，无需常规触发评估。经阴道超声检查对于无出血的绝经后妇女来说不是子宫内膜癌的合适筛查工具。
Cancer of the endometrium is the most common type of gynecologic cancer in the United States. Vaginal bleeding is the presenting sign in more than 90% of postmenopausal women with endometrial carcinoma. Clinical risk factors for endometrial cancer, including but not limited to age, obesity, use of unopposed estrogen, specific medical comorbidities (eg, polycystic ovary syndrome, type 2 diabetes mellitus, atypical glandular cells on screening cervical cytology), and family history of gynecologic malignancy also should be considered when evaluating postmenopausal bleeding. The clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia. Transvaginal ultrasonography usually is sufficient for an initial evaluation of postmenopausal bleeding if the ultrasound images reveal a thin endometrial echo (less than or equal to 4 mm), given that an endometrial thickness of 4 mm or less has a greater than 99% negative predictive value for endometrial cancer. Transvaginal ultrasonography is a reasonable alternative to endometrial sampling as a first approach in evaluating a postmenopausal woman with an initial episode of bleeding. If blind sampling does not reveal endometrial hyperplasia or malignancy, further testing, such as hysteroscopy with dilation and curettage, is warranted in the evaluation of women with persistent or recurrent bleeding. An endometrial measurement greater than 4 mm that is incidentally discovered in a postmenopausal patient without bleeding need not routinely trigger evaluation, although an individualized assessment based on patient characteristics and risk factors is appropriate. Transvaginal ultrasonography is not an appropriate screening tool for endometrial cancer in postmenopausal women without bleeding.