Asymptomatic endometrial thickening in postmenopausal women


Dear Sir

Two recent articles [1, 2] in TOG have addressed the problem of how to manage incidental abnormal endometrial findings in asymptomatic postmenopausal women but have failed to clarify this issue. In their useful review of management of women with postmenopausal bleeding, Bakour et al.[2] cite evidence that follow up and/or treatment of endometrial polyps incidentally diagnosed in asymptomatic postmenopausal patients could safely be restricted to a few select cases based on polyp diameter. However, Annan et al.[1] recommend removal of all such polyps. Given that 10% of asymptomatic women are diagnosed with endometrial polyps, this represents a massive potential workload for hysteroscopic services. The main dilemma for clinicians is that the majority of asymptomatic postmenopausal polyps are diagnosed because of incidental finding of increased endometrial thickness on scans performed for investigation of non gynaecological symptoms. Bakour et al. appear to support a policy of offering hysteroscopy to all asymptomatic women with endometrial thickness over 6 mm, based on interpretation of data from the UK Collaborative Trial for Ovarian Cancer Screening (UKCTOCS).[3] The latter case-control study measured endometrial thickness in over 40 000 women, 133 of whom went on to develop endometrial cancer or atypical hyperplasia within 1 year of follow-up. Of the control group, 4878 women (13.3%) had endometrial thickness between 5 and 10 mm and 1116 (3%) between 10 and 20 mm but did not go on to develop cancer. Asymptomatic postmenopausal thickening is most commonly due to presence of a polyp and the overwhelming majority of such polyps are entirely benign.[1, 2] Surely the current recommendation should be that asymptomatic endometrial thickening in postmenopausal women should normally be ignored unless there are other features of concern and women reassured that the appearance is due to the presence of a small polyp which is most unlikely to do them any harm in the absence of any warning sign of bleeding? To do otherwise is to cause unnecessary worry, inconvenience and potential risk to thousands of women and add to the burden of already overstretched services.