What's new in endometrium care?

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Steven R. Goldstein, MD, discusses holes in clinicians' understanding of the endometrium, and how these knowledge gaps can be remedied.

Steven R. Goldstein, MD:

Well, I think based on what we heard at this meeting, there are some people who still don't seem to understand basic physiology of the menstrual cycle and what happens with the endometrium. The endometrium consists of a basalis and a functionalis. Estrogen causes the functionalis to proliferate when you ovulate or you give it progesterone or progestogen, it converts to a secretory phase. So, for instance, there was a presentation here, where they said the endometrial biopsy was done on a woman with bleeding and it was benign. She had been on hormone replacement therapy. I said, you need a new pathologist, because if she has proliferative endometrium, she has inadequate progestational effects, she needs additional progestogen. If she has secretory or inactive endometrium, that's what you'd like to see. So, if you're getting a report from your pathologist that says endometrium benign, you need to find a new person because there's a big difference. Now, granted, it's not cancer hyperplasia, but understanding what hormones either in the premenstrual phases do, or in the hormone replacement phase do to the endometrium will go a long way toward you understanding of how you're going to approach these patients, how you're going to work them up, how you may treat them or reassure them. And that's something that I realized is not that well understood by a lot of people based on what happened at this meeting.

Takeaways

  • Some individuals lack a basic understanding of the physiology of the menstrual cycle, specifically the changes in the endometrium in response to hormones like estrogen and progesterone.
  • It is crucial to correctly interpret endometrial biopsy results. Different endometrial states, such as proliferative or secretory, indicate varying hormonal effects, and benign results should not be assumed as sufficient.
  • Blind endometrial biopsies can be inaccurate, especially when cancer occupies less than 50% of the endometrial cavity. Negative biopsies are not definitive, and further evaluation is often necessary, especially for women with risk factors.
  • Sonohysterography and office hysteroscopy can help distinguish global from focal endometrial issues and provide better visualization than blind biopsies.
  • The idea of using a fixed 4-millimeter cutoff for endometrial thickness is not universally applicable. Clinical context and risk factors should guide decision-making regarding the need for further evaluation, even when measurements fall slightly below or above this threshold.

Steven R. Goldstein, MD:

I think the problem really stems from the fact that in most other areas, you do a biopsy, it's representative of the tumor. It's been shown time and time again 25 years ago, and finally in 2012, ACOG adopted this. If a cancer occupies less than 50% of the surface area of the endometrial cavity, a blind sampling, which we use interchangeably with the word biopsy, can be fraught with error. There have been numerous studies on women with cancer that showed miss rates as high as 33%, 17%, and there was just one study where it was 2.5%. And ACOG, went on record as saying that a negative biopsy is not a stopping point in these women that have suspicion for cancers, let's say, and that's premenopausal women with risk factors. Anybody over 40 or 45, and any postmenopausal woman who bleeds is cancer until proven otherwise. So, sure, you can start with the biopsy, but if it doesn't show cancer, or what we now call endometrial inter epithelial neoplasia, or what many of you think of as complex, atypical hyperplasia, you're not done. You're really, you know, and the problem is that the incidence of bad things is low enough that those clinicians who simply do the biopsy and then stop get away with it more often than not, but the workup is really not complete. What I've been saying for years is, I don't think you're entitled to really do a blind biopsy in my mind unless you first prove to me that the process is global and not focal. Now, not everybody has access to do that. Biopsies are easy to do in an office setting. So, sure, start with a biopsy but don't be overly reassured just because it doesn't show cancer.

Steven R. Goldstein, MD:

Sonohysterography can distinguish global from focal and office hysteroscopy, I think is definitely on par with saline infusion, whichever you're good at or have access to or easy to, that's visualization that's not a blind sampling. So, I would be all for that as well. You asked about the millimeters of thickness, and I'd say a word about that as well. Originally ACOG said you know 4 millimeters was some magical cutoff and I'm probably single handedly responsible for making that happen. Fortunately, the most recent committee opinion now gives risks of cancer for 3, 4, and 5 millimeters. And, you know, I shudder because machine can measure to a 100th of a millimeter, so people send the patient to radiology and get back a report, endometrium measures 3.96 millimeters, they sleep like a baby, measures 4.04, they feel they have to go all the way to get a piece of tissue to rule out cancer. Where is the thinking? For instance, if a patient has high risk, if a patient is obese, diabetic, had a history of PCOS, has postmenopausal bleeding, she may measure 3.2. I'm still concerned. She's a risk. I've said somebody else who's got to stand she's on Eliquis, there's an episode of bleeding, maybe she measures 4.8. Well, maybe I'll wait and see if she bleeds again. In other words, I think there needs to be some thinking. It's not just a written in stone, “4 millimeters applies to every single person.” You have to think about the clinical backdrop.

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