When You Don’t Look But You Do Find: Pragmatic Approach To Management Of Asymptomatic Endometrial Thickening In Postmenopausal Patients

The endometrium varies in thickness through the menstrual cycle, largely in response to estrogen and progesterone stimulation. Following menopause, the endometrium should remain homogenously atrophied due to the relatively low circulating levels of estrogen. In postmenopausal women, the endometrium is considered thickened when it measures greater than 5 mm. Measuring endometrial thickness includes assessing the width of the anterior and posterior layers of the endometrium made on the midline sagittal image obtained by transvaginal ultrasound. The principal objective of investigating a thickened endometrial lining is to diagnose endometrial hyperplasia or cancer. Patients who experience postmenopausal bleeding and are found to have an endometrial thickness greater than 5 mm necessitate endometrial sampling. However, whether endometrial sampling is required in the absence of symptoms, namely postmenopausal bleeding, is a more nuanced clinical decision. This article provides an approach to evaluating patients presenting with asymptomatic endometrial thickening, including a review of guidelines for when further testing is warranted. It will specifically address unique populations, namely patients using menopausal hormonal therapies as well as those on tamoxifen.