Note: The Summary of Evidence section summarizes the published evidence on this topic. The rest of the summary describes the evidence in more detail.
Other PDQ summaries on
Transvaginal Ultrasound: Benefits
There is no evidence that screening by ultrasonography (e.g., endovaginal ultrasound or transvaginal ultrasound) reduces mortality from endometrial cancer. Most cases of endometrial cancer (85%) are diagnosed at low stage because of symptoms, and survival rates are high.
Transvaginal Ultrasound: Harms
Based on solid evidence, screening asymptomatic women will result in unnecessary additional biopsies because of false-positive test results. Risks associated with false-positive tests include anxiety and complications from biopsies.
Study Design: Evidence obtained from cohort studies. |
Internal Validity: Fair. |
Consistency: One study for endometrial biopsy and one study for hysteroscopy. |
Magnitude of Effects on Health Outcomes: Small negative magnitude. |
External Validity: Fair. |
Endometrial Sampling (Biopsy): Benefits
There is inadequate evidence that screening by endometrial sampling (i.e., biopsy) reduces mortality from endometrial cancer. Most cases of endometrial cancer (85%) are diagnosed at low stage because of symptoms, and survival rates are high.
Endometrial Sampling (Biopsy): Harms
Based on solid evidence, endometrial biopsy may result in discomfort, bleeding, infection, and rarely, uterine perforation.
Study Design: Evidence obtained from cohort studies. |
Internal Validity: Fair. |
Consistency: One study for endometrial biopsy and one study for hysteroscopy. |
Magnitude of Effects on Health Outcomes: Small negative magnitude. |
External Validity: Fair. |
Epidemiology of Endometrial Cancer
Incidence and mortality
Endometrial cancer is the most common invasive gynecologic cancer in U.S. women, with an estimated 67,880 new cases expected to occur in 2024 and an estimated 13,250 women expected to die of the disease.[
Risk Factors
Estrogen therapy unopposed by progesterone therapy is a cause of endometrial cancer in women with an intact uterus. However, women taking combination estrogen-progesterone therapy (hormone therapy) exhibit similar risk to women who do not take postmenopausal hormone therapy.[
In addition to the increased risk of developing endometrial cancer that is observed in women who use unopposed estrogen therapy or tamoxifen, a number of additional risk factors have been identified, and most appear to be related to estrogenic effects. Among these factors are obesity, a high-fat diet, and reproductive factors such as nulliparity, polycystic ovary syndrome, early menarche, and late menopause. Hereditary nonpolyposis colorectal cancer (HNPCC) syndrome is associated with a markedly increased risk of endometrial cancer compared with women in the general population. Among women who are HNPCC carriers, the estimated cumulative incidence of endometrial cancer ranges from 20% to 60% by age 70 years (for more information, see
Major differences exist between Black and White women in stages of endometrial cancer at detection and at subsequent survival. Although the incidence of endometrial cancer is lower among Black women, mortality is higher. The National Cancer Institute initiated a Black/White Cancer Survival Study [
References:
Measuring endometrial thickness (ET) with transvaginal ultrasound (TVU) and endometrial sampling with cytological examination have been proposed as possible screening modalities for endometrial cancer. The Papanicolaou (Pap) test, used successfully for screening for cervical cancer, is too insensitive to be used as a screening technique for the detection of endometrial cancer,[
Routine screening of asymptomatic women for endometrial cancer has not been evaluated for its impact on endometrial cancer mortality.[
Modalities of Endometrial Cancer Screening
Ultrasonography in women with vaginal bleeding
TVU is used as a diagnostic tool to evaluate symptomatic women with vaginal bleeding. Among women with postmenopausal uterine bleeding and cancer, 96% will have an abnormal ET (>6 mm). The specificity varies by whether women used hormone therapy. Among nonusers, the specificity was 92%.[
A group of researchers used dilation and curettage (D&C) as a gold standard, to evaluate TVU measurement of ET as a predictor of endometrial cancer in women reporting postmenopausal bleeding (PMB) (estrogen-progestin therapy [hormone therapy] and nonhormone therapy users). Of the 339 participants, 39 (11.5%) were diagnosed with endometrial cancer (four had an ET of 5–7 mm and 35 had an ET >8 mm) based on histopathology from curettage. No cancers were detected in women with an ET of less than 4 mm. Using a cutoff point of 4 mm, TVU has 100% sensitivity and 60% specificity.[
Ultrasonography in women without vaginal bleeding
A comparison of TVU and endometrial aspiration was conducted among asymptomatic postmenopausal women potentially eligible for an osteoporosis prevention trial [
One study assessed the usefulness of TVU among a cohort of postmenopausal, asymptomatic women receiving hormone therapy. Utilizing the Postmenopausal Estrogen and Progestin Interventions Trial participants who had undergone both TVU and endometrial biopsy, sensitivity, specificity, positive predictive value, and negative predictive value were determined for women who received placebo, estrogen alone, and estrogen-progestin therapy. At a threshold value of 5 mm for ET, TVU had 90% sensitivity and 48% specificity. Using this threshold, more than half the women would receive a biopsy while only 4% of them had serious disease.[
Another study obtained endometrial biopsy specimens from 801 asymptomatic perimenopausal and postmenopausal women prior to enrollment in a hormone therapy study. Of the specimens, 75% of the samples contained sufficient tissue for diagnosis. Among these women, one case of endometrial cancer was diagnosed, illustrating the low yield of screening among asymptomatic women and the difficulty with endometrial cavity access.[
Although TVU can be used to evaluate asymptomatic and occult endometrial pathology, the technique has not been evaluated as a screening method for reducing mortality in asymptomatic women.
Ultrasonography in women using tamoxifen
Tamoxifen is widely used as part of adjuvant therapy for breast cancer and as chemoprevention for women at increased risk of breast cancer. In addition to the protective effects for breast cancer, the biological and endocrine effects of tamoxifen increase patients' risk of developing endometrial pathology, including endometrial polyps, endometrial hyperplasia, and endometrial carcinoma.
There is interest in trying to reduce the morbidity from endometrial cancer through early detection, and there has been interest in using endovaginal ultrasound as a method to screen women to detect endometrial cancer.
In a prospective, observational study of 304 women using tamoxifen over 6 years, women underwent annual endovaginal ultrasound screening; women with abnormal ultrasound findings and women who were symptomatic with bleeding all underwent endometrial biopsy. Thirty-two percent of the ultrasound examinations had associated significant uterine abnormalities identified that required further medical or surgical investigation and treatment. However, most abnormalities (80%) represented benign polyps for which no treatment was needed. Six cases of primary endometrial cancer were detected, and all cases presented with irregular bleeding. The sensitivity of ultrasound was only 63.3%, with a specificity of 60.4%, and had a low positive predictive value for cancer of only 1%.[
Other reports have noted similar results. Routine ultrasound surveillance in asymptomatic women using tamoxifen is not useful because of its low specificity and low positive predictive value. Evaluation of the endometrium in women taking tamoxifen should be limited to women symptomatic with vaginal bleeding.
Sonohysterography
Sonohysterography (hydrosonography) is a diagnostic test used to help guide biopsies in asymptomatic women that is able to separate space occupied by endometrial lesions from an abnormal endometrial-myometrial junction. There is no evidence that routine screening sonohysterography will confer clinical benefit.
Endometrial sampling in women with uterine bleeding
In the setting of abnormal uterine bleeding, endometrial sampling has gained favor largely as an alternative to more invasive procedures such as fractional D&C. Several methods of biopsy exist (e.g., Pipelle, Tao Brush, and Uterine Explora Curette) to identify endometrial pathology. Although endometrial sampling has largely replaced D&C as the first choice in the evaluation of women with bleeding, issues of access to the endometrial cavity and sampling error limit the clinical significance of a negative result. In the Arimidex, Tamoxifen, Alone or in Combination trial, 36% of biopsies had insufficient tissue for diagnosis. A meta-analysis of PMB reported that 91% (95% confidence interval [CI], 87%–93%) of women with endometrial cancer reported PMB. However, among women with PMB, only 9% (95% CI, 8%–11%) were diagnosed with endometrial cancer. This report is limited by a lack of histology-specific estimates.[
No studies have evaluated the use of endometrial sampling as routine screening in reducing endometrial cancer mortality.
Hysteroscopy
Hysteroscopy is used in the office setting to directly visualize the uterine cavity. A group of researchers noted that hysteroscopy is not as useful in detecting endometrial cancer as biopsy or D&C.[
References:
Hormone Therapy
There is no evidence to suggest that screening women prior to or during estrogen-progestin therapy, also known as hormone therapy, would decrease endometrial cancer mortality.[
Hereditary Nonpolyposis Colorectal Cancer
The lifetime risk of endometrial cancer for women with hereditary nonpolyposis colorectal cancer (HNPCC) and for women who are at high risk for HNPCC is as high as 60%. These cases are often diagnosed in the fifth decade, 10 to 20 years earlier than sporadic cases.[
Women Treated With Tamoxifen
The risk of endometrial cancer is increased in women who are treated with tamoxifen and is even greater in the subset of women who have a history of prior estrogen therapy.[
Endometrial cancers that occur in tamoxifen-treated women are very similar to those cancers occurring in the general population, with respect to stage, grade, and histology.[
There have been no published studies evaluating the effect of endometrial cancer-screening modalities on mortality among women taking tamoxifen for breast cancer treatment or prevention.
References:
Abnormal ultrasound typically requires further investigation including endometrial biopsy (sampling). The evidence is solid that endometrial sampling may result in discomfort, bleeding, infection, and rarely uterine perforation. A study designed to evaluate performance, patient acceptance, and cost-effectiveness of blind biopsy, hysteroscopy with biopsy, and ultrasound, in 683 women with vaginal bleeding, reported that minor events, including discomfort and distress, occurred in 16% of women who had hysteroscopy with biopsy, and in 10% of the women who had a blind biopsy.[
References:
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This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about endometrial cancer screening. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
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PDQ® Screening and Prevention Editorial Board. PDQ Endometrial Cancer Screening. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at:
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Last Revised: 2024-03-15
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