Translated Abstract
Background and Objective:
Asymptomatic postmenopausal women with endometrium thickened typically refers to postmenopausal women＇s endometrial thickness has increased and exceeds a certain thickness of cut-off point and without vaginal bleeding. As we all know, endometrial cancer is the second most common malignant tumor of the female reproductive tract, which seriously threatens women＇s health but could be properly treated if it is diagnosed in its early stages.Existing studies have demonstrated that postmenopausal endometrial thickening is associated with endometrial cancer and precancerous lesions, while there exist significant differences on clinical diagnosis between symptomatic and asymptomatic postmenopausal endometrial thickening, which mainly refers to the choice of cut-off point for pathological examination [1-3]. A large number of data indicate that postmenopausal women with symptoms and endometrium thickness ≥4 mm have a higher risk of malignancy [4-6], which is widely adopted that 4 mm is the cut-off point for endometrial pathological examination in symptomatic populations after menopause. Due to the popularity of ultrasonography and increased awareness of women＇s health, the number of asymptomatic endometrial thickening after menopause has increased. However, this group of patient lacks proper management strategies and the consensus on endometrial thickness has not been reached. In 2009, the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommended 11 mm for the endometrial thickness for these patients[7]. In 2014, Giannella completed a prospective study of 258 women with postmenopausal asymptomatic endometrial thickening and lesions. The results showed that 8mm had the best sensitivity and specificity as the cut-off point [8]. A retrospective analysis performed by Louie et al.[9] in 2016 suggested that the cut-off point for asymptomatic thickening of women after menopause should be 14-15 mm. If postmenopausal women with asymptomatic endometrial thickening are treated according to the cut-off points of symptomatic women, it will inevitably lead to inappropriate clinical treatment. Furthermore, it has been discussed that it would increase excessive medical treatment, cause waste of medical resources, and make this part of women suffer from tremendous physiology and Psychological pressure[10]. Therefore, the cut-off point of endometrial thickness of asymptomatic endometrial thickening after menopause has become popular research topic around the world.
The most widely used methods of endometrial evaluation currently rely on traditional dilatation and curettage (D&C) and hysteroscopic histological examinations. However, the use of histological examination in asymptomatic postmenopausal women with endometrial thickening usually results in low sensitivity and high rate of missed diagnosis. Besides, the pain and serious complications caused by such sampling process are often difficult to accept by patients. Therefore, scholars tend to use cytopathology for early endometrial cancer and precancerous lesions in recent years, especially for endometrial assessment of high-risk groups of endometrial cancer. In 2006, Zhao Jian’s research found that endometrial pathological examination can not only improve the patient’s feelings during and after surgery, but also can obtain high diagnostic accuracy. It can achieve better treatment in early detection and early intervention of endometrial cancer[11, 12]. In 2016, Du J. et al.[13]observed that the endometrial cytopathology had a higher diagnostic efficiency for endometrial cancer, with a sensitivity of 78% to 100% and a specificity of 66% to 100%. Similarly, in 2017, the Expert Committee on Endometrial Cancer Screening in China published the Expert Consensus for Screening and Early Diagnosis of Endometrial Carcinoma (Draft), confirming the Advantages and feasibility of endometrial cytopathological examination in endometrial cancer screening[14].
This study analyzed 59 asymptomatic postmenopausal women with endometrium thickening (≥4mm). Based on which, our work aims to sum up the cytopathology features in those patients, and to seek the best cut-off point of asymptomatic postmenopausal women with endometrium thickening. Furthermore, we propose to explore the relevance of endometrial thickening and the risk of endometrial cancer in this population, and to provide a theoretical basis for the clinical management of asymptomatic postmenopausal women with endometrium thickening. By achieving the above goals, we may reduce unnecessary medical waste, and achieve accurate screening and management of this population.
Methods:
Patients’ information is collected from October 2016 to October 2017 at the First Affiliated Hospital of Xi’an Jiao tong University, who has been in menopause for over at least 1 year, endometrium thickness is larger than 4mm with no clear symptoms (including vaginal bleeding and bellyache etc.) and meets the enrollment conditions of our work. After excluding relevant contraindications, we informed patient with the potential risks and benefits and an informed consent form (Appendix B) was signed after we obtained the consent from both patients themselves and their family. In order to build the original database from patients, we first collected endometrial cells using “Li brush” tool in our work, then the sampled cells were sent to the Department of Pathology in our Hospital for further analyzes, including a liquid-based thin-layer preparation and HE cell staining, and finally pathological cytology experts determined the results for diagnosis. According to these procedures, we created an Excel database of each patients’ clinical diagnosis results, and then all the data were analyzed by SPSS 19.0 software. Specifically, we first represented all the data distribution using its mean and standard deviation, and several statistical analysis methods were conducted, including chi-square test for qualitative data, independent samples t test and single-factor test for quantitative data, in which the significance were all measured by p value and p ＜ 0.05 indicates statistically significant exists across different data distributions.
Results:
1. Clinical characteristics of the patients: The mean age of asymptomatic endometrial thickening in 59 postmenopausal patients is 58.8 years (47-80 years), mean menopause time is 106.2 months (12-360 months), and average endometrial thickness is 8.4mm (4 -21mm).All patients have given birth, of which 11 cases were diagnosed with diabetes, 7 cases of hypertension, average weight is 61.2kg (49-80kg), average BMI is 23.56 (19.81-30kg/m2).
2. Cytopathology features in asymptomatic postmenopausal women with endometrial thickening
1) Cytopathology features: The cytopathology features of 59 patients are shown as follows: The benign changes of the endometrium accounts for 95% of the total, which contains 20 patientsin the atrophic endometrium group, which accounts for 34% in that group. Specifically, the average age is 61.9 years, the average menopause time is 145.2 months, and the average endometrial thickness is 7.34mm (4-14mm) in that group. Apart from that, there are 36 patients in the proliferative endometrium group, accounting for 61% of the total. From which we observe that the average age, the average menopause time, the average endometrium thickness are 56.3 years,77.6 months, and 8.95mm (4.4-21mm) respectively. Finally, the endometrial cancer group had 3 patients, accounting for 5% of the total. In details, the average age is 68 years, the average menopause time is 188.4 months, and the average endometrial thickness is 9.9mm (9-11mm) in this group.
2) Comparison of age, menopause time and intimal thickness between different cytopathology groups: There is a statistically significant difference in age and menopause between the three groups (p=0.005, ＜0.05). The patients in the endometrial cancer group are the oldest, with an average age of 68 years, and the average menopause is the longest, averaging 188.4 months.Besides, the proliferative endometrium group has the youngest patients with an average age of 56.3 years and the shortest average 77.6 months of menopause time.There is no statistical difference in endometrial thickness between the three groups (p=0.155, ＞0.05). In addition, 59 patients are grouped according to age but no significant difference is found in endometrial thickness between different age groups (P=0.525, ＞0.05).
3) Comparison of obesity, diabetes, and hypertension among different cytopathology groups: There is no statistical difference between the three groups in the prevalence of diabetes and hypertension (all P＞0.05). In addition, there is a statistically significant difference in BMI between the three groups (P=0.015, ＜0.05), with the highest BMI of the endometrial cancer group being 25.6 kg/m2 and the smallest BMI of the atrophic endometrium group being 22.52 kg/m2. In addition, 59 patients were grouped according to BMI and no significant difference is found in endometrial thickness between different BMI groups (P=0.231, ＞0.05).
4) Endometrial thickness in the benign endometrium cytopathology group and the endometrial cancer group: There is no significant difference in the intimal thickness between the atrophic endometrium group and the endometrial cancer group (P=0.116, ＞0.05). There is no statistically significant difference in the intimal thickness between the proliferative endometrium group and the endometrial cancer group (P=0.655, ＞0.05).
3. Thecut-off point in asymptomatic postmenopausal women with endometrium thickening：Asymptomatic endometrium thickening endometrium thickness cut-off point after menopause: When the endometrium is 9mm, the sensitivity for the diagnosis of endometrial cancer is 100%, the specificity is 64.3%, and the norden index is 0.6.
Conclusions:
1. Asymptomatic endometrial thickening in postmenopausal women with endometrial thickening is mainly benign. The proportion of atrophic endometrium and proliferative endometrium is 95%, and the proportion of patients with endometrial cancer is 5 %;
2. The postmenopausal asymptomatic endometrium thickening of the intimal thickness at the border point of 9mm, has good diagnostic efficacy for endometrial cancer and precancerous lesions.
Translated Keyword
[asymptomatic, Cut-off Point, Cytopathology, Endometrial thickening, Postmenopausal]
Corresponding authors email
