Endometrial Biopsy in an Outpatient Gynaecological Setting: Overinvestigation

Objective

We reviewed the indications for endometrial biopsy at the general gynaecology outpatient clinic of the Université de Montréal Hospital Center and measured their compliance with the Society of Obstetricians and Gynaecologists of Canada and other international guidelines.

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.     

Diagnosis and therapy of low-risk endometrial hyperplasia. Experience with LH-RH-A]

Endometrial hyperplasia is a endometrial condition often found in perimenopausal age. AUB is the most frequent symptom of endometrial hyperplasia. The combination of hysteroscopy and endometrial biopsy is the most suitable approach for the diagnosis of endometrial hyperplasia in symptomatic patients. The Authors have studied endometrial modifications due to LH-RH analogue, a depot formula, in 60 perimenopausal patients with AUB and with hysteroscopic and histologic picture of low-risk endometrial hyperplasia. They report the result of treatment efficacy (disappearance of symptoms and tendency to hypoatrophy of the mucosa). The use of LH-RH A seems to have a good result in the management of oestrogen-dependent gynaecological benign diseases.     

Endometrial Biopsy in Low-Risk Women: Are We Over-Investigating?

The appropriate age at which to perform endometrial biopsy for abnormal uterine bleeding (AUB) is controversial. This study aimed to determine the prevalence of malignant and premalignant pathologies in women aged 41–49 years with AUB and without risk factors for endometrial cancer. Records of women who had undergone a biopsy at the gynaecology clinic of the Centre hospitalier de l'Université de Montréal between 2014 and 2018 were reviewed. Of the 209 women included in the study, 2 had atypical hyperplasia, which resolved without treatment, and 3 had hyperplasia without atypia. The remaining women had benign results, showing that the prevalence of malignant and premalignant endometrial pathologies is low in this subgroup of patients.     

Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding

STUDY OBJECTIVE: To validate hysteroscopic view with histology in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding (AUB) DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospitals in Rio de Janeiro and S?o Paulo, and private office in Rio de Janeiro. PATIENTS: Four thousand and fifty-four patients with AUB in whom hysteroscopic views were complete and the histologic result was conclusive. INTERVENTION: Four thousand and fifty-four office hysteroscopies with complete views and conclusive histologic results. The material for histologic examination was obtained through biopsy of the lesion in an outpatient unit or through the resection of the entire lesion in patients who underwent surgery. Histology was considered the "gold standard" and compared with the hysteroscopic view. MEASUREMENTS AND MAIN RESULTS: In the histology of the 4054 examinations, 613 (15.2%) were endometrial hyperplasia, and 105 (2.6%) were endometrial cancer. The most frequent hysteroscopic finding was endometrial polyps (31.2%). In endometrial hyperplasia, the sensitivity of the hysteroscopic view was 56.3% (95% CI 52.2%-60.2%), specificity was 89.1% (95% CI 88.0%-90.1%), positive predictive value (PPV) was 48.0% (95% CI 44.3%-51.7%), negative predictive value (NPV) was 92.0% (95% CI 90.1%-92.9%), and accuracy was 72.7% (95% CI 70.7%-74.7%). Accuracy was defined as the proportion of correct results among the hysteroscopic examinations. In endometrial cancer, the sensitivity of the hysteroscopic view was 80.0% (95% CI 71.1%-87.2%), specificity was 99.5% (95% CI 99.2%-99.7%), PPV was 81.5% (95% CI 72.7%-88.5%), NPV was 99.5% (95% CI 99.2%-99.7%), and accuracy was 89.8% (95% CI, 85.9%-93.6%). In the 814 patients (20.0%) in whom the hysteroscopic view was normal, there were no false negatives for endometrial cancer; however, there were 37 (4.5%) false negatives for endometrial hyperplasia. In the histologic cases of endometrial cancer, 101 (96.2%) hysteroscopic views were compatible with cancer or hyperplasia (80.0% and 16.2%, respectively). Ninety-seven out of 103 hysteroscopic views with cancer findings (94.2%) had histologic diagnosis of cancer or hyperplasia (81.5% and 12.6%, respectively). CONCLUSION: It seems that even in face of good validity of hysteroscopic view for endometrial hyperplasia and cancer, histologic study is mandatory in the presence of any lesion as the hysteroscopic view cannot completely replace the histologic study in patients with AUB.     

Resectoscopic surgery in 10 women with abnormal uterine bleeding and atypical endometrial hyperplasia

STUDY OBJECTIVE: To evaluate the role of the resectoscope in the diagnosis and treatment of women with abnormal uterine bleeding (AUB) and atypical endometrial hyperplasia. DESIGN: Retrospective case series (Canadian Task Force classification III-3). SETTING: University-affiliated teaching hospital. PATIENTS: Ten women. Intervention. Hysteroscopic evaluation after preoperative endometrial biopsy indicated simple hyperplasia without atypia, complex hyperplasia with atypia, or inadequate specimen. MEASUREMENTS AND MAIN RESULTS: Atypical hyperplasia was confirmed in eight patients after total endomyometrial resection. Hysterectomy was offered to all patients but accepted by only two: one for bilateral ovarian serous cystadenomas and the second for a granulosa cell ovarian tumor. No residual endometrium was found in hysterectomy specimens. Seven women were amenorrheic and well 1 to 9 years after resection. An additional patient with amenorrhea died from colon cancer 2 years after resection. CONCLUSION: Resectoscopic surgery confirmed or detected atypical endometrial hyperplasia in eight women and excluded it in two patients with AUB and a previous diagnosis of simple hyperplasia, atypical hyperplasia, or inadequate specimen. Skillful resectoscopic surgery may be an alternative to hysterectomy in selected patients with atypical hyperplasia who are compliant with regular and long-term follow-up.     

Investigation of abnormal uterine bleeding in perimenopausal women by hysteroscopy and endometrial biopsy

The causes of abnormal uterine bleeding (AUB) during the perimenopausal period in women receiving hormone replacement therapy (HRT) were investigated, along with the causes of postmenopausal bleeding, the efficacy of hysteroscopy in the diagnosis of endometrial pathology was investigated. The patients studied were referred to our academic gynaecological clinic during the period 1999–2003. 145 cases that had undergone hysteroscopy and endometrial biopsy for AUB during the perimenopausal period over the last four years were reviewed retrospectively. The main group (76 patients) presented AUB while they were taking sequential or continuous HRT for menopausal symptoms and to prevent osteoporosis. The control group (69 patients) presented postmenopausal bleeding. There was an increased incidence of endometrial pathology in the group receiving HRT in comparison with the control group (52.6% vs. 40.4%), but this difference was not significant. The main findings were functional endometrium (38.1%) in the group receiving HRT and atrophic endometrium (40.6%) in the control group, respectively. These differences were statistically significant between the two groups. Diagnostic hysteroscopy was performed successfully with no serious complications and was performed without anesthesia in over 30% of the patients in both groups. The incidence rates of the structural endometrial causes of AUB in perimenopausal period are similar in women taking HRT and those presenting postmenopausal bleeding. Hysteroscopy is a safe and efficient method of investigating women with AUB during the perimenopausal period. In addition, the increasing use of outpatient hysteroscopy will simplify assessments of patients presenting with AUB during the perimenopausal period.     

Which surgical procedure for patients with atypical endometrial hyperplasia?

OBJECTIVE: To determine the occult coexistence of endometrial carcinoma in patients with atypical endometrial hyperplasia and to compare histological prognostic factors according to lymph node status in occult endometrial carcinoma. MATERIALS AND METHODS: Two hundred and four patients from two referral centers (during the period 1990-2003) who were operated on within 1 month of endometrial biopsy for symptomatic endometrial hyperplasia without receiving any medical treatment were included retrospectively. Patients having preoperative endometrial biopsy results of concomitant endometrial hyperplasia and carcinoma were excluded from the study. Fifty-six patients having atypia in preoperative biopsy (group I) were compared with 148 patients without atypia (group II). Chi-square and Mann-Whitney U-tests were used for statistical analyses. RESULTS: No significant difference was observed between the two groups according to age or menopausal status. Patients in group II had significantly higher parity than patients in group I. In group I, 62.5% of the patients had endometrial carcinoma, 21.4% had endometrial hyperplasia, and 16.1% had normal endometrium in hysterectomy specimens. In group II, the percentages were 5.4, 38.5, and 56.1%, respectively. Complete surgical staging was performed in 20 patients. Four patients had metastatic lymph nodes. All of them had grade 2 tumors with lymphovascular space involvement. Three of them had nonendometrioid tumors. CONCLUSION: Careful intraoperative and preoperative evaluation of the endometrium must be the sine qua non for patients with atypical endometrial hyperplasia. It is reasonable to do frozen section at the time of hysterectomy for atypical endometrial hyperplasia, and if grade 2/3 of nonendometrioid cancer with lymphovascular space involvement is found, complete surgical staging should be performed.     

Hysteroscopy as a diagnostic method in postmenopausal metrorrhagia]

We performed 215 hysteroscopies for post-menopausal bleeding. The most common abnormalities found were endometrial hypoatrophy and low-risk hyperplasia, the less common high-risk hyperplasia and adenocarcinoma of the endometrium. The correlation between hysteroscopic view and endometrial sampling was always very high. Hysteroscopy seems to be a very accurate method for evaluating patients with post-menopausal bleeding especially if associated with endometrial sampling.     

Surgery without radiotherapy for primary treatment of endometrial cancer

Objective: To analyze the role of surgery alone, including pelvic and para-aortic lymphadenectomy, in patients with endometrial cancer who did not receive radiotherapy.Methods: Between August 1987 and January 1997, 225 women with disease clinically confined to the uterus were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy in women with high risk factors. No radiation was administered before or after surgery.Results: The combination of preoperative endometrial biopsy grade and gross depth of myometrial invasion identified 123 (55%) high-risk patients who had lymphadenectomy and 102 (45%) low-risk patients who did not. Eighteen (15%) high-risk patients had lymph node metastases and received postoperative systemic therapy. Three low-risk, eight high-risk-node-negative, and no high-risk-node-positive patients were diagnosed with recurrent cancer, corresponding to 5-year recurrence-free proportions of 0.95, 0.89, and 1.00, respectively. Although sample sizes and limited follow-up limit conclusions, the experience to date suggests a high rate of survival in all three groups.Conclusion: Our preliminary experience indicates that even high-risk patients have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.     

宫腔镜联合B超在异常子宫出血中的诊断价值

目的评价宫腔镜联合B超对异常子宫出血的诊断价值。方法应用宫腔镜联合B超检查异常子宫出血106例。术中行定位取材或诊断性刮宫。结果宫腔镜联合B超诊断子宫内膜增生过长35例，符合率为65．71％；子宫内膜息肉28例，符合率为96．42％；子宫黏膜下肌瘤10例，符合率为90．00％；子宫内膜癌2例，符合率为100．00％。结论官腔镜联合B超检查对异常子宫出血可以提高对子宫内膜息肉及子宫黏膜下肌瘤的诊断率。尽管对子宫内膜增生过长及子宫内膜癌的敏感性与单纯诊刮相似，但可观察到更详细的形态学变化。     

Hormonal replacement therapy and evaluation of intrauterine pathology in postmenopausal women: a ten-year study

BACKGROUND: To evaluate the role of hormonal replacement therapy (HRT) in determining: a) abnormal uterine bleeding (AUB); b) increased endometrial thickness at transvaginal sonography (TVS); c) the correct indication for outpatient hysteroscopy (HS) and biopsy in diagnosing intrauterine pathology. METHODS: Between April 1991 and April 2001 a group of 3,400 postmenopausal women was referred to the Department of Obstetrics and Gynecology of Rome University "La Sapienza"; 16.7% of them had received HRT. 587 out of the 3,400 women were recruited for a comparative study, including four groups. To assess statistical significance of HRT in determining AUB, and/or endometrial thickness related to malignant disease the chi-square test was used; p < 0.05 was considered significant. Histology was considered the true result (control). RESULTS: An increase in the endometrial thickness occurred significantly more often in women on HRT (p < 0.03); as well as the percentage of AUB (p < 0.0001). No difference in the incidence of endometrial adenocarcinoma was reported between the HRT and the non HRT groups. CONCLUSIONS: In postmenopausal women using HRT we can confirm that a higher incidence of signs (AUB, endometrial thickness > or = 5 mm) does not coincide with a higher incidence of malignant pathology. The data obtained from the recruited patients was arranged and evaluated by the most suitable methods for screening endometrial adenocarcinoma. According to our experience, we believe a cut-off point of 8 mm to be significant (p < 0.001) to perform an hysteroscopy and biopsy except for asymptomatic patients on HRT.     

Outpatient hysteroscopy in the diagnosis of neoplastic and preneoplastic lesions of the endometrium

The results of a study performed on a case series of 250 women treated in our out-patient department for abnormal uterine bleeding are reported. Half of these patients (125) were 45 years of age or over and therefore at risk of adenocarcinoma or endometrial hyperplasia while the other half were under 45 years of age. All the patients were submitted to hysteroscopic examination as out-patients (no important side-effects occurred), together with cytologic and/or histological examination of the endometrium. This procedure revealed no disease in 59 cases (23.6%) and the presence of one or more benign conditions in 188 patients (75.2%) (inflammation, polyposis, myomatosis, endocervical or uterine adenomiosis, endometrial hyperplasias, dysfunctional patterns, intrauterine foreign bodies). Endometrial adenocarcinoma was diagnosed in 3 patients (1.2%). The discovery of 3 cases (1.2%) of adenocarcinomas and 62 cases (24.8%) of endometrial hyperplasias (58 simple glandular hyperplasia, 3 cystic-glandular hyperplasias and 1 polypoid hyperplasia) emphasive the reliability of hysteroscopy in the diagnosis of endometrial neoplasias and their precursors.     

Hysteroscopy with directed biopsy versus dilatation and curettage for the diagnosis of endometrial hyperplasia and cancer in perimenopausal women

BACKGROUND: The present study was undertaken to compare the effectiveness of dilatation and curretage (D&C) with hysteroscopy and guided biopsy (H+B) for the collection of endometrial samples adequate for histological examination in perimenopausal women at risk of endometrial hyperplasia or cancer. METHODS: We performed hysteroscopy and biopsy followed by dilatation and curettage in 734 patients with abnormal perimenopausal bleeding or sonographically revealed endometrial pathology. Two hundred and ninety-two patients in whom lesions were totally removed during hysteroscopy were excluded from further study. RESULTS: Using both methods we disclosed 64 cases of endometrial polyps, 60 cases of endometrial hyperplasia, and 49 cases of endometrial cancer. Hysteroscopy left just four cases of endometrial pathology undiagnosed as opposed to 21 cases using dilatation and curettage. Histology could not be performed on material obtained with hysteroscopy in four cases and with curettage in 23 cases. CONCLUSIONS: 1) Hysteroscopy with directed biopsy is more sensitive in disclosing all types of uterine lesions than dilatation and curettage. 2) Curettage done after hysteroscopy and directed biopsy does not improve the detection of endometrial cancer.     

Endometrial hyperplasia and the risk of carcinoma

Recent reports suggest that atypical endometrial hyperplasia diagnosed by biopsy or curettage is accompanied by a higher than expected risk of coexistent invasive cancer. In order to test this hypothesis we reviewed the pathology and clinical history of all patients at our institution who underwent hysterectomy for endometrial hyperplasia with or without cytologic atypia. We found 24 patients of 45 with a preoperative diagnosis of hyperplasia with cytologic atypia, and 21 with simple or complex hyperplasia without atypia. No cancers were found at surgery in the latter group nor were any significant historical differences found between the two groups. Of the patients with atypia, 12/24 (50%) had an endometrial carcinoma and nine patients (37.5%) were stage IB or greater. This is a significantly greater risk than previously reported in the literature. Endometrial hyperplasia with cytologic atypia may carry a higher risk of coexistent invasive endometrial carcinoma than previously believed. Methods to identify those patients at highest risk should be determined.     

Clinical over- and under-estimation in patients who underwent hysterectomy for atypical endometrial hyperplasia diagnosed by endometrial biopsy: the predictive value of clinical parameters and diagnostic imaging

OBJECTIVE: The aim of this study was to analyze the clinical and imaging characteristics in patients diagnosed with atypical endometrial hyperplasia based on endometrial biopsy in comparison with the final diagnosis from resected uteri; i.e. to determine the rates of underestimation (endometrial cancer), equivalent diagnosis (atypical hyperplasia), and overestimation (hyperplasia without atypia or non-hyperplastic lesion). MATERIALS AND METHODS: We reviewed 33 patients who were diagnosed with atypical endometrial hyperplasia by endometrial biopsy using a small curette and then underwent total abdominal hysterectomy between September 1992 and May 2002. Clinical parameters obtained from patients' charts, and imaging analyses using transvaginal ultrasonography (TUS) and magnetic resonance (MR) imaging were retrospectively re-examined. RESULTS: Among 33 patients who underwent hysterectomy due to a diagnosis of atypical hyperplasia, nine cases (27.2%) were underestimated (cancer), nine cases (27.2%) were equivalent and 15 cases (45.6%) were overestimated as indicated by examination of the endometrium of the resected uterus. There was no difference among these groups in either clinical parameters or diagnostic images obtained by TUS or MR. CONCLUSION: Diagnosis of atypical endometrial hyperplasia by endometrial biopsy often resulted in under- or over-estimation, as shown by examination after hysterectomy. As there is neither a reliable clinical parameter nor imaging feature to distinguish between these groups, hysterectomy is still the best treatment for these patients if they are willing to give up their fertility.     

Postoperative radiotherapy in stage I endometrial adenocarcinoma

OBJECTIVE: To evaluate postoperative whole pelvic radiation for high-risk patients with Stage I endometrial adenocarcinoma. METHODS: One hunderd and twenty-two patients with irregular premenopausal or postmenopausal haemorrhage were included into the study. Fractional curettage was performed in all cases. When the pathohistological report confirmed endometrial adenocarcinoma, abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Low-risk patients include women with Stage IA tumours and Stage IB grade 1 or 2 histology. High-risk group include patients with Stage IB grade 3 tumours and Stage IC carcinomas. High-risk patients received whole pelvic radiotherapy between two and four weeks after surgery. RESULTS: Eighty-two patients (67.21%) were low-risk and forty patients (32.79%) were high-risk. In the low-risk group of patients, CA-125 was negative in ten cases and positive in 72 patients with a mean value of 30.12 +/- 12.42 U/ml serum. In the high-risk group of the patients, CA-125 was negative in two cases and positive in 38 patients with a mean value of 60, 48 +/- 20, 14 U/ml serum. Locoregional recurrences were diagnosed in four patients (4.87%) in the surgery group and in two patients (5.00%) assigned to radiotherapy. The incidence of distant metastases was 2.43% in the surgery group and 2.50% in the radiotherapy group. Overall survival at five years was 90.25% in the low-risk group and 87.50% in the high-risk group of patients. CONCLUSION: Five-year overall survival, locoregional and distant metastasis were similar in the low-risk and high-risk groups of patients. That emphasizes the value of whole pelvic radiation in patients with unfavourable prognostic factors in Stage I endometrial cancer.     

Adjuvant chemotherapy as treatment of high-risk stage I and II endometrial cancer

OBJECTIVE: This study was performed to define the subgroups of patients who benefit from postoperative adjuvant chemotherapy in stage I and II endometrial carcinoma. METHODS: A retrospective review of 170 International Federation of Gynecology and Obstetrics (FIGO) stage I and II endometrial carcinoma patients treated between 1988 and 2000 at Niigata University Hospital was performed. All patients underwent surgery, of which 41 patients underwent adjuvant chemotherapy, consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Multivariate analysis was performed for the prognostic factors and actuarial techniques were used for the survival and recurrence rates. RESULTS: The patients were divided into low-risk and high-risk groups based on the number of prognostic factors (tumor grade G3, outer half myometrial invasion, lymph-vascular space involvement (LVSI), and cervical invasion). The 5-year disease-free survival and the 5-year overall survival for the low-risk group were 97.4%, and 100%, respectively, which were significantly better than 77.4% and 88.1% for the high-risk group (P < 0.0001, P < 0.0001), respectively. Among high-risk group patients, the 5-year disease-free survival and the 5-year overall survival were 88.5% and 95.2% in 26 patients treated with adjuvant chemotherapy, and 50.0% and 62.5% in eight cases who underwent only surgery (P = 0.0150, P = 0.0226). Disease recurrence occurred in 7 (20.6%) of 34 high-risk group patients. Four of seven recurrences occurred in patients who did not receive postoperative chemotherapy, in which all four were distant failure. In the remaining three patients who were in the CAP group, two had vaginal wall recurrence and only one had pulmonary recurrence. Three recurrences were also observed in the 133 low-risk group patients. Only isolated vaginal wall recurrence occurred in three patients without adjuvant chemotherapy after the initial surgery. CONCLUSIONS: There is possibility that postoperative adjuvant CAP may be omitted in surgical stage I or II endometrial cancer patients with 0 or 1 prognostic factor. The high-risk group of patients should be treated with postoperative adjuvant CAP to decrease distant failure and improve prognosis.     

Premenopausal bleeding: When should the endometrium be investigated?—A retrospective non-comparative study of 3006 women

Objective

There is lack of consensus amongst professional organizations as regards the cut-off age for endometrial sampling of premenopausal women presenting with abnormal uterine bleeding (AUB) to exclude endometrial hyperplasia or carcinoma. Therefore we conducted this study to quantify the prevalence of hyperplasia and carcinoma in different age categories in premenopausal women with AUB to identify the appropriate cut-off age for endometrial sampling.

Study design

A retrospective review of the histopathology reports of endometrial samples taken from 3006 women presenting with AUB and aged from ≥30 to ≤50 years at Ipswich Hospital, UK, from 1 January 1998 to 31 December 2007. Women were divided into three subgroups according to age; group 1: 30 to ≤40 (n = 862), group 2: 40 to ≤45 (n = 1035) and group 3: 45 to ≤50 (n = 1109).

Results

Logistic regression revealed that the prevalence of atypical hyperplasia (OR: 3.85; 95% CI: 1.75, 8.49; p = 0.01) and carcinoma (OR: 4.03; 95% CI: 1.54, 10.5; p = 0.04) was significantly higher in women in group 3 when compared to younger women. There was no statistically significant difference as regards simple and complex hyperplasia in the different age categories. All but one of the women (n = 23) who had complex atypical hyperplasia or carcinoma under the age of 45 years, presented with irregular rather than cyclical heavy menstrual bleeding.

Conclusion

Our study, the largest in the literature, suggests using the age 45 years as a cut-off for sampling the endometrium in all women with AUB. However, irregular menstrual bleeding justifies investigating women regardless of their age.