Endometrial thickness threshold and management of asymptomatic postmenopausal patients.

Abstract

With a great deal of interest, we read the article entitled ‘Can a higher endometrial thickness threshold exclude endometrial cancer and atypical hyperplasia in asymptomatic postmenopausal women? A systematic review’ by Li et al.1 As we know, there is a lack of consensus regarding the endometrial thickness threshold of asymptomatic postmenopausal women. According to the systematic review, postmenopausal women with endometrial thickness of less than 10 mm can be observed without any surgical intervention. Although we do agree with these author’s statement, several parameters of such a proposal should be considered for clinical practice. Several recent published articles have raised several questions regarding the endometrial thickness in postmenopausal women that should be evaluated with biopsy. In a recent retrospective cohort study based on the SEER national cancer registry, the authors found a racial discrepancy in endometrial cancer diagnosis when endometrial biopsy was based on endometrial thickness threshold of more than 3 or more than 5 mm. Such a discrepancy can be explained either by the fact that Black women have a greater prevalence of fibroids that can lead to misdiagnosis of endometrial thickness or by the higher prevalence of such women to nonendometrioid histologictype endometrial cancer that does not combine with increased endometrial thickness.2 Similarly, another study concluded that for Black patients the recommended threshold of more than 4 mm led to 50% of newly diagnosed endometrial cancer patients to be missed and to an eightfold higher frequency of falsenegative results compared to the general population.3 For such reasons, some authors suggest that the decision whether a patient must be surgically investigated by endometrial biopsy should be based on a casebycase basis after examining any predisposing factors for endometrial pathology, such as obesity or unopposed oestrogen exposure.4 Of course, a new consensus regarding the endometrial thickness threshold of such patients is essential to avoid unnecessary endometrial biopsies, but definitely racial characteristics should be considered to avert any racial inequity in the provided medical services and in the health outcome. Moreover, several questions could be raised under the prisma of either resourcesdependent action in every national health system or potential medicolegal consequences. Once again, we thank the authors for their excellent contribution.