Imaging Guidelines for Endometrial Cancer

Diagnostic Evaluation

The American College of Radiology recommends endometrial sampling when ultrasound cannot completely evaluate the endometrium or adnexa, based on a patient's risk factors for endometrial cancer, and recommends transvaginal ultrasound with Doppler as the first-line imaging modality for evaluating abnormal uterine bleeding 1
Magnetic Resonance Imaging (MRI) can visualize the endometrium even when ultrasound cannot, providing excellent tissue contrast and multiplanar capabilities, with a sensitivity of ~78% and specificity of ~93% for diagnosing gynecologic pathology, and is recommended if ultrasound is inconclusive 1
Sonohysterography is recommended if a focal endometrial abnormality is detected on transvaginal ultrasound to help distinguish between focal and diffuse pathology 1
Endometrial biopsy or curettage is mandatory to rule out endometrial hyperplasia or cancer, particularly in patients with risk factors such as obesity, and if the endometrium remains <4 mm in a postmenopausal woman, the negative predictive value for cancer is nearly 100% 2, 1

Risk factors for endometrial cancer include:

Risk Factor	Relative Risk or Odds Ratio
Obesity	2.54
Hypertension	1.81
Diabetes mellitus	2.1
Nulliparity and infertility	-
Polycystic ovarian syndrome	2.79-2.89
Unopposed estrogen therapy	10-30 fold increased risk with 5+ years of use
Early menarche and late menopause	-
Tamoxifen use	2.53
Lynch syndrome genetic mutations	-

Routine screening for endometrial cancer is not recommended in asymptomatic women with fibroids, according to the American College of Oncology 2

Selective progesterone receptor modulators (SPRMs) can reduce both bleeding and bulk symptoms, especially in perimenopausal women, but require monitoring for endometrial changes 4
Uterine artery embolization (UAE) is an option for patients with concurrent fibroids and adenomyosis, less invasive than hysterectomy, and may preserve fertility 5
Combination treatment with low doses of estrogen and progestin is FDA-approved for fibroid-related heavy menstrual bleeding, as recommended by the American College of Radiology 3
MR-guided high-frequency focused ultrasound ablation (MRgFUS) has shown effectiveness for certain fibroid types, according to the American College of Radiology 3

Monitor for any increase in fibroid size or new abnormal bleeding, which would warrant immediate evaluation 3
If a perimenopausal patient with fibroids requires hormone therapy for severe menopausal symptoms, an endometrial biopsy should be conducted prior to intervention to rule out endometrial neoplasia, as recommended by the American College of Radiology 3
Postmenopausal women with fibroids and abnormal uterine bleeding should undergo endometrial biopsy to rule out endometrial cancer prior to any interventional treatment 3