I had my last period about three years ago. But a few months ago I started having some spotting. I saw my gynecologist, who offered me a choice of an ultrasound or an endometrial biopsy to help diagnose the problem. I am a Black woman and read a study the other day that said ultrasound isn’t a good way to diagnose in Black women specifically. Why is that, and do you have any insight about how to make this decision?
—Anonymous
When I was in medical school — longer ago than I would care to admit — I learned that any woman with vaginal bleeding more than a year after her last period needed to have an endometrial biopsy. I watched the procedure several times and eventually learned to perform the biopsy, in which a long thin straw is inserted through the opening to the uterus to sample the uterine lining.
While an endometrial biopsy is a relatively quick procedure, it can be quite painful. So it made sense to me that researchers wanted to find a less painful option for assessing whether postmenopausal bleeding was a sign of endometrial cancer. Using ultrasound to measure the thickness of the uterine lining was studied and determined to be a reasonable alternative to endometrial biopsy. A doctor could then give the patient a choice between an endometrial biopsy or ultrasound to rule out endometrial cancer if she has postmenopausal bleeding.
However, the study you mention that was published earlier this year found that determining endometrial thickness with ultrasound was not a reliable method for ruling out endometrial cancer in Black women. The study included nearly 1,500 women and explored a number of different cutoffs for endometrial thickness. At this point, we don’t know why this would be different for Black women. So if you identify as Black, you may want to take this under consideration when deciding what to do.
The guidelines from the American College of Obstetricians and Gynecologists recommend using a cutoff of 4 millimeters, meaning that if the uterine lining is thicker than 4 mm on ultrasound, further evaluation should be done. The current study notes that with that threshold, the probability of a false negative was 9.5%. This means that nearly 10% of patients with a uterine lining less than 4 mm thick will have endometrial cancer. For comparison, endometrial biopsy has a false-negative rate of just 0.9%.
Ultimately, endometrial biopsy may be better able than an ultrasound to detect endometrial cancer, particularly in Black women with postmenopausal bleeding.
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