A 58-year-old postmenopausal woman presents with abnormal uterine bleeding for 3 months. On examination, the uterus is bulky. Transvaginal ultrasound shows an endometrial thickness of 18 mm with heterogeneous echotexture. What is the investigation of choice to confirm the diagnosis of endometrial cancer?

Explanation

## Investigation of Choice for Endometrial Cancer Diagnosis **Key Point:** Hysteroscopy with endometrial biopsy is the gold standard for diagnosing endometrial cancer in symptomatic postmenopausal women with abnormal uterine bleeding and thickened endometrium on ultrasound. ### Why Hysteroscopy with Biopsy? 1. **Direct visualization** of the endometrial cavity and any focal lesions 2. **Tissue diagnosis** under direct visualization ensures adequate sampling from suspicious areas 3. **Highest diagnostic accuracy** — sensitivity >95% for endometrial malignancy 4. **Therapeutic potential** — allows removal of polyps or fibroids if identified 5. **Staging information** — permits assessment of myometrial invasion and cervical involvement ### Comparison of Endometrial Sampling Methods | Investigation | Sensitivity | Specificity | Advantages | Limitations | |---|---|---|---|---| | **Hysteroscopy + biopsy** | 95–99% | 98–100% | Direct visualization, targeted sampling, therapeutic | Requires anesthesia, operator-dependent | | **Pipelle sampling** | 60–90% | 98–100% | Office procedure, minimal anesthesia | Blind sampling, may miss focal lesions, higher false-negative rate | | **Dilatation & curettage** | 85–90% | 98–100% | Older standard, therapeutic | Blind sampling, requires anesthesia, risk of perforation | | **Diagnostic curettage alone** | 80–85% | 98–100% | Simpler procedure | Blind, may miss lesions, less accurate than hysteroscopy | **High-Yield:** In a postmenopausal woman with abnormal bleeding and endometrial thickening >8 mm, hysteroscopy with directed biopsy is preferred over blind sampling methods because it allows visualization of the lesion and ensures adequate tissue from the abnormal area. **Clinical Pearl:** Pipelle sampling is acceptable as a first-line office procedure in low-risk women (e.g., thin endometrium, no focal lesion on ultrasound), but once a thickened or heterogeneous endometrium is identified, hysteroscopy is indicated to rule out malignancy. ### When Hysteroscopy Is Mandatory - Postmenopausal bleeding with endometrial thickness >8 mm - Heterogeneous or focal endometrial lesion on ultrasound - Failure to obtain adequate tissue on office sampling - Suspicion of endometrial polyp or submucosal fibroid