Sru Consensus for En Dome Trial Measurement

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Objectives. A panel of 14 physicians practicing medicine in the United States with expertise in radiol-

ogy, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was

convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women

with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understand-

ing of the utility of different diagnostic techniques for evaluating the endometrium in women with

postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women

with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer sug-

gestions for future research projects. Setting. October 24 and 25, 2000, Washington, DC, preceding the

annual Society of Radiologists in Ultrasound Advances in Sonography conference. Procedure. Specificquestions to the panel included the following: (1) What are the relative effectiveness and cost-effec-

tiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial

examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for

evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings

in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or

hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic

approach be modified for patients taking hormone replacement medications, tamoxifen, or other

selective estrogen receptor modulators? Conclusions. Consensus recommendations were used to cre-

ate an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that

because postmenopausal bleeding is the most common presenting symptom of endometrial cancer,

when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that

either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first

diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physiciansassessment of patient risk, the nature of the physicians practice, the availability of high-quality sonog-

raphy, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for

transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnor-

mal and for endometrial biopsy when sufficient tissue is obtained. Currently, with respect to mor-

tality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which

approach is more effective. The conference concluded by identifying several important unanswered

questions and suggestions that could be addressed by future research projects. Key words: post-

menopausal bleeding; menopause; sonography; ultrasound; transvaginal sonography; endometrium;

endometrial cancer.

A complete list of presentersand panelists appears inAppendix.

Address correspondenceand reprint requests to Ruth B.Goldstein, MD, Departmentof Radiology, University ofCalifornia, San Francisco, 505Parnassus Ave, Room M-396,Box 0628, San Francisco, CA94143-0628.

AbbreviationsD&C, dilation and curettage; EMB,endometrial biopsy; HRT, hor-mone replacement therapy; PMB,postmenopausal bleeding; SIS,saline infusion sonohysterogra-phy; SRU, Society of Radiologistsin Ultrasound; TVS, transvaginalsonography

Evaluation of the Woman WithPostmenopausal Bleeding

Society of Radiologists in UltrasoundSponsoredConsensus Conference Statement

Ruth B. Goldstein, MD, Moderator,Robert L. Bree, MD, Carol B. Benson, MD,Beryl R. Benacerraf, MD, Jeffrey D. Bloss, MD,Ruth Carlos, MD, Arthur C. Fleischer, MD,Steven R. Goldstein, MD, Robert B. Hunt, MD,

Robert J. Kurman, MD, Alfred B. Kurtz, MD,Faye C. Laing, MD, Anna K. Parsons, MD,Rebecca Smith-Bindman, MD, Joan Walker, MD

2001 by the American Institute of Ultrasound in Medicine J Ultrasound Med 20:10251036, 2001 0278-4297/01/$3.50


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Definition

The term postmenopausal bleeding (PMB) refersto any vaginal bleeding in a postmenopausal

woman other than expected cyclic bleeding thatoccurs with sequential hormone replacementtherapy (HRT).

Summary of Issues Addressed by thePanel

The consensus panel addressed the role oftransvaginal sonography (TVS) in the evalua-tion of women with PMB. The majority of thedebate and discussion focused on 3 issues:

whether TVS can be used safely as the initialdiagnostic test in women with PMB; whether a

thin endometrium can be used to obviate theneed for additional attempts at tissue sampling(in women in whom office endometrial biopsy[EMB] is nondiagnostic); and formulation ofrecommendations for an appropriate thresholdof endometrial thickness, measured sono-graphically, below which the sonographic find-ings can safely be interpreted as negative. Thepanel also discussed the clinical importance ofdetecting other benign uterine abnormalitiesthat may be the cause of PMB. The potentialrole of saline infusion sonohysterography (SIS)and hysteroscopy was discussed.

Background and Summary of Literature

Endometrial cancer may be found in 1% to 25%(typically quoted as 10%) of women with un-expected PMB, depending on age and riskfactors.13 Endometrial cancer is the most com-mon gynecologic malignancy.4 More than 90%of cases occur in women older than 50 years,and abnormal bleeding is the most commonpresenting symptom. Vaginal bleeding, howev-er, may be due to many causes other than cancer3,5

and is a common problem in postmenopausal

women, occurring in as many as 1 per 10women older than 55 years.6,7Although PMB isoften due to other conditions, endometrialcancer is the most serious. Thus, acceptedpractice in the United States includes furtherevaluation to exclude endometrial carcinomain women with PMB.8

Before 1982, diagnostic evaluation was rou-tinely accomplished by surgical dilation andcurettage (D&C) of the endometrium. More

recently, a suction catheter technique forendometrial tissue sampling, performed in anoffice setting, has been shown to be more than85% sensitive for the detection of endometrialcarcinoma7,9,10 and is more convenient and lesscostly. Unlike surgical D&C, EMB can easily beperformed in the office with minimal or noanalgesia.

Transvaginal sonography has also become anincreasingly popular tool for endometrialassessment and, in comparison with officeEMB, has similar (or slightly lower) false-negative rates for cancer detection.7 Althoughtissue is not obtained during sonography,sonographic imaging of the endometrium canbe extremely helpful, because endometrialcancer is nearly always associated with thick-

ening and heterogeneity of the endometri-um6,11 and is rarely present when theendometrium is thin. In fact, the positive pre-dictive value for cancer on a sonogram increases

with the thickness of the endometrium.6,7,1214

Furthermore, a large number of studies fromthe United States and Europe have confirmedthat a very thin endometrial lining almostnever harbors carcinoma.7,15

To determine how thin an endometriumshould be to reasonably exclude cancer, manylarge studies have been performed. These stud-ies have shown that when an endometrial

thickness threshold of 4 or 5 mm is used, thesensitivity for detecting endometrial carcino-ma approaches 95%.6,7 Furthermore, in partbecause the prevalence of endometrial canceris low, the negative predictive value of a thinendometrium is very high. Thus, the presenceof a thin endometrium can be used reliably toexclude cancer. These observations, in combi-nation with evidence that TVS assessment ofendometrial thickness is highly reproducible,16

have fueled interest in using TVS in 2 importantsettings. The first is to assess the endometrium

with TVS as the initial diagnostic test (after his-

tory and physical examination) in women withPMB. Some physicians and patients may electto begin the evaluation with TVS because officeEMB may be uncomfortable.17 In comparison

with EMB, TVS is better tolerated and has ahigher rate (>95%) of diagnostic results.7,14

Furthermore, in some patients, office EMBcannot be adequately performed because ofcervical stenosis or patient intolerance or, asoccurs in 5% to 15% of patients, because the

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Evaluation of the Woman With Postmenopausal Bleeding


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specimen may not provide sufficient informa-tion to exclude endometrial cancer.2,3,14,18,19

The second setting in which TVS can beextremely helpful is in the group of women in

whom EMB has been attempted but has notbeen diagnostic. In this setting, the high nega-tive predictive value of a thin, homogeneousendometrium can be used to obviate the needfor a more invasive procedure such as surgicalD&C.

Panel Discussion

The consensus panel addressed the following 5questions:

1. What are the relative effectiveness and cost-effectiveness of using sonography versus

blind EMB as the initial test for PMB?

The panelists concluded that, after a history andphysical examination, either TVS or EMB wouldbe effective and diagnostic as the first step in theevaluation of women with PMB. The relativecost-effectiveness of using EMB versus TVS asthe first diagnostic procedure has not been deter-mined by prospective testing. The choice willdepend on the physicians practice and expertiseand the availability of high-quality sonography.Some of the panelists thought that in womenconsidered to be at high risk for endometrial can-

cer (e.g., women older than 60 years, not receiv-ing HRT or treatment with unopposed estrogen,or women with obesity or diabetes), EMB may bepreferred as the first step in this evaluation,although the efficacy of using a 5-mm endome-trial threshold in this particular subset of patientshas not been carefully studied.

Using published data on sensitivities and costprojected onto varying algorithms, Weber et al14

addressed theoretical considerations to assesscost-effectiveness, but some of the assumptionsused by these authors may not be universallyapplicable (i.e., costs and outcomes may vary).

They concluded that the costs are reasonablycomparable for either approach. The panel spec-ulated that if a study were done prospectively, thefalse-positive rates and patient referral patterns

would likely have the greatest influence on cost.

2. What are the sonographic standards for eval-uating a woman with PMB?

To use sonography to exclude cancer in a woman with PMB, sonography must be per-

formed according to the following standards.The sonography should be performed transvagi-nally with a 5- to 10-MHz transducer and anempty bladder, for resolution of the endometrialechotexture, margins, and double-layer thick-ness measurement. In the majority of patients,the TVS will provide diagnostic information forassessing the endometrium. Transverse/coronal(short-axis) and longitudinal/sagittal (long-axis)images of the uterus should be obtained in eachexamination and should also include images ofthe cervix and fundal and cornual portions ofthe endometrium (Fig. 1). The uterus andadnexa should be imaged in each examination,although it is understood that the ovaries maynot be visible in all postmenopausal women.

Transabdominal sonography alone is not suffi-

cient in a woman with PMB because of subopti-mal resolution of the endometrium and itsborders (Fig. 2). Many panelists thought that thetransabdominal portion of the sonographicexamination, however, should be included toensure that a large mass or fluid collection is notmissed (owing to the limited field of view ofTVS). Most agreed that the transabdominal scancould be performed with either a full or anempty bladder.

Endometrial thickness should be measured ona sagittal (long-axis) image of the uterus, and themeasurement should be performed on the thick-

est portion of the endometrium, excluding the

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Goldstein et al

Figure 1. Complete endometrial imaging has been accomplished on this sagittal

image of the uterus using TVS. A small amount of fluid is shown in the endome-trial canal. In the postmenopausal woman, this is not necessarily pathologic. The

endometrium is visualized in its entirety, including the cervix (arrow). An inciden-

tally observed nabothian cyst is seen in the cervix (arrowhead). Image courtesy ofPeter M. Doubilet, MD, PhD (Brigham and Womens Hospital, Boston, MA).


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hypoechoic inner myometrium (Figs. 3 and 4).The endometrial thickness should be reported asthe double-thickness measurement. A smallamount of fluid will be found in the endometrialcanal of some postmenopausal women withoutabnormalities. This fluid should not be includedin the endometrial measurement. In these cases,the reported endometrial thickness should be thesum of the thickness of the 2 endometrial layers,

excluding the fluid (Fig. 5).The endometrium should be visualized com-

pletely. If the entire endometrium cannot beimaged because of obscuration by fibroids, or if

the endometrial margins are indistinct suchthat the borders of the endometrium cannotbe delineated to measure the double wallthickness, the study should be consideredinadequate, and other means of evaluating theendometrium should be used (Fig. 6).Practitioners are reminded that nondiagnosticfindings may occur more commonly in women

with invasive carcinoma because of indistinct

endometrial margins. With recognition of thepotentially pivotal role of TVS in the diagnosticevaluation of these patients, a statementshould be included in the report regarding thetechnical adequacy of the sonogram.

3. What are the abnormal sonographic findingsin a woman with PMB?

A. The sonogram should be interpreted asabnormal if the double thickness of theendometrium is greater than 5 mm. This conclu-sion is based on 2 important observations:(1) nearly all patients with proven endometrial

cancer had an endometrial thickness of greaterthan 5 mm; and (2) when this threshold is used,the sensitivity of detecting endometrial cancer

with TVS is comparable with that of EMB.6,7,15,20Ameta-analysis of 85 published studies thatincluded 5892 women showed that an endome-trial thickness of greater than 5 mm identified96% of endometrial cancer.7 These sensitivitiesdid not vary with the use of HRT (see question 5).The panel discussed whether 4 mm might be a

1028 J Ultrasound Med 20:10251036, 2001


Figure 2. Endometrial polyp shown to better advantage with TVS than transabdominal sonography. A, Transabdominal sonogram (4-MHz transduc-

er). The endometrium is not adequately visualized, although there is a vague abnormality of the endometrium (arrows). Calipers mark the margins ofthe uterus. B, Transvaginal sonogram performed with an 8-MHz transducer in same patient as in A. A cystic and solid endometrial polyp (arrows) is

resolved better with TVS.

A B

Figure 3. Measuring the endometrium. Endometrial measurement should include

the double thickness (arrows) excluding the hypoechoic myometrium (asterisks).


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more sensitive and, therefore, a better threshold.They noted, however, that Smith-Bindman andcoworkers7 found that decreasing the thresholdto 4 mm negligibly alters the sensitivity for cancerdetection but substantially decreases the speci-ficity (more false-positive results). As a result,

most panelists favored using a threshold of 5 mm.The panel agreed that it is important to empha-

size that this threshold does not apply to anasymptomatic woman with an incidentallyobserved endometrium of greater than 5 mm.

Among these postmenopausal women, a normalmaximal endometrial thickness measurementhas not yet been established.

B. The sonogram should be interpreted as non-diagnostic if the endometrium cannot be visual-ized in its entirety. This observation, found inapproximately 5% to 10% of patients,15,21,22 is notspecific for disease, but an incompletely visualized

endometrium cannot be interpreted as benign orreassuring. Because this appearance can occur

with endometrial cancer, a nondiagnostic sono-gram should lead to the further evaluation, similarto positive sonographic findings (Fig. 6).

C. The sonographic findings are abnormal if afocal endometrial abnormality is detected.

Among women with PMB, endometrial cancer isfound in approximately 10%, but polyps, hyper-plasia, and fibroids will be found in as many as

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Goldstein et al

Figure 4. Focal endometrial mass. Care should be taken to scrutinize the entire endometrium carefully in real time. The thickest portion of the

endometrium should be reported as the double-thickness measurement. A, A portion of the endometrium appears homogeneous and thin (calipers).B, Further evaluation discloses a focal abnormality, which was an endometrial polyp (calipers).

A B

Figure 5. Transvaginal sonogram of a postmenopausal woman with a small vol-ume of fluid in the central canal. Fluid should not be included in the endometrial

thickness measurement. In this case, each endometrial wall should be measured

separately (lines) and summed for the reported double-thickness measurement.Image courtesy of Peter M. Doubilet, MD, PhD.


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40%. A focal area of thickening, a mass, or inho-mogeneity on TVS warrants further evaluation ina woman with PMB. Tissue sampling, SIS, orhysteroscopy with D&C should be performed.

D. The sonographic findings are abnormal ifthe margins of the endometrium are indistinct.Endometrial cancer often expands theendometrial cavity and, in addition to thicken-ing, may result in an indistinct appearance of

the endometrial lining (Fig. 7). An indistinct

endometrium can also be seen in benign condi-tions, such as adenomyosis.

4. When should SIS or hysteroscopy be used inthe evaluation of PMB?

Consensus was uniform among panelists thateither SIS or hysteroscopy is appropriate when afocal abnormality is suspected on the transvagi-nal sonogram. One advantage of hysteroscopy isthat it permits biopsy of a focal mass. Most pan-elists favored surgical hysteroscopy compared

with office hysteroscopy, although this requiresconsiderable anesthesia and expense. Salineinfusion sonohysterography is a relatively newimaging procedure during which TVS is per-formed while sterile saline is infused into theendometrial cavity via a transcervically placed

catheter. Saline infusion sonohysterography canbe performed safely and easily as an outpatientprocedure. Anesthesia is not required, and detec-tion rates for focal abnormalities are comparable

with those of hysteroscopy.23 Thus, many on thepanel favored SIS when a focal endometrialabnormality is suspected on the transvaginalsonogram to confirm that a focal abnormality isindeed present (Figs. 2 and 8) and to define thenature of the focal abnormality better (e.g., polypversus fibroid). Subsequent hysteroscopy couldthen be used to remove the focal abnormality, ifappropriate.

Saline infusion sonohysterography may also behelpful when a thickened endometrium hasbeen identified on the sonogram to allow moreefficient triaging of patients.24 The SIS will show

whether the endometrium is diffusely thickened,in which case EMB or D&C would be the nextstep, or focally thickened, in which case hys-teroscopy would be the next step (Fig. 8). Salineinfusion sonohysterography is also helpful ifthere is a discrepancy between the findings onthe transvaginal sonogram and the EMB (Fig. 9). An issue is the clinical importance of finding

benign endometrial abnormalities in women

with PMB. The majority agreed that in patients in whom a focal abnormality was suspected onTVS, SIS might be helpful to characterize theabnormality more fully. The panelists agreed thatthere is good evidence that SIS is more sensitivethan TVS alone to detect focal abnormalities in

women with PMB. The important but as yetunanswered question is whether finding andtreating these benign conditions improve thepatients quality of life, morbidity, and survival.

1030 J Ultrasound Med 20:10251036, 2001


Figure 6. Inadequate transvaginal sonogram. Despite the placement of calipers,the endometrium could not be examined in its entirety; therefore, endometrial car-

cinoma cannot be safely excluded.

Figure 7. Endometrial cancer. A transabdominal sonogram shows an indistinctand thickened endometrium.


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The panelists concluded that further investiga-tion into this issue is warranted. A minority ofpanelists thought that all women with PMBshould undergo SIS. The opinion of these pan-elists is a reflection of recent published evidencethat suggests that SIS is more sensitive for detect-ing focal endometrial abnormalities than eitherTVS or EMB.22,23 It is becoming apparent thatfocal endometrial abnormalities are more com-mon than previously thought. Many of theseabnormalities are benign polyps and fibroids,and these may account for abnormal bleeding.In a multicenter study investigating the utility ofSIS, Bree et al23 reported polyps in 47% andendometrial hyperplasia in 4% of women withPMB. These results should be considered, how-ever, in light of a recent study published by Neale

et al,22

who found that nearly 35% of asymp-tomatic postmenopausal women had endome-trial abnormalities detected with SIS.

5. Should the diagnostic approach be modified for patients taking HRT medications,tamoxifen, or other selective estrogenreceptor modulators?

Women taking sequential regimens of HRT mayhave cyclic alterations in endometrial thickness.For these women, the TVS should be performed4 to 5 days after completion of the cyclic bleed-ing. For those taking continuous regimens of

HRT, including unopposed estrogen, or no HRT,sonography can be performed any time duringthe monthly cycle. Sensitivities for the detectionof cancer do not differ for women taking HRTcompared with those not taking HRT.7

In considering cost-effectiveness, the rate offalse-positive sonographic findings among hor-mone users is considerably higher than thatamong those who do not take HRT.7 Althoughthe rate of cancer detection does not differ, ifTVS is the first diagnostic test, a greater rate ofpositive sonographic findings is likely to leadto more additional testing and higher cost for a

complete evaluation for patients taking HRT.The panelists acknowledged that treatment

with tamoxifen (used in adjuvant therapy forbreast cancer) is associated with increased riskof endometrial proliferation, including polypformation, endometrial hyperplasia, andendometrial cancer (Fig. 10).25 This is especiallytrue with increasing durations and dosages ofthis medication. Panelists thought there wasinsufficient evidence to warrant recommenda-

tion of routine evaluation of asymptomatic women treated in this way. The panel recom-mended that bleeding women treated withtamoxifen or other selective estrogen receptormodulator therapy be evaluated in a fashionsimilar to that of other women with PMB (use anendometrial thickness threshold of 5 mm, andsonography can be performed anytime duringthe month).

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Goldstein et al

Figure 8. Saline infusion sonohysterogram showing that there is focal thickeningof the endometrium in several places (arrows). This patient might benefit from hys-

teroscopy and biopsy.

Figure 9. Discordant sonographic findings and EMB result. Transvaginal sonogram

in a postmenopausal woman with bleeding shows a markedly thickenedendometrium (arrows) containing numerous small cysts. Office EMB showed a nor-

mal endometrium. This patient should undergo further evaluation, which might

include SIS.


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Research Agenda

1. The prevalence of benign endometrialabnormalities in women with PMB is higherthan previously thought. Further investiga-tion into the clinical significance of benignendometrial abnormalities associated withPMB is warranted. This might include betterdocumentation of the rate of malignancy inpolyps detected in patients with PMB andinvestigation into the impact of detecting,treating, and removing these benign abnor-malities on outcome.

2. Hormone replacement therapy appears toinfluence the specificity of TVS. More false-positive sonographic results (by definitionabnormal) are found in women taking HRT.The panelists suggested studies to determinehow HRT affects the cost-effectiveness ofdoing TVS or EMB first for the detection ofcancer.

3. Further investigation into the relative effec-tiveness of using TVS versus EMB as the ini-tial test in women with PMB is suggested.This would ideally represent a prospectivetrial with end points of not only cancerdetection but also quality-of-life measures(e.g., patient preference, risk of additionaltests, and tolerance of the need for addition-al testing).

4. Quality control of TVS in the communityshould be studied further. If TVS may replaceEMB as the first diagnostic step in the evalu-ation of PMB, reproducibility of endometrialmeasurements in the community settingshould be investigated. The Society ofRadiologists in Ultrasound (SRU) has fundedan educational program to provide standards

for performing TVS in this setting.

5. Because TVS has become an acceptablemeans of commencing the evaluation ofPMB, methods of standardizing the sono-graphic evaluation may be useful. The valueof an educational program for improving thequality of TVS in the community should beinvestigated.

6. Some think that the causes of PMB in womentaking HRT or tamoxifen are present beforethe commencement of therapy. Whether it

would be beneficial to perform pretreatmentTVS on women before commencement oftamoxifen or HRT should be investigated

Conclusions

Conclusions from the panel discussion are sum-marized in algorithms 1 and 2 (Figs. 11 and 12)and include the following:

1. Transvaginal sonography can be used safelyas the initial diagnostic test to evaluate theendometrial lining in a woman with PMB.

2. If the sonogram shows a normal-appearingendometrium with a double-thickness mea-surement of less than 5 mm, the test can beconsidered negative for endometrial cancer.

3. In women in whom office EMB is nondiag-nostic, a thin endometrium can be used safe-ly to obviate additional attempts at tissuesampling.

1032 J Ultrasound Med 20:10251036, 2001


Figure 10. Tamoxifen effect. Transvaginal sonogram shows marked endometrialthickening. This appearance is nonspecific and may represent endometrial hyper-

plasia, polyp, or carcinoma.


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Goldstein et al

Figure 11. Proposed algorithm for evaluating PMB commencing with EMB. ET indicates endometrium; and *, physician preference.

Figure 12. Proposed algorithm for evaluating PMB commencing with TVS. ET indicates endometrium; and *, physician preference.


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4. Both office EMB and TVS may miss benigncauses of vaginal bleeding. However, whethercost or clinical benefit results from theirdetection is not known at this time. Furtherinvestigation of this issue would be helpful.

Appendix: Summary of Conference Activities

Preconference ActivitiesThe conference directors (R.B.G. and R.L.B.) andconsultants (The Lewin Group, Falls Church, VA[Sean Tunis, MD, MS, Senior Research Scientist])together determined the key topics and identi-fied experts to participate in the conference. A lit-erature search was performed on the topic ofPMB and reviewed for content and authorship.Our intention was to assemble a panel of experts

with representatives from general gynecology,gynecologic oncology, hysteroscopy, radiology,pathology, and epidemiology. The consultantsand Drs Goldstein and Bree wrote the objectivesand formulated 5 questions to the panelists.These were distributed to them before the con-ference. Several months before the conference,the consensus conference presenters were askedto identify 4 or 5 key references. These were dis-tributed to the participants before the con-ference. A general announcement of theconference was placed in the SRU newsletter,and a number of organizations and journal edi-

tors were invited to send representatives to par-ticipate in the audience. These included the

American Academy of Family Physicians, American College of PhysiciansAmericanSociety of Internal Medicine, American Instituteof Ultrasound in Medicine, American College ofObstetricians and Gynecologists, NationalCancer Institute, National Institutes of Health,Office of Womens Health, Health Care Financing

Administration, and the editors ofRadiology, American Journal of Roentgenology, Journal ofUltrasound in Medicine, andJournal of WomensImaging.

Conference ActivitiesThe consensus conference, sponsored by theSRU, was held on October 24 and 25, 2000, atLEnfant Plaza Hotel (Washington, DC). A seriesof presentations (each 30 minutes) were madefrom 8 AM until 5 PMwith two 30-minute discus-sion sessions. Questions were taken during thepresentations so that discussion was ongoingduring the day.

Topics of the presentations included ClinicalSummary of Postmenopausal Bleeding; Patho-logy of the Endometrium in Postmenopausal

Women; American College of Obstetricians andGynecologists Guidelines for the Evaluation ofPostmenopausal Bleeding; Nonimaging Meansof Assessing the Endometrium in Women WithPostmenopausal Bleeding (Pipelle, D&C, etc);Transvaginal Sonography; Sonohysterography;HysteroscopyOffice and Operative; TheEffects of Tamoxifen; and Summary of Cost ofTransvaginal Sonography, Pipelle, Sonohysterog-raphy, D&C, Office Hysteroscopy, and OperativeHysteroscopy.

The consensus panel members met in theevening after the day of presentations and discus-sions to outline the salient features and conclu-

sions reached during the conference. The nextday, all participants met to further refine the con-sensus outline. Dr Goldstein presented thismaterial at the plenary session of the annualmeeting of the SRU, held on October 27, 2000.

Presenters and Panelists

Presenters

Jeffrey D. Bloss, MD, Vice-Chairman of Obstetricsand Gynecology, Director and Assistant Professorof Gynecologic Oncology, University of Missouri

Health Sciences Center, Columbia, Missouri;Robert L. Bree, MD, Professor and Chair,Department of Radiology, University of MissouriHealth Sciences Center, Columbia, Missouri;Ruth Carlos, MD, Lecturer, Robert Wood JohnsonClinical Scholars Program, University ofMichigan, Ann Arbor, Michigan; Arthur C.Fleischer, MD, Professor of Radiology andRadiological Sciences, Professor of Obstetricsand Gynecology, Chief of Diagnostic Ultrasound,

Vanderbilt University Medical Center, Nashville,Tennessee; Steven R. Goldstein, MD, Professor ofObstetrics and Gynecology, New York University

School of Medicine, Director of GynecologicUltrasound, Codirector of Bone Densitometry,New York University Medical Center, New York,New York; Robert B. Hunt, MD, Assistant ClinicalProfessor, Harvard Medical School, Boston,Massachusetts; Robert J. Kurman, MD, RichardTeLinde Distinguished Professor of GynecologicPathology, Johns Hopkins Medical Institutions,Baltimore, Maryland; Anna K. Parsons, MD,

Associate Professor and Director of Image-Based

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Gynecology, University of South Florida, Tampa,Florida; Rebecca Smith-Bindman, MD, AssistantProfessor of Radiology, Epidemiology, andBiostatistics, University of California SanFranciscoMount Zion Medical Center, SanFrancisco, California; and Joan Walker, MD,

Associate Professor and Chief, Section ofGynecologic Oncology, University of OklahomaHealth Sciences Center, Oklahoma City,Oklahoma.

Panelists

Ruth B. Goldstein, MD (Moderator), Professor ofRadiology and Obstetrics, Gynecology, andReproductive Sciences, University of California,San Francisco, California; Beryl R. Benacerraf,MD, Clinical Professor of Radiology, Obstetrics,

and Gynecology, Harvard Medical School,Brigham and Womens Hospital, Boston,Massachusetts; Carol B. Benson, MD, AssociateProfessor of Radiology, Harvard Medical School,Director of Ultrasound, Brigham and WomensHospital, Boston, Massachusetts; Robert L. Bree,MD; Alfred B. Kurtz, MD, Professor and ViceChair, Thomas Jefferson University Hospital,Jefferson Medical College, Philadelphia,Pennsylvania; Faye C. Laing, MD, Professor ofRadiology, Harvard Medical School, Brighamand Womens Hospital, Boston, Massachusetts;

Anna K. Parsons, MD; Rebecca Smith-Bindman,MD; and Joan Walker, MD.

Postconference ActivitiesIn addition to the outline generated and pre-sented on the final day of the conference, allhandouts, slides, and notes taken during theconference were reviewed and summarized bythe conference codirectors. This summary wassent to each conference participant, who wasasked to contribute comments and suggestions.This article represents the culmination andsummary of those activities.

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Sru Consensus for En Dome Trial Measurement

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