Angela Nolin, MD
Angela Nolin, MD, a gynecologic oncology fellow at Duke University Health System in Durham, North Carolina, and colleagues conducted a multi-institutional study to determine whether racial differences in transvaginal ultrasound efficacy combined with timely receipt of indicated endometrial sampling could be contributing to delays in diagnosis of endometrial cancer in women with postmenopausal bleeding. Their study results, which were presented at the 2025 Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer,1 suggest it may be time to change the diagnosis protocol for endometrial cancer to improve outcomes across diverse racial populations.
“Nearly one in four non-Hispanic Black patients in our study did not receive a timely biopsy and risked a delayed or missed diagnosis of endometrial cancer,” Dr. Nolin stated in an SGO press release. “This is a likely contributor to disparities in outcomes between non-Hispanic Black and non-Hispanic White patients.”
Transvaginal ultrasound, followed by endometrial sampling (if the endometrium exceeds 4 mm or is inadequately visualized), is one of the most common diagnostic strategies for endometrial cancer. However, according to Dr. Nolin, transvaginal ultrasound is an “imperfect tool in the workup of postmenopausal bleeding, particularly in non-Hispanic Black patients.”
Study Details
The PUMBA (Performance in Ultrasound Menopausal Bleeding Assessment) study reviewed the records of 6,466 patients with postmenopausal bleeding from three institutions: Duke, Mount Sinai, and Columbia. A total of 40.7% were non-Hispanic White, 25.7% were non-Hispanic Black, 15.4% were Hispanic, 3% were non-Hispanic Asian, and 16% were other or unknown. All of the patients underwent transvaginal ultrasound at three academic institutions between 2013 and 2022.
Their transvaginal ultrasound results were categorized as thin (< 4 mm), thick (> 4 mm), or inadequate (endometrium was inadequately visualized). For thin results, biopsy is not indicated, but for thick or inadequate results, biopsy is indicated, noted Dr. Nolin.
Guideline-concordant care was defined as a thin endometrial stripe or receipt of endometrial sampling within 3 months of an inadequate ultrasound or thick endometrium. This care was compared across transvaginal ultrasound result categories, patient race and ethnicity, and fibroid presence.
Key Results
Overall, a total of 13.2% of the patients (n = 852) had inadequate transvaginal ultrasound. Nearly 3,000 patients (46.3%) had a thick endometrium, and 2,619 (40.5%) had a thin endometrium. Fibroids were present in 74% of non-Hispanic Black patients and 48% of non-Hispanic White patients. Fibroids were associated with a higher likelihood of sampling for inadequate transvaginal ultrasound regardless of race or ethnicity (55.9% vs 37.0% in non-Hispanic Black patients, P = .013; 61.4% vs 46.3% in non-Hispanic White patients, P = .043). Fibroids were not found to be associated with the rate of sampling of a thick endometrium regardless of race or ethnicity (72.3% vs 74.1% non-Hispanic Black patients, P = .595; 76.6% vs 75.3% non-Hispanic White patients, P = .600).
Ultimately, the study found that two-thirds of patients with abnormal or inadequate transvaginal ultrasound received timely endometrial sampling. This dropped to one-half among those with inadequate transvaginal ultrasound. Furthermore, the rate of guideline-nonconcordant care was significantly higher in non-Hispanic Black patients than in non-Hispanic White patients (23.1% vs 14.7%; P < .001).
“A universal biopsy-based approach decreases the risk of delayed or missed endometrial cancer diagnosis among all patients with postmenopausal bleeding while simultaneously eliminating a source of disparity in care between non-Hispanic Black and non-Hispanic White patients,” Dr Nolin concluded.
DISCLOSURE: Dr. Nolin reported no conflicts of interest.
REFERENCE
1. Nolin A, et al: 2025 SGO Annual Meeting on Women’s Cancer. Abstract LBA03.
