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  Routine endometrial sampling of asymptomatic
  premenopausal women shedding normal
  endometrial cells in Pap tests is not cost-effective

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November 2007
PAP/NGC Programs Review

William D. Tench, MD

Understanding the significance of the presence of normal-appearing endometrial cells in the Pap test presents an ongoing challenge, as reported in a May 2006 "Recommended Reading" in CAP TODAY (Related article: Significance of benign endometrial cells in cervicovaginal smears). In the previous report, it was noted that one of the most recent and comprehensive reviews of the topic published by Fadare, et al (Adv Anat Pathol. 2005;12:274-287) still concluded that the recommendations in the Bethesda System 2001 for reporting endometrial cells was appropriate but worthy of continued evaluation. The authors indicated that, particularly for premenopausal women 40 years of age or older, the issue is essentially one of sensitivity versus specificity. A more recent publication appears to provide a thorough examination of the problem by assessing the cost-effectiveness of endometrial sampling in women of this age group found to have normal endometrial cells in their Pap tests (Kapali M, Agaram NP, Dabbs D, et al. Cancer Cytopathol. 2007;111:26-33).

The authors studied a cohort of 499 women 40 years of age and older reported to have normal endometrial cells in their Pap tests who also underwent endometrial sampling. In this cohort, the population was divided into two age groups, 40-45 years and older than 45 years; day of the menstrual cycle, before day 12 or after day 12; and menopausal or postmenopausal status. The type of sampling and the results were obtained from the surgical pathology reports, and the cutoff for significant endometrial disease was set at atypical complex hyperplasia or endometrial adenocarcinoma. The cost of the sampling, including the pathology and gynecology components, was estimated based on Medicare reimbursement for the type of procedure used.

Of the 499 patients included in the study, only six patients were found to have significant pathology, and of these six patients, four were postmenopausal, including the three asymptomatic patients. No asymptomatic premenopausal women presenting with normal endometrial cells in their Pap smears were found to have significant disease. The total cost of sampling the 350 asymptomatic women was $107,272.

The authors conclude that endometrial sampling of asymptomatic premenopausal women in their 40s presenting with normal endometrial cells in their Pap tests is not cost-effective. Furthermore, they indicate that reporting normal endometrial cells in postmenopausal women produces the highest yield of women with significant endometrial pathology confirmed on biopsy. Of note, the authors also report that the distinction between normal and abnormal endometrial cells may not be a simple problem, and it may be significantly affected by the type of sample processing. They recommend a conservative approach to identifying endometrial glandular cell atypia in conjunction with implementing the reduction of unproductive endometrial sampling.


Dr. Tench, a member of the CAP Cytopathology Committee, is chief of cytopathology and associate director of the laboratory at Palomar Medical Center, Escondido, Calif.