ORIGINALARTICLE

TRANSVAGINAL ULTRASONOGRAPHY IN DETECTING ENDOMETRIAL HYPERPLASIA IN

POST-MENOPAUSAL WOMEN

Tabassum Begum¹, Sumaira Noureen¹, Neelofar Azam¹, Marya Anwar²

How to cite this article

ABSTRACT

OBJECTIVES

Begum T, Noureen S, Azam N, Anwar

This study aimed to determine the diagnostic accuracy of transvaginal

M. Transvaginal Ultrasonography in

ultrasonography in detecting histopathologically conrmed endometrial

Detecting Endometrial Hyperplasia in

pathology in post-menopausal women, using histopathological examination as

the reference standard.

METHODOLOGY

Post-menopausal Women. J Gandhara

Med Dent Sci. 2026; 13(2): 87-92.

https://doi.org/10.37762/jgmds.13-3.913

This descriptive cross-sectional diagnostic accuracy study was conducted at

MTI Bacha Khan Medical College and Mardan Medical Complex, Mardan. A

total of 93 post-menopausal women were enrolled through consecutive

sampling. TVS assessed endometrial thickness and associated ultrasound

ndings. Histopathological examination of the endometrial sample was used

as the reference standard. Data were analyzed using SPSS version 25.

Sensitivity, specicity, positive predictive value, negative predictive value,

diagnostic accuracy, and 95% condence intervals were calculated. Receiver

operating characteristic curve analysis was performed, and the optimal cuto

was determined using the Youden index.

Date Submission:

Date Revised:

15-04-2026

20-05-2026

Date Acceptance: 22-05-2026

²Specialist Registrar, Bacha Khan

Medical College, Mardan Teaching

Institute of Mardan Medical College

RESULTS

Correspondence

The mean age of participants was 58.8 ± 8.8 years, and the mean endometrial

thickness was 8.45 ± 3.67 mm. Histopathology showed normal endometrium in

31 (33.3%) cases, endometrial hyperplasia in 52 (55.9%), and endometrial

carcinoma in 10 (10.8%). Using a predened cuto of >10 mm, TVS showed

sensitivity of 58.1% (95% CI: 45.7-69.5), specicity of 100.0% (95% CI: 89.0–

100.0), positive predictive value of 100.0% (95% CI: 90.4–100.0), negative

predictive value of 54.4% (95% CI: 41.6–66.6), and diagnostic accuracy of

72.0% (95% CI: 62.2–80.1). ROC analysis showed an area under the curve of

0.935 (95% CI: 0.887–0.984; p < 0.001). The optimal cuto by the Youden

index was ≥5.65 mm, with a sensitivity of 93.5% and a specicity of 77.4%.

CONCLUSION

¹Sumaira Noureen, Assistant Professor,

Department of Radiology, Bacha Khan

Medical College, Mardan Teaching

Institute of Mardan Medical College

+92-312-0911235

sumairajvd@yahoo.com

Transvaginal ultrasonography is a useful initial, non-invasive tool for

evaluating endometrial pathology in post-menopausal women. The >10 mm

cuto showed excellent specicity but moderate sensitivity, indicating that it is

more useful for ruling in disease than for ruling it out. A lower ROC-derived

cuto may improve screening sensitivity, but histopathological conrmation

remains essential for denitive diagnosis.

KEYWORDS: Transvaginal Ultrasonography, Postmenopausal Bleeding,

Diagnostic Accuracy, Histopathology, ROC Curve

INTRODUCTION

nulliparity, and exogenous estrogen exposure, all of

which increase the risk of endometrial hyperplasia and

malignant

transformation.^2,3

post-menopausal

Endometrial hyperplasia is a clinically important

gynecological condition characterized by abnormal

proliferation of endometrial glands relative to the stroma,

resulting in thickening of the endometrial lining. It is

considered a precursor lesion for endometrial carcinoma,

particularly when cytological atypia is present.¹The

underlying pathophysiology is mainly related to

prolonged unopposed estrogen stimulation, which

promotes continuous endometrial proliferation without

women, abnormal uterine bleeding is an important

clinical warning sign, and timely evaluation is essential

to detect premalignant or malignant endometrial disease

at an early stage. Transvaginal ultrasonography (TVS) is

widely used as a rst-line, non-invasive imaging

modality for evaluating endometrial pathology in post-

menopausal women.⁴Measurement of endometrial

thickness is one of the most commonly used sonographic

parameters because it is simple, reproducible, and

clinically useful for deciding whether further invasive

evaluation is required. However, the diagnostic accuracy

adequate

progesterone-mediated

secretory

transformation. This hormonal imbalance is commonly

associated with obesity, diabetes mellitus, hypertension,

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Transvaginal Ultrasonography in Detecting Endometrial Hyperplasia

of TVS varies across studies due to dierences in patient Complex, Mardan, from 9th February to 9th April.

characteristics, menopausal status, bleeding symptoms, Ethical approval was obtained from the Ethical Review

operator expertise, ultrasound technique, and selected Board of Bacha Khan Medical College, Mardan, with

endometrial thickness cuto values. Lower cutoff values reference number 98/BKMC, dated 09/02/2026. A total

generally improve sensitivity and reduce the chances of of 93 post-menopausal women were included in the

missing disease, whereas higher cuto values improve study. The sample size was calculated using the WHO

specicity but may fail to detect early or less extensive sample size formula, a 95% condence level, P was

hyperplastic changes.^5,6Therefore, selecting an assumed to be 50% due to variability in reported

appropriate cuto remains clinically important, prevalence of endometrial pathology in previous

particularly when balancing the need to avoid literature, and the margin of error was set at 10%, giving

unnecessary biopsies with the risk of missing clinically a required sample size of 93 participants. Because

signicant pathology. Although TVS is useful for initial reliable local estimates of sensitivity and specicity for

assessment, it cannot reliably dierentiate all benign, transvaginal ultrasonography in this population were

premalignant, and malignant endometrial lesions on its limited, a prevalence-based estimate was used for

own.⁷Histopathological examination remains the recruitment feasibility; however, diagnostic precision

reference standard because it provides denitive tissue was addressed in the revised analysis by reporting 95%

diagnosis and allows classication of normal condence intervals for sensitivity, specicity,

endometrium,

endometrial

hyperplasia,

atypical predictive values, and diagnostic accuracy.⁹A non-

hyperplasia, and carcinoma. This is particularly probability consecutive sampling technique was used,

important in women with persistent post-menopausal and all eligible patients presenting during the study

bleeding, focal lesions, heterogeneous endometrial period were enrolled until the required sample size was

pattern, or risk factors for endometrial carcinoma. In achieved. The study included post-menopausal women

resource-limited settings, however, TVS remains aged 45 and above with bleeding or suspected

valuable as a triage tool because it is accessible, non- endometrial issues who underwent transvaginal

ultrasonography and endometrial sampling. Exclusions

were women with endometrial carcinoma, incomplete

records, refusals, or hormonal treatments aecting

endometrial thickness. Inclusion of symptomatic cases

aimed to mirror clinical practice but may introduce

spectrum bias due to varying disease severity. After

obtaining written informed consent, demographic and

clinical data were collected using a structured pro forma,

including age, body mass index, parity, post-menopausal

bleeding, diabetes mellitus, hypertension, hormone

replacement therapy, and other relevant variables. All

participants underwent transvaginal ultrasonography

(TVUS), performed by trained radiologists using a

standardized protocol. Radiologists were blinded to

histopathology ndings to minimize observer bias.

Endometrial thickness was measured in millimeters on

the sagittal plane as the maximum double-layer thickness

invasive, relatively inexpensive, and useful for

identifying women who require endometrial sampling.^8,9

Despite the routine use of TVS in clinical practice, local

evidence regarding its diagnostic performance in post-

menopausal women remains limited. In addition, cuto

variability has not been adequately evaluated in many

local studies, and reliance on a single xed threshold

may lead to either missed cases or unnecessary invasive

procedures. Therefore, this study was conducted to

determine the diagnostic accuracy of transvaginal

ultrasonography

detecting

histopathologically

conrmed endometrial pathology in post-menopausal

women, using histopathological examination as the

reference standard. The study also aimed to evaluate the

diagnostic performance of endometrial thickness and

compare the predened >10 mm cuto with an ROC-

derived optimal cuto.

between

the

endometrial-myometrial

interfaces.

METHODOLOGY

Additional ndings, including endometrial pattern,

echogenicity, and focal lesions, were also recorded.

Endometrial thickness was categorized as ≤4 mm, 5–10

mm, and >10 mm. For diagnostic accuracy analysis, >10

mm was considered TVUS-positive, while ≤10 mm was

considered TVUS-negative. Following TVUS, all

participants underwent endometrial sampling, and

histopathology served as the reference standard.

Specimens were classied as normal endometrium,

endometrial hyperplasia, or endometrial carcinoma by

blinded pathologists using standard diagnostic criteria.

For analysis, normal endometrium was considered

histopathology-negative, whereas hyperplasia and

This study was a descriptive, cross-sectional diagnostic

accuracy study to evaluate the role of transvaginal

ultrasonography in detecting endometrial hyperplasia in

post-menopausal women, using histopathological

examination as the reference standard. The study was

reported in accordance with the key principles of the

Standards for Reporting of Diagnostic Accuracy Studies

(STARD), including clear denition of the index test,

reference standard, participant eligibility, diagnostic

cuto, and measures of diagnostic precision. The study

was carried out at the Department of Radiology, MTI

Bacha Khan Medical College and Mardan Medical carcinoma were considered histopathology-positive.

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Transvaginal Ultrasonography in Detecting Endometrial Hyperplasia

Table 2: Transvaginal Ultrasonography and Histopathological

Consecutive sampling was used to reduce selection bias;

Findings (n = 93)

Variable

however, some spectrum bias may have remained due to

inclusion of women with post-menopausal bleeding and

suspected endometrial pathology. Data were entered and

analyzed using IBM SPSS version 25. Quantitative

variables, including age, body mass index, and

endometrial thickness, were reported as mean ± standard

deviation, along with minimum and maximum values,

whereas qualitative variables were presented as

frequencies and percentages. The Chi-square test was

used to assess associations between categorical

variables, and Cramér's V was used to assess the strength

of association between endometrial thickness categories

and histopathological ndings. A p-value of ≤0.05 was

considered statistically signicant. Diagnostic accuracy

of transvaginal ultrasonography (TVUS) at the

predened cuto of endometrial thickness >10 mm was

evaluated using histopathology as the reference standard.

Sensitivity, specicity, positive predictive value,

negative predictive value, and overall diagnostic

accuracy with 95% condence intervals were calculated.

Category

45-55 years

56-65 years

>65 years

Normal

Overweight

Obese

Frequency (%)

37 (39.8%)

33 (35.5%)

23 (24.7%)

28 (30.1%)

36 (38.7%)

29 (31.2%)

45 (48.4%)

48 (51.6%)

52 (55.9%)

41 (44.1%)

55 (59.1%)

38 (40.9%)

47 (50.5%)

46 (49.5%)

44 (47.3%)

49 (52.7%)

Specificity

Age group

Positive predictive value

Negative predictive value

Diagnostic accuracy

BMI category

Note: Chi-square test applied; χ² = 29.368, p < 0.001; Cramer’s V = 0.562.

Post-menopausal

bleeding

Yes

Parity

Multiparous

Nulliparous

Yes

Table 5: Two-by-Two Diagnostic Accuracy Table for TVS Cuto

>10 mm

TVS result

Diabetes mellitus

Hypertension

Histopathology-positive

positive

negative

Yes

Positive >10 mm

Negative ≤10 mm

Hormone replacement

therapy

Yes

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Transvaginal Ultrasonography in Detecting Endometrial Hyperplasia

important sonographic marker; however, thickness alone

cannot fully dierentiate benign hyperplasia, atypical

hyperplasia, and carcinoma. Therefore, TVS should be

interpreted along with clinical risk factors and

histopathological conrmation.^15,16At the >10 mm

cuto, transvaginal ultrasonography demonstrated a

sensitivity of 58.1% and a specicity of 100%. This

strong rule-in value yielded no false positives, but the

moderate sensitivity led to many histopathology-positive

cases being missed. Additionally, the negative predictive

value was limited because endometrial thickness ≤10

mm did not reliably exclude disease. Therefore, despite

high specicity, the overall diagnostic reliability is

questionable due to the inuence of disease prevalence

in this study population. Several factors may account for

the moderate sensitivity observed in this study. A higher

cuto, such as >10 mm, increases specicity but may

reduce sensitivity, potentially leading to the omission of

Figure 1: ROC Curve Analysis of Endometrial Thickness for

Histopathology-Positive Endometrial Pathology (area under the

curve was 0.935 (95% CI: 0.887–0.984; p < 0.001), and the optimal

cutoff

the

Youden

index

was

≥5.65

mm).

early

less

extensive

hyperplastic

changes.

Additionally, histopathology-positive cases vary widely,

from hyperplasia to carcinoma, and not all lesions cause

signicant endometrial thickening. Focal lesions can

exist even with normal overall thickness, indicating that

relying on a single cuto may overlook important

disease. Similar variability in sensitivity and specicity

has been reported in the literature, driven by factors such

as cuto selection, study population, and operator

expertise.^17,18,19The ROC curve analysis improved

diagnostic interpretation by continuously assessing

endometrial thickness rather than relying solely on the

>10 mm threshold. The AUC was 0.935, indicating

excellent performance. The optimal cuto identied

through the Youden index was ≥5.65 mm, yielding

sensitivity of 93.5% and specicity of 77.4%. This

suggests a lower cuto is better for screening to reduce

missed cases, while the >10 mm threshold is more

appropriate for ruling in pathology with higher

specicity. This illustrates the sensitivity-specificity

trade-o and emphasizes the importance of cuto

selection based on clinical goals. Additionally, the

ndings align with previous studies showing that TVS

DISCUSSION

The present study evaluated the diagnostic performance

of transvaginal ultrasonography (TVS) for detecting

histopathologically conrmed endometrial pathology in

post-menopausal women. The mean age was 58.8 ± 8.8

years, comparable to previous studies on post-

menopausal bleeding and suspected endometrial

disease.¹⁰A high proportion of participants were

overweight/obese and had diabetes or hypertension,

supporting the established association

between

metabolic

dysfunction

and

endometrial

proliferation.^11,12,13Histopathology showed that 52

women had endometrial hyperplasia and 10 had

endometrial carcinoma, while 31 had normal

endometrium. For diagnostic accuracy analysis,

hyperplasia

and

carcinoma

were

grouped

histopathology-positive endometrial pathology because

both represent clinically signicant abnormal ndings

requiring further evaluation or management. The

proportion of abnormal histopathological ndings was

higher than that reported in some international cohorts,

diagnostic

performance

varies

widely

across

but the hospital-based nature of the study and inclusion populations, depending on factors such as menopausal

status and bleeding symptoms. (19). Comparative

endometrial pathology may explain this. Similar studies

indicate that while hysteroscopy and

of women with post-menopausal bleeding or suspected

variation has been reported in studies in which disease histopathology oer greater diagnostic certainty, TVS

prevalence diers according to symptoms, referral remains a valuable, non-invasive rst-line assessment

setting, and biopsy threshold.¹⁴The mean endometrial for post-menopausal women.²⁰The study suggests that

thickness in this study was 8.45 ± 3.67 mm, and greater transvaginal sonography (TVS) should not be used alone

endometrial thickness was signicantly associated with to rule out endometrial issues, especially with ongoing

histopathologically positive ndings. None of the clinical suspicion. A threshold of >10 mm may indicate

women with endometrial thickness ≤4 mm had abnormal a higher disease probability, although a lower threshold

histopathology, whereas all women with thickness >10 (≥5.65 mm) could be better for screening. In resource-

mm had histopathology-positive disease. This nding limited settings, TVS can aid risk stratication and

supports the role of endometrial thickness as an biopsy prioritization, but histopathological examination

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Transvaginal Ultrasonography in Detecting Endometrial Hyperplasia

2. Capasso I, Cucinella G, Wright DE, Takahashi H, De Vitis LA,

remains essential for a denitive diagnosis. Overall,

TVS is a useful initial assessment tool for endometrial

pathology in post-menopausal women, particularly when

thickness is signicantly increased, though its moderate

sensitivity requires thoughtful clinical interpretation.

Gregory AV, et al. Articial intelligence model for enhancing

accuracy of transvaginal ultrasound in detecting endometrial

cancer and atypical hyperplasia. Int

Gynecol Cancer.

2024;34(10):1547–55. https://doi.org/10.1136/ijgc-2024-005652

PMID: 39074219.

3. S V, Kudva R. Histopathological prole of endometrium among

peri- and post-menopausal women with abnormal uterine

bleeding and correlation with endometrial thickness by

transvaginal sonography. Diagn Pathol. 2025;20(1):127.

https://doi.org/10.1186/s13000-025-01717-z (PMID pending)

4. Günkaya OS, Tekin A, Tekelioğlu M, Gedik Özköse Z, Bestel A,

Kalkan Ü, et al. Role of transvaginal ultrasonography in

determining endometrial cancer risk in asymptomatic post-

menopausal women with thickened endometrium. Deney Klin

Tip Derg. 2023;40(1):42–6.

LIMITATIONS

The study was limited by non-probability, consecutive

sampling; possible spectrum bias; lack of inter-observer

variability assessment; and the use of a prevalence-based

sample size formula.

Vitale SG, Riemma G, Haimovich S, Carugno J, Alonso Pacheco

L, Perez-Medina T, et al. Risk of endometrial cancer in

asymptomatic post-menopausal women in relation to

ultrasonographic endometrial thickness: systematic review and

diagnostic test accuracy meta-analysis. Am J Obstet Gynecol.

2023;228(1):22–35.e2.

CONCLUSIONS

https://doi.org/10.1016/j.ajog.2022.07.043 PMID: 35931112.

Li JXL, Chan F, Johansson CYM. Can a higher endometrial

thickness threshold exclude endometrial cancer and atypical

Transvaginal ultrasonography is a useful, non-invasive

initial modality for evaluating endometrial pathology in

post-menopausal women. In this study, the predened

endometrial thickness cuto of >10 mm showed

excellent specicity and positive predictive value but

only moderate sensitivity, suggesting that this threshold

is more useful for ruling in disease than for ruling it out.

ROC curve analysis showed excellent discriminatory

performance of endometrial thickness, with an AUC of

0.935. The ROC-derived optimal cuto of ≥5.65 mm

provided higher sensitivity and may be more suitable for

screening, although it had lower specicity than the >10

mm cuto. Therefore, TVS should be interpreted in

relation to clinical presentation, risk factors, and the

purpose of testing. A higher cuto may conrm a high

probability of pathology, while a lower cuto may

reduce the risk of missed cases during screening.

Histopathological examination remains the reference

standard for denitive diagnosis, particularly in

symptomatic women or those with persistent clinical

suspicion. The ndings should be interpreted with

consideration of the study limitations, including

hyperplasia in asymptomatic post-menopausal women?

systematic review. Aust N Z J Obstet Gynaecol. 2022;62(2):190–

7. https://doi.org/10.1111/ajo.13472 PMID: 34787988.

7. Tuersun B, Zhang Q. Application of vaginal ultrasound and

hysteroscopy in diagnosis of perimenopausal endometrial

lesions. Clin Exp Obstet Gynecol. 2024;51(6):128.

https://doi.org/10.31083/j.ceog5106128

8. Li X, Wang H, Wang T, Cui H, Wu L, Wang W, et al. Combining

demographic data and transvaginal ultrasonography: predictive

model for endometrial carcinoma in post-menopausal patients.

BMC

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9. Yang X, Ma K, Chen R, Meng YT, Wen J, Zhang QQ, et al.

Evaluation of liquid-based endometrial cytology and transvaginal

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Gynecol

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10. Rahman S, Nila TA, Laila A, Akter F, Shilpi US, Sultana N, et

al. Sensitivity and specicity of transvaginal ultrasonography in

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bleeding. Int

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and diagnostic utility in post-menopausal women: retrospective

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CONFLICT OF INTEREST: None

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FUNDING SOURCES: None

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AUTHORS CONTRIBUTION

Tabassum Begum - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Supervision; Final Approval

17. Ahmad MWA, SNAMTASGAA. Diagnostic accuracy of

transvaginal ultrasound versus hysteroscopy in detecting

endometrial pathologies in women with abnormal uterine

Sumaira Noureen - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Supervision; Final Approval

Neelofar Azam - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Supervision; Final Approval

Marya Anwar - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Final Approval

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

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Med Health Sci. 2024;18(1):590.

https://doi.org/10.53350/pjmhs02024181590

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A, et al. Assessing the role of transvaginal sonography in post-

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al. Advances in ultrasound-based imaging for diagnosis of

endometrial cancer. World

https://doi.org/10.4329/wjr.v17.i9.111493 (PMID pending)

Radiol. 2025;17(9):111493.

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