Introduction/Background Hysteroscopy is crucial for assessing intrauterine pathology, with ultrasound-measured endometrial thickness guiding referrals in postmenopausal patients. However, consensus lacks for asymptomatic cases. This study aimed to delve beyond endometrial thickness, evaluating other ultrasound factors influencing referrals for hysteroscopy.

Methodology In this cross-sectional study spanning 2015–2023, 426 postmenopausal patients with documented ultrasound indications underwent comprehensive analysis. Among these patients, data were available for 223 individuals regarding endometrial thickness, 171 for polyp length, 413 for the presence of liquid in the endometrial cavity and 388 for endometrial homogeneity. Subsequently, statistical analyses were applied, including ANOVA for endometrial thickness and polyp length, chi-square tests for endometrial homogeneity and conspicuous liquid content (specifically reported as hematometra or mucometra), and risk estimates to evaluate relationships between these ultrasound features and the risk of malignancy.

Results Endometrial thickness and polyp length showed no significant differences between cancer/precancer and non-cancer cohorts. However, an inhomogeneous endometrium was significantly associated with malignancy risk (χ² = 15.537, p < 0.001; OR = 8.200, 95% CI: 2.409–27.910). Presence of conspicuous liquid content in the uterine cavity also indicated higher risk (χ² = 27.852, p < 0.001; OR = 10.265, 95% CI: 3.639–28.955). Prevalence of cancer and precancer lesions in the studied population was 3.8%.

Conclusion This study challenges the sole reliance on endometrial thickness in asymptomatic postmenopausal patients. An inhomogeneous endometrium and conspicuous fluid in the uterine cavity, emerged as significant indicators of malignancy risk. Integrating these factors into referral criteria could enhance the precision of hysteroscopic evaluations, optimizing the identification of underlying pathologies in this population. Future researchers should prioritize these factors to generate more robust data, laying the foundation for refined clinical guidelines and enhancing the accuracy of hysteroscopic assessments in this specific patient population.

Disclosures The authors declare no conflict of interest.