*3.4. Clinical Presentation and Diagnostic Tools*

Nowadays, for the general population there are no approved screening programs for the early detection of EC [90].

Patients' evaluation should include thorough history taking, especially focusing on family history and possible risk factors [90]. Symptoms of EC are non-specific; thus, diagnosis of the condition is challenging in some cases. Abnormal uterine bleeding (AUB) is the most common symptom of endometrial cancer and is present in 90% of affected patients [3,84,85,90,106,107]. However, this symptom appears to be present in many other female genital disorders. Furthermore, as AUB can also be a sign of EC in premenopausal women, who comprise 20% of cases of EC, the approach to a patient with abnormal uterine bleeding will depend on the age group this patient belongs to (reproductive or postmenopausal) [79,84,85]. All postmenopausal women with AUB, especially if any of the risk factors discussed above are present [108,109], should undergo endometrial biopsy [3,79,84]. The risk of EC in postmenopausal women with uterine bleeding is up to 10% [3,84,90].

Women may also present with vague complaints of increased vaginal discharge or an incidental finding of a thickened endometrium on imaging [90]. Patients with advanced stages of the disease may complain of pelvic pain, abdominal distension, early satiety, changes in bowel or bladder function, pain during intercourse, and dyspnea because of pleural effusion [90]. However, it is important to keep in mind that up to 5% of patients with EC are asymptomatic [3,90].

Transvaginal ultrasound (TVUS) is a widely used approach for further investigations in patients suffering from AUB [3,85]. After the thorough investigation via sonography, the vast majority will undergo endometrial sampling [110,111]. The most useful approach to diagnose and confirm EC is endometrial sampling with histological examination [3,84,106,107].

The strategy with TVUS, followed by endometrial biopsy if an abnormality is detected, is the most cost-effective; therefore, TVUS is considered as the first step in any woman presenting with AUB [3,85,112,113].

Endometrial biopsy could be performed using different devices [84]. However, the most popular are the following methods: dilation and curettage (D&C), Pipelle sampling (Pipelle de Cornier prototype), and hysteroscopy with targeted biopsy. Histological examination reports may include presence of endometrial cells, atypical glandular cell of uncertain significance, or adenocarcinoma in situ [3,85,90].
