Page 112 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 6
Abstract
Objective To evaluate the cost-effectiveness of hysteroscopic treatment of endometrial polyps versus expectant management in women with postmenopausal bleeding and a thickened endometrium with a benign result of endometrial sampling.
Materials and methods An economic evaluation was performed alongside a randomised trial. Women with postmenopausal bleeding and an endometrial thickness > 4 millimetres with a benign result of endometrial sampling, had been randomised into a group receiving further diagnostic work-up by hysteroscopy (combined with preceded saline infusion sonography) and a group receiving expectant management. Primary clinical outcome was recurrent bleeding within 12 months. In the hysteroscopy group, the presence of polyps and the results of their histology were registered. Outcomes for the cost-effectiveness analysis were cost-differences and incremental cost-effectiveness ratios for both the prevention of recurrent bleeding and detecting of endometrial (pre) cancers.Statistical uncertainty in the cost-effectiveness analyses was estimated using bootstrapping.
Results Costs were statistically significantly higher in the hysteroscopy-group compared to the expectant management group (€ 888 versus € 108, cost difference € 780 (95% 550; 1158)).There was no statistically significant difference in the number of women with recurrent bleeding (15 % versus 18 %, -3%, 95% CI -13; 8%). The CEA for the detection of endometrial (pre) cancers during a follow-up of 12 months showed a statistically significant effect difference (7% (95% CI 3; 14%)). In the hysteroscopy group, the ICER to detect one case of (pre) cancer was € 10,917. Decision makers should be willing to pay €19,500 to detect one cancer extra to reach a probability of cost-effectiveness of 0.95.
Conclusion In women with postmenopausal bleeding, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding but detects focal endometrial (pre) cancer in 7% of these women.The capacity of hysteroscopy in all patients to identify (pre) cancers comes at a price of around € 11,000 euro per woman identified with (pre) cancer.
Trial registration Dutch trial register number NTR2130. 110