Page 113 - The diagnostic work-up of women with postmenopausal bleeding

Introduction
Postmenopausal bleeding (PMB) is a common symptom encountered in gynaecological practice1. Because about 10% of these women have an underlying endometrial cancer,2,3 the diagnostic work-up focuses on diagnosing or ruling out endometrial cancer. To distinguish between women with a low- or high risk for endometrial cancer, measurement of endometrial thickness is used with a high accuracy.4-6 If the endometrium is thickened the woman is considered to have a high risk, and endometrial sampling is performed to obtain a histological diagnosis.7
Current guidelines leave room for individual doctors and patients to decide on the next step when endometrial sampling shows a benign result.8-10 Saline infusion sonography (SIS) and hysteroscopy are used for the detection and removal of benign endometrial polyps, which are a potential cause of recurrent bleeding.11,12 Hysteroscopy, despite being safe, well tolerated and performed in an outpatient setting, remains an invasive procedure with a potential risk of complications and at considerable cost11. Therefore, some doctors and patients prefer expectant management over immediate hysteroscopy.
We performed a randomised clinical trial in which we randomised women
with PMB to expectant management or further diagnostic work-up by SIS and 6 hysteroscopy.This trial showed no difference in the number of women presenting
with recurrent bleeding, within the first 12 months after randomization. However,
we found that 6% of women undergoing hysteroscopy were diagnosed with a (pre)
cancer of the endometrium, leading to a false negative rate of 6% of endometrial
sampling.This is higher than anticipated based on current literature.13-15The conclusion
of our trial is that in women with PMB, a thickened endometrium and a benign result
of endometrial sampling, further diagnostic work-up seems to be warranted to
detect focal endometrial (pre) cancers that are missed by endometrial sampling.16
However, it is unclear which diagnostic strategy is most efficient with regard to costs and effects. Therefore, the aim of this paper was to evaluate the cost- effectiveness of the diagnostic work-up by hysteroscopy (preceded by SIS) compared to expectant management over a 12-month period in women with PMB, a thickened endometrium and a benign result of endometrial sampling in order to prevent recurrent postmenstrual bleeding and detected (pre) cancers.
Cost-effectiveness
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