Page 126 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 6
Finally, this study was not powered for the detection of endometrial cancer and this could also be a coincident finding. More research is needed on the prevalence of focal endometrial (pre) cancers in large cohorts of women.
Comparison to other studies
To our knowledge this is the first economic evaluation in which strategies using SIS or direct hysteroscopy in women with a thickened endometrium and benign result of endometrial sampling are studied. Clark et al performed a study in which they analysed cost-effectiveness of different strategies in the diagnostic work-up in women with PMB.28 They concluded that compared to undertaking no initial investigation when a woman presents with PMB, a strategy using TVS with a 5 mm cut-off was the least expensive and that strategies using outpatient hysteroscopy were not cost-effective. However, these results are difficult to compare with this study, because Clark et al used survival as the primary outcome measure instead of recurrent bleeding or the diagnosis of endometrial (pre) cancer.28
In a study by Dijkhuizen et al a strategy using SIS in all women to select for therapeutic hysteroscopy was cost-effective in comparison with immediate hysteroscopy in all women. The primary outcome in this study was successful treatment (i.e. no bleeding), however, this study was performed in premenopausal women and therefore not applicable on a postmenopausal population.29
Breijer et al performed an economic analysis in which they studied different strategies based on patient characteristics of women with PMB.They concluded that a strategy in which patients are selected for TVS or direct endometrial biopsy based on patient characteristics is the most cost-effective strategy.Their primary outcome was five-year survival. Comparison to our results is again difficult because of a different outcome measure and because both SIS and hysteroscopy were not studied.30
Unanswered questions and future research
Because the number of patients with an endometrial (pre) cancer in this study is limited, the results of this study only suggest that in women with PMB, a thickened endometrium and a benign endometrial sampling further diagnostic work-up is indicated to diagnose possible focal endometrial (pre) cancers, that the costs to detect one woman with an endometrial (pre) cancer are € 10,917 and that a strategy using SIS is cheaper than a strategy using direct hysteroscopy. More research with larger cohorts of patients is needed.
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