Page 133 - The diagnostic work-up of women with postmenopausal bleeding

The accuracy of endometrial sampling
Introduction
Postmenopausal bleeding (PMB) is one of the most frequent complaints with which women present in the outpatient gynaecology clinic.As PMB might be the first sign of endometrial cancer, accurate diagnostic work-up is necessary in these women. Despite many studies on the different diagnostic measures in women with PMB, there is no consensus on the best diagnostic pathway.1-4
In many guidelines the measurement of endometrial thickness by transvaginal sonography (TVS) is used as a first step in the diagnostic pathway to distinguish women with a low and a high risk of having endometrial cancer. Clark et al found that a strategy withTVS as the initial test with a cut-off of 4 mm followed by endometrial sampling was the most cost-effective.5 In situations where ultrasound is not directly available, endometrial sampling can be used as the first step.6
The meta-analysis by Dijkhuizen et al was the first meta-analysis on the diagnostic accuracy of endometrial sampling in women with postmenopausal bleeding.7 Several years after that, two other meta-analyses were published.8,9 These meta-analyses found that sensitivity, which is crucial to rule out endometrial cancer, was around 99%. However, in these studies (blind) dilatation and curettage (D&C) had been used as reference standard. Nowadays, D&C is almost completely replaced by hysteroscopy as a reference standard.10 Also, only a small proportion of women in these meta- analyses was postmenopausal.
In view of this, we decided to conduct a systematic review and meta-analysis 7 to study the diagnostic accuracy of endometrial sampling in women with PMB
regarding the diagnoses of endometrial cancer and atypical hyperplasia compared
to two different reference standards: blind D&C and the current reference standard: hysteroscopy with histology or hysterectomy.10
Methods
Identification of studies
In April 2015, we performed a computerized search in MEDLINE, EMBASE and Science Direct® to identify all studies on the diagnostic accuracy of endometrial sampling published between January 1965 and March 2015.The search was limited to studies in humans; language restrictions were not applied. We used all known synonyms for the following keywords: postmenopausal bleeding AND endometrial
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