Page 154 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 8
evaluated two previously developed prediction models in two independent datasets of women with PMB: one Dutch dataset (559 women) and one Swedish dataset (433 women).We also evaluated three diagnostic strategies:
• a‘patient characteristics’rule,based on characteristics of the women without TVS;
• a ‘sequential’ rule, i.e. TVS in case the probability for cancer exceeded 4% based on characteristic, and subsequent endometrial sampling when the endometrial thickness exceeded 4 mm;
• an ‘integrated’ rule with a probability estimate based on both characteristics of the women and ultrasound results and endometrial sampling when the probability of cancer exceeded 4%.
In both the Dutch and the Swedish databases, the two models showed good performance in terms of discrimination and calibration. Based on these two models, each of the three strategies detected all women with endometrial (pre) cancer. Applying the ‘integrated’ or ‘sequential’ strategy would, compared to current practice (ultrasound only), lead to a 7% decrease in the number of women in need of fur ther invasive testing.Thus, the use of a prediction model based on ‘patient characteristic and ultrasound’ factors in a sequential or integrated strategy, could only slightly reduce the number of invasive procedures without loss in detection of endometrial cancer.
4. Is the diagnostic work-up for and the removal of benign endometrial polyps effective in women with PMB to prevent recurrent bleeding?
Chapter 5 presents the results of a multicentre, randomised controlled trial on the effectiveness of hysteroscopic diagnosis and treatment of endometrial polyps versus expectant management in women with PMB, a thickened endometrium and benign endometrial sampling. We randomised 98 women for diagnostic work-up by hysteroscopy (preceded by SIS) versus 102 women for expectant management. The primary outcome measure was the recurrence of PMB within a year after randomisation. Pathology results were registered as well. Results show that within one year a total of 15 women (15.3%) in the hysteroscopy group experienced recurrent bleeding, versus 18 (18.0%) in the expectant management group (relative risk 0.85 (95% CI 0.46-1.59)). In the hysteroscopy group, we found 50 (51%) polyps
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