Page 51 - The diagnostic work-up of women with postmenopausal bleeding

Introduction
Endometrial cancer is the most common gynaecologic cancer. Approximately 95% of women with endometrial cancer present with postmenopausal bleeding (PMB).1, 2 PMB signals endometrial cancer, which is present in about 10% of cases,3, 4 or less serious conditions, such as benign endometrial polyps or endometrial atrophy.3, 5-7
To reduce invasive procedures in women with PMB, measurement of the
endometrial thickness is used to stratify women into low versus high risk of having 3 endometrial cancer. Measurement of endometrial thickness has shown to be accurate
in excluding endometrial cancer, although the risk of endometrial cancer with a
negative test is still 0.7-3.5% depending on the cut-off point used.8, 9
In women with PMB there is considerable variability in endometrial thickness and the likelihood of endometrial cancer.10 Individual patient characteristics including age, time since menopause, obesity, hypertension, diabetes mellitus and reproductive factors, are associated with a higher risk of endometrial cancer.10-16 While the probability of postmenopausal bleeding decreases with increasing age,17 the probability of endometrial cancer in women with PMB increases significantly with increasing age.The probability rises from 1% in women younger than 50 years to 24% in women older than 80 years.18
In clinical practice, tests are commonly combined in diagnostic sequences and disease probabilities are usually estimated in a hierarchical manner: first combining information from history and examination, followed by additional information obtained from diagnostic tests.The post-test probability is not only dependent on test characteristics but also on the pre-test probability, which is altered by patient’s characteristics. However, current diagnostic policy in women with PMB is not based on these patient specific risk factors, but only on one fixed cut-off point for endometrial thickness.2, 19-21
Clinical doctors want to identify women with a high risk for endometrial cancer when presenting with PMB. Several articles have studied this subject and developed models to estimate the individual chance of endometrial cancer in women presenting with PMB.The purpose of this review is to give an overview of the existing prediction models for endometrial cancer in women with PMB, to assess their quality and to identify important predictor variables.
Prediction models
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