Page 93 - The diagnostic work-up of women with postmenopausal bleeding

Introduction
Postmenopausal bleeding (PMB) is a common symptom in gynaecological practice1. It signals endometrial cancer in about 10% of the women.2,3
Guidelines on PMB emphasise the importance to diagnose or rule out endometrial cancer.Transvaginal sonography is used to distinguish between women with a low- or high risk for endometrial cancer. If the endometrium is thickened, endometrial sampling is performed to evaluate for endometrial cancer.4-7
When endometrial sampling shows a benign result, it is uncertain whether
the work-up should be continued to detect benign intracavitary pathology.When
women present with recurrent or persistent bleeding, further evaluation for focal
lesions is required.8-10 When a woman does not have persistent bleeding, guidelines
leave room for individual patients and doctors to choose for expectant management
or further diagnostic work-up,8-10 since strong evidence on the effectiveness of
polypectomy on the chance of recurrent bleeding is lacking. SIS and hysteroscopy are 5 potentially helpful in the detection and removal of endometrial polyps.11,12 However, 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 cost.11
In case endometrial polyps remain undetected,they are believed to be responsible for recurrent vaginal bleeding.13 Although polypectomy is one of the most performed hysteroscopic operations, only one cohort study is available, showing no difference in recurrent bleeding after hysteroscopy versus expectant management.14
In view of this lack of knowledge, we performed a multicentre randomised controlled trial in which we investigated the effectiveness of diagnostic work-up with hysteroscopy and subsequent polypectomy versus expectant management in women with PMB and benign endometrial biopsy. Since we performed SIS preceding the hysteroscopy, we were able to evaluate whether a strategy with SIS as triage for hysteroscopy would be effective.
Methods
Between January 2010 and October 2013, we performed a multicentre, randomised clinical trial in three academic and nine non-academic teaching hospitals.The trial was performed within the Dutch Consortium for research in Women’s Health, a
Diagnostic work-up: a RCT
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