Page 12 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 1
Background and problem
Endometrial cancer is defined as cancer from the lining or inside of the uterus (endometrium), and is the most common gynaecological cancer in industrialised countries. Endometrial cancer is linked to a higher age and obesity.1-3 Worldwide, people are getting older and the incidence of overweight and obesity is rising.4,5 The increase in both life expectancy and body weight increases people’s risk of certain diseases.The incidence of endometrial cancer and precancer (atypical hyperplasia) is therefore expected to rise even further in the coming decades.6
The expected increase of women with endometrial cancer makes it all the more relevant to focus on ways to diagnose and treat the disease. If endometrial cancer is found at an early stage, curative treatment by removing the uterus and ovaries is still possible. Endometrial cancer can manifest diffuse in the endometrium or focal, inside an endometrial polyp.A common sign of endometrial cancer is vaginal bleeding, which makes its detection easier. For 95% of women with endometrial cancer, the disease presents in an early stage with postmenopausal bleeding (PMB), vaginal bleeding that occurs after a period of 12 months without menstruations at the menopausal age. To exclude endometrial cancer, it is therefore considered important to investigate all women who present with PMB.7
Yet, although women with PMB have an approximately 10% risk of having endometrial cancer, the majority of these women, instead of having endometrial cancer, have benign endometrial pathology or atrophy. Frequent findings in women with PMB are endometrial polyps, with a prevalence of about 20% in the general population of women with PMB, and of about 40% in women with both PMB and a thickened endometrium.8,9 Endometrial polyps are believed to be responsible for recurrent PMB10,11, although sparse evidence is available on this. As a consequence, the removal of endometrial polyps is a subject of debate and research. Current guidelines on PMB leave room for individual doctors and patients to choose between expectant management or further diagnostics to diagnose and remove endometrial polyps.7,12,13
Diagnostic work-up of women with PMB thus focuses on both the exclusion of endometrial cancer and on the (possible) diagnosis and treatment of endometrial polyps. Despite the many studies investigating this, there is no consensus on the best diagnostic pathway.The diagnostic steps vary in different guidelines, depending on the structure of patient flow in different settings and healthcare systems, as well as the availability of specific procedures, for example, ultrasound, endometrial sampling
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