Page 14 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 1
Answering these questions in conjunction will help to assemble the most efficient diagnostic work-up of women with PMB, with the aim to miss as few diagnoses as possible of endometrial cancer and to perform as few (unnecessary) invasive procedures as possible. What follows is an elaboration of the specific research questions and the research conducted to answer them.
1. What is known in the literature about the diagnostic work-up of women with postmenopausal bleeding?
In the Netherlands, a general practitioner will refer a woman with PMB to a gynaecologist to exclude the presence of endometrial cancer. In the past, the principal method of diagnostic work-up of women with PMB was dilation and curettage (D&C), performed under general anaesthesia.This procedure was invasive and not very cost-effective. About three decades ago, the measurement of the endometrial thickness by transvaginal ultrasound (TVS) was introduced as a more patient-friendly way to distinguish between women with a low or high risk of having endometrial cancer.14,15 Not all women needed to undergo a D&C anymore.We know now that D&C misses around 50-85% of focal intracavitary pathology and therefore is not accurate enough in the diagnostic work-up of women with PMB.8 Today, D&C is almost completely replaced by outpatient endometrial sampling and hysteroscopy. However, there is still no consensus in (inter) national guidelines on the most accurate and efficient diagnostic pathway.To give an overview of different diagnostic tools and the different sequences in the use of these tools, we first review the existing literature on diagnostic work-up of women with PMB.
2. Which prediction models on the chance of endometrial cancer in women with PMB are available in literature and which model shows the best performance?
In women with PMB there is considerable variance in endometrial thickness and the likelihood of having endometrial cancer. A meta-analysis done by Smith-Bindman et al showed a mean endometrial thickness of 4 mm for women with normal histological findings, 10 mm for women with endometrial polyps, 14 mm for women with hyperplasia, and 20 mm for women with endometrial cancer.16 Because of this variance, it would be useful to identify women with a high risk of having endometrial cancer based not only on an endometrial thickness of more than four millimetres,
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