Page 16 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 1
its effectiveness. In premenopausal women only one randomised trial has been done, which shows only a subjective decrease of the amount of bleeding after polypectomy was performed.25 No randomised trials are available on the effectiveness of hysteroscopic polypectomy in women with PMB.The only cohort study, which researched the chance of recurrent bleeding in women with an endometrium of more than four millimetres (and therefore a higher chance of having a polyp), shows no difference in the number of women presenting with recurrent bleeding, regardless if these women underwent expectant management, a diagnostic hysteroscopy or hysteroscopic polypectomy.26
In an attempt to answer the question if polypectomy in women with PMB is effective to prevent recurrent bleeding,Timmermans et al conducted a randomised trial.27 In this trial women with PMB and an endometrial polyp, diagnosed with hysteroscopy, were randomised between expectant management and polypectomy. Unfortunately,this study was stopped after 26 months because of lack of recruitment. A large majority of patients did not give informed consent once the polyp was diagnosed and also the doctors did not want to participate in the study once a polyp was diagnosed with hysteroscopy.To answer the above question,Timmermans et al suggested a different study-design.This study design can be found in Figure 1.
The design presented in Figure 1 addresses the effectiveness of diagnostic hysteroscopy and possible subsequent polypectomy in patients with PMB, rather than the effectiveness of polypectomy itself.The most important difference compared to the previous protocol is that women do not have to decide on polypectomy when the polyp is already diagnosed. Instead, the decision for further diagnostic work-up and for participation in this study is made after endometrial sampling shows a benign result. In this thesis, we describe the randomised trial performed according to the protocol suggested by Timmermans and colleagues.
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