Page 18 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 1
5. Is the diagnostic work-up for and the removal of benign endometrial polyps cost-effective in women with PMB?
In addition to clinical effectiveness of a treatment, costs of this treatment are also an important issue to consider, especially in times when significant financial cuts in healthcare are taking place. Alongside the above-described randomised trial on the diagnosis and treatment of endometrial polyps, we will perform an economic evaluation. In this study, we will perform a cost-effectiveness analysis in which we compare direct health care costs for the two groups in the randomised trial: hysteroscopy versus expectant management. Because we also perform an SIS in all patients in the hysteroscopy group, we are able to compare costs for a strategy in which SIS is used to select patients with a polyp for hysteroscopic polypectomy. Furthermore,we calculate the cost-effectiveness of (SIS and) hysteroscopy performed to diagnose women with endometrial (pre) cancer in a polyp.
6. Is the diagnostic accuracy of outpatient endometrial sampling as high as we thought based on previous literature?
Besides the reduction of recurrent bleeding, another reason to remove an endometrial polyp could be the underlying risk of endometrial (pre) cancer in the polyp. Literature does not clarify exactly how high this risk is. A systematic review on the risk of cancer in endometrial polyps describes a risk of 4.47% in women with PMB.28 This could be an argument to remove all endometrial polyps in women with PMB. However, until now, (inter) national guidelines do not give a strict advice on this. Again, the guidelines leave room to the individual woman and doctor to choose for expectant management if the endometrium is more than four millimetres and endometrial sampling shows a benign result. From current literature, we can conclude that a benign result of endometrial sampling is reliable in these cases. In three meta-analyses, the sensitivity (a statistical measure, which gives the percentage of sick people who are correctly identified by the test as having the condition) of endometrial sampling has been tested.29-31 All three articles include both pre- and postmenopausal women.The diagnostic accuracy of endometrial sampling in the small group of postmenopausal women is high, with a sensitivity of 97.0-99.6%.The most used device for endometrial sampling in the Netherlands is the Pipelle® and the post-test probability of endometrial cancer after a benign result of specifically
16