Page 27 - The diagnostic work-up of women with postmenopausal bleeding

Introduction
Postmenopausal bleeding (PMB), defined as blood loss occurring at least 12 months
after menopause, is a common complaint in general gynaecological practice. 2 The prevalence of PMB is approximately 10% immediately after menopause.1 Postmenopausal bleeding (PMB) signals endometrial cancer in around 10% of
cases,2,3 or less serious conditions, such as benign endometrial polyps, in a further
20 to 40%.2,4,5 Endometrial cancer is the most common gynaecologic cancer and
95% of women with endometrial cancer present with PMB.6,7 Unlike ovarian cancer,
endometrial cancer often presents at an early stage, when there is a possibility of
curative treatment by hysterectomy (and bilateral salpingo-oophorectomy);therefore early,accurate and timely diagnosis is important.Any PMB needs further investigation.
In the past, the principal method of investigation was dilatation and curettage (D&C).8 To reduce the invasiveness of investigatory procedures, ultrasonography was introduced. Endometrial biopsy and hysteroscopy have now almost completely replaced D&C. The use of outpatient endometrial biopsy reduces costs in the diagnostic work-up, without affecting life expectancy.9 Despite many studies on the investigation of PMB, there is still no consensus on the most accurate and efficient diagnostic pathway.7,10-13 This article describes a systematic literature search for guidelines and systematic reviews on this subject.The aim is to recommend an evidence-based diagnostic pathway for patients with PMB.
Methods
Identification of studies
We performed a computerised MEDLINE and EMBASE search to identify all studies on the evaluation of PMB published between January 1965 and January 2010.The search was limited to human studies; language restrictions were not applied. We included systematic review articles of observational studies on the evaluation of the endometrium in women with PMB. In addition we searched for national and international guidelines on this subject. References cited in the selected reviews were checked for further relevant articles not identified by the electronic searches. We used all known synonyms for the following keywords: postmenopausal bleeding, endometrial thickness, ultrasound, hysteroscopy and biopsy.The search strategies for the two databases are detailed in Appendices A and B.
Diagnostic evaluation
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