Page 36 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 2
Saline infusion sonography
Only one systematic review, by de Kroon et al has described the evaluation of the diagnostic accuracy of SIS in pre- and post- menopausal women with abnormal uterine bleeding.21 The main outcome measures were LRs, post-test probabilities and the success rate of SIS in the prediction of uterine cavity abnormality.We focus here on the results regarding women with PMB.The review identified 24 studies with homogeneous data, but only five of these concerned postmenopausal women. Pooling the data from these five articles gives a sensitivity of 95% and a specificity of 88%.The calculations for endometrial cancer were not mentioned. Sensitivity and specificity were not separately described for pre- and postmenopausal women, but the overall success rate was significantly lower in postmenopausal women: 87%, compared with 95% for premenopausal women (P < 0.01).
Hysteroscopy
Clark et al 2002 performed a systematic quantitative review in which they focused on the diagnostic accuracy of hysteroscopy in diagnosing endometrial cancer or hyperplasia.24 Postmenopausal women represented 29% of the populations studied. Only two studies concerning postmenopausal women were rated as high quality. Pooled data from these showed a post-test probability of a positive test of 71.8% (95% CI 67.0–76.6%). In these studies the failure rate for hysteroscopy (ambulant or inpatient) was 3.4% (67 of 1948 women), which was comparable with the overall failure rate in premenopausal women. Sensitivity and specificity were not separately described for pre- and postmenopausal women, but the overall sensitivity and specificity were 86.4% and 99.2% respectively.The authors concluded that when the uterine cavity is adequately visualized, hysteroscopy is highly accurate and clinically useful in the diagnosis of endometrial cancer. However, its high accuracy relates to diagnosing cancer rather than its exclusion.
Another systematic review and meta-analysis of diagnostic hysteroscopy was performed by van Dongen et al25 This article focused on studies of the use of hysteroscopy in the diagnosis of intrauterine abnormalities, rather than endometrial cancer per se, because Clark et al had already shown in their meta- analysis that diagnostic hysteroscopy is accurate in the diagnosis of endometrial cancer.24 In this review five studies of postmenopausal women with homogeneous data were included. The pooled sensitivity and specificity in the assessment of uterine cavity abnormality were 96% (95% CI 93–99%) and 90% (95% CI 83– 95%) respectively. With a pre-test probability of uterine cavity abnormalities of
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