Page 37 - The diagnostic work-up of women with postmenopausal bleeding

61.0% (the prevalence in this group), they found a post-test probability for a
positive test of 93% (95% CI 88–95%).The conclusion was that this meta-analysis
gives strong evidence that diagnostic hysteroscopy is accurate in the diagnosis of
intrauterine abnormalities. 2
International guidelines
The published national and international guidelines describe different diagnostic pathways in the diagnostic work-up of women with postmenopausal bleeding.When a patient presents with PMB the first step in every guideline is referral to a gynaecologic practice for examination, pap smear andTVS. Only the US guidelines10,12 recommend eitherTVS or outpatient endometrial sampling as the first step in diagnosing women with PMB, based on similar sensitivities and cost-effectiveness for the detection of endometrial cancer for an endometrial thickness of 5 mm or more and for endometrial sampling when ‘sufficient’ tissue is obtained.16,28 In the other guidelines the first step is TVS, based on the high sensitivity and non-invasive character of the procedure. Different guidelines use different cut-off values of endometrial thickness, varying from 3 to 5mm.These cut-off points are mostly based on the meta-analysis by Smith-Bindman,7,10,12,16 but also on Swedish literature,11 and the review by Gupta et al19The most important issue is what probability of endometrial cancer is deemed acceptable after a negative test.
In the US guidelines, endometrial sampling is recommended with a cut-off value for the endometrial thickness of 5 mm and at the same time they recommend TVS when the endometrial sampling is deemed ‘insufficient’. SIS is used to distinguish between a diffusely thickened endometrium, for which D&C could be the next step,12 and between a focal lesion, for which a hysteroscopy is the next advised step.10,12 The National Guideline Clearinghouse stated that D&C in women with PMB should be performed only when endometrial sampling is indicated and cannot be performed or is inconclusive and sonographic techniques are non-reassuring. D&C should always have concomitant hysteroscopy, in case of focal pathology.11
The European guidelines advise endometrial sampling only when the endometrial thickness is above the cut-off value, possibly together with a SIS to distinguish between diffuse and focal pathology.7,11,13 With focal lesions the recommendation is to perform a (therapeutic) hysteroscopy and with diffuse lesions D&C, but only when endometrial sampling is insufficient or has failed. Where the endometrium is thin, the guidelines recommend conservative management. Only the Scottish guideline recommends fur ther investigation if the clinician, the patient or both are not
Diagnostic evaluation
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