Page 38 - The diagnostic work-up of women with postmenopausal bleeding

Chapter 2
reassured.The exact sequence of investigation will depend upon clinical judgment, local resources, local expertise and patient preference.13
With recurrent or persistent PMB there are different strategies. In the Dutch guideline immediate hysteroscopy is advised;7 the Swedish guideline advises outpatient endometrial sampling or, if technically not possible, D&C.11 The further investigation and management of benign lesions in women with PMB require more research.The question is whether the treatment of benign lesions improves the patient’s quality of life, morbidity and survival.7,12
Discussion
The goal of this systematic review was to produce an evidence-based diagnostic pathway for patients with PMB.The most important conclusion is that in neither systematic reviews nor international guidelines can consensus be found regarding the sequence in which the different procedures should be implemented. All four types of test have been shown to be accurate and feasible in excluding or diagnosing endometrial cancer, by their high sensitivities and specificities.
Based on the available evidence, discussed in this review, we can conclude that TVS is an accurate method to exclude endometrial cancer, although there is still debate over the best cut-off value for endometrial thickness that should warrant endometrial sampling. Based on the highest sensitivity, a cut-off value of 3 mm is recommended, but the cost-effectiveness of this value has yet to be demonstrated.
Regarding the use of outpatient endometrial sampling, the two included reviews showed the high accuracy of this diagnostic method.22,23 Clark et al focused mainly on hyperplasia,22 while Dijkhuizen et al concluded that outpatient endometrial sampling is an accurate method for excluding cancer in women with PMB.23 However, the technique had a high rate of insufficient or failed sampling (0–54% in different observational studies).22,23 An insufficient sample should be an indication for further investigation.22,27,30 From the available reviews we cannot draw conclusions regarding the sequence of the tests in the diagnostic pathway of PMB.All the studies evaluated the tests independently, without any consideration of combinations of tests or previous test results.
In determining the best sequence of tests, different factors have to be taken into account, such as cost-effectiveness, the prevalence of endometrial cancer, local logistics (the availability of ultrasound, the use of outpatient endometrial sampling and
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