Elsevier

Maturitas

Volume 68, Issue 2, February 2011, Pages 155-164
Maturitas

Review
Diagnostic evaluation of the endometrium in postmenopausal bleeding: An evidence-based approach

https://doi.org/10.1016/j.maturitas.2010.11.010Get rights and content

Abstract

Postmenopausal bleeding (PMB) is a common complaint in general gynecological practice. Women with PMB have around a 10% chance of having endometrial carcinoma and therefore PMB always needs further evaluation. This article summarizes the reviews on the subject and provides an overview of the use of diagnostic tools in patients with PMB. Four types of diagnostic test are described: sonographic measurement of endometrial thickness, endometrial sampling, hysteroscopy and saline infusion sonography. All four have been independently shown to be accurate in excluding endometrial cancer. However, neither in systematic reviews nor in international guidelines is consensus found regarding the sequence in which these methods should be employed in women with PMB. For measurement of endometrial thickness in symptomatic women, a cut-off value of 3 mm is recommended, but the cost-effectiveness of this strategy has yet to be shown. Research should now focus on the incorporation of individual patient characteristics and pre-test probabilities for cancer in algorithms for the investigation of PMB, and the most cost-effective sequenced combination of the four types of test.

Introduction

Postmenopausal bleeding (PMB), defined as blood loss occurring at least 12 months after menopause, is a common complaint in general gynecological practice. The prevalence of PMB is approximately 10% immediately after menopause [1]. Postmenopausal bleeding (PMB) signals endometrial carcinoma in around 10% of cases [2], [3], or less serious conditions, such as benign endometrial polyps, in a further 20–40% [2], [4], [5]. Endometrial carcinoma is the most common gynecologic malignancy and 95% of women with endometrial carcinoma 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], [11], [12], [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.

Section snippets

Identification of studies

We performed a computerized 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

Study selection

A total of nine systematic reviews assessed (part of) the diagnostic pathway for women with PMB and met the criteria for inclusion (Fig. 1). Of the selected systematic reviews, four articles assessed the use of TVS [16], [18], [19], [20], one described the use of SIS [21], two assessed the use of outpatient endometrial sampling [22], [23] and two assessed the use of hysteroscopy in patients with abnormal uterine bleeding [24], [25]. Table 1 shows further details of these studies.

Five of the

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

Conclusions

  • Neither in systematic reviews nor in international guidelines is consensus found regarding the best sequence of diagnostic procedures for women with PMB.

  • Measurement of endometrial thickness, endometrial sampling and hysteroscopy have been independently shown to be accurate in excluding endometrial cancer.

  • In relation to endometrial thickness, a cut-off value of 3 mm is recommended, but the cost-effectiveness of this strategy has yet to be demonstrated.

  • Future research should focus on the

Contributors

NvH, MB and AT wrote the manuscript. Drafting the article and revising it critically was performed by all authors. All authors approved the final draft.

Competing interests

None.

Provenance

Commissioned and externally peer reviewed.

Role of funding source

None.

Details of ethics approval

None.

Acknowledgement

The authors would like to thank Dr. C.E.J.M. Limpens, clinical librarian at Medical Library and Dutch Cochrane Centre, AMC, for her useful help with the electronic literature searches.

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