A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding

Objective. To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples. Design. Retrospective cohort study. Setting. Single hospital pathology laboratory. Population. Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up an

The diagnostic work-up of women with postmenopausal bleeding

In this thesis we describe the diagnostic work-up that can be used to diagnose or exclude endometrial cancer in women with postmenopausal bleeding. Despite the many studies investigating this, there is no consensus in literature. The diagnostic steps vary in different guidelines, depending on the structure of patient flow in different settings and healthcare systems, as well as the availability of specific procedures. One important question in this thesis is if we can reassure women with a benign result of endometrial sampling. Is it (cost-)effective to diagnose and remove endometrial polyps to prevent recurrent bleeding? And is it necessary to diagnose and remove a polyp to detect a possible endometrial (pre)cancer? From the randomised trial described in this thesis, we can conclude that in women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Yet, hysteroscopy detected focal endometrial (pre) cancer in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic work-up is warranted to detect focal (pre)cancers missed by endometrial sampling. Furthermore, we can conclude that the diagnostic accuracy of endometrial sampling is lower that we thought based on previous literature. We have also looked into the value of predictionmodels, which we could use to select women with a high risk of endometrial cancer for further diagnostic work-up based on their patient-characteristics. We can conclude that until now, no predictionmodels are available which can select women based on their characteristics, without on the other hand missing women with endometrial cancer

Prediction models in women with postmenopausal bleeding: a systematic review

Postmenopausal bleeding is associated with an elevated risk of having endometrial cancer. The aim of this review is to give an overview of existing prediction models on endometrial cancer in women with postmenopausal bleeding. In a systematic search of the literature, we identified nine prognostic studies, of which we assessed the quality, the different phases of development and their performance. From these data, we identified the most important predictor variables. None of the detected models completed external validation or impact analysis. Models including power Doppler showed best performance in internal validation, but Doppler in general gynecological practice is not easily accessible. We can conclude that we have indications that the first step in the approach of women with postmenopausal bleeding should be to distinguish between women with low risk versus high risk of having endometrial carcinoma and the next step would be to refer patients for further (invasive) testing.Nehalennia van Hanegem, Maria C Breijer, Brent C Opmeer, Ben WJ Mol & Anne Timmerman

Diagnostic accuracy of saline contrast sonohysterography in detecting endometrial polyps in women with postmenopausal bleeding: systematic review and meta-analysis

Objective: In women with postmenopausal bleeding, endometrial polyps are a frequent finding and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women, preferably by a minimally invasive method, is important. The aim of this systematic review was to assess the accuracy of saline contrast sonohysterography (SCSH) for diagnosis of endometrial polyps in women with postmenopausal bleeding. Methods: In August 2018, an electronic search was performed of MEDLINE, EMBASE and Web of Science databases to identify all diagnostic studies in which SCSH was used to detect endometrial polyps in postmenopausal women. Studies were included if SCSH was performed to detect endometrial polyps in women with postmenopausal bleeding and if detection of a polyp on hysteroscopy or diagnosis on histopathology was used as a reference standard. Two reviewers assessed methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Two separate analyses were performed for each reference standard. Pooled sensitivity and specificity were calculated using the hierarchical summary receiver–operating characteristics (HSROC) model and HSROC curves were plotted. Results: After selection and quality assessment, five studies were included. Using ‘polyps diagnosed with histopathology’ as the reference standard, the pooled sensitivity of SCSH was 86.5% (95% CI, 63.6–100%) and the pooled specificity was 91.1% (95% CI, 63.2–100%). Using ‘polyps seen on hysteroscopy’ as the reference standard, the pooled sensitivity of SCSH was 85.1% (95% CI, 66.9–100%) and the pooled specificity was 84.5% (95% CI, 68.1–100%). Excluding the one study that included women in whom the SCSH examination was reported to be suboptimal, the pooled sensitivity increased to 90.7% (95% CI, 72.8–100%) using hysteroscopy as the reference standard. The sensitivity of hysteroscopy to detect polyps, as reported in two studies, was 81–98%. Conclusions: Provided that the SCSH examination is of optimal quality, it can be considered as a method to stratify women with postmenopausal bleeding for further diagnostic workup and treatment with hysteroscopy. In women without suspicion of a polypoid lesion on SCSH, and with a benign endometrial sample, expectant management should be considered