Diagnostic workup for postmenopausal bleeding: a randomised controlled trial.

To evaluate the effectiveness of hysteroscopy for the detection and treatment of endometrial polyps versus expectant management in women with postmenopausal bleeding (PMB), a thickened endometrium and benign endometrial sampling. Multicentre, randomised controlled trial. Three academic hospitals and nine non-academic teaching hospitals in the Netherlands. Women with PMB, an endometrial thickness >4 mm and benign result from endometrial sampling. Women were randomised to either further diagnostic workup by hysteroscopy (preceded by saline infusion sonography) or expectant management. The primary outcome measure was recurrence of PMB within a year after randomisation. Secondary outcome measures were time to recurrent bleeding and recurrent bleeding after more than 1 year. In the hysteroscopy group, the presence of polyps and the results of their histology were registered. Between January 2010 and October 2013, 200 women were randomised; 98 to hysteroscopy and 102 to expectant management. Within 1 year a total of 15 women (15.3%) in the hysteroscopy group experienced recurrent bleeding, versus 18 (18.0%) in the expectant management group (relative risk 0.85 (95% CI 0.46-1.59). In the hysteroscopy group, 50/98 (51%) polyps were diagnosed of which 6/98 (6%) showed evidence of endometrial (pre)malignancy; final pathology results after hysterectomy showed three women with hyperplasia with atypia and three women with endometrial cancer. In women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Hysteroscopy detected focal endometrial (pre)malignancy in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic workup is warranted to detect focal (pre)malignancies, missed by blind endometrial sampling. In women with PMB, hysteroscopy does not reduce recurrent bleeding but is warranted to detect focal malignancy.

van Hanegem N ，Breijer MC ，Slockers SA ，Zafarmand MH ，Geomini P ，Catshoek R ，Pijnenborg J ，van der Voet LF ，Dijkhuizen F ，van Hoecke G ，Reesink-Peters N ，Veersema S ，van Hooff M ，van Kesteren P ，Huirne JA ，Opmeer BC ，Bongers MY ，Mol B ，Timmermans A ... -  《-》

Recurrent postmenopausal bleeding: a prospective cohort study.

To estimate the prevalence of genital tract diseases in women with initial and recurrent postmenopausal bleeding (PMB) to help inform diagnostic pathways. Prospective cohort study (Canadian Task Force classification: II-2). Large urban teaching hospital. Of 1938 consecutive women with postmenopausal bleeding, 106 (5%) were investigated for a recurrent episode after having normal findings of previous investigations. All women underwent pelvic examination and ultrasound scanning. An endometrial biopsy was performed when endometrial thickness was >4 mm in women with a first episode of PMB, with recourse to outpatient hysteroscopy after correlation between clinical and pathologic findings. All women with a recurrent PMB episode underwent endometrial biopsy and outpatient hysteroscopy. The risk of having endometrial cancer or hyperplasia with atypia was significantly less in women with recurrent PMB (9%) as compared with those with a first episode of PMB (8%) (p = .002), but were significantly more likely to have benign endometrial polyps (28%) compared with women with a first episode of PMB (19%) (relative risk, 1.47; 95% confidence interval, 1.07-2.02; p = .02). Recurrent PMB results in less likelihood of premalignant and malignant endometrial disease; however, in 1 of 4 women PMB is caused by endometrial polyps. First-line investigation in women with recurrent PMB should be tests that have high accuracy for enabling diagnosis of focal diseases, such as outpatient hysteroscopy or saline infusion sonography.

Smith PP ，O'Connor S ，Gupta J ，Clark TJ ... -  《-》

The accuracy of endometrial sampling in women with postmenopausal bleeding: a systematic review and meta-analysis.

Postmenopausal bleeding (PMB) can be the first sign of endometrial cancer. In case of thickened endometrium, endometrial sampling is often used in these women. In this systematic review, we studied the accuracy of endometrial sampling for the diagnoses of endometrial cancer, atypical hyperplasia and endometrial disease (endometrial pathology, including benign polyps). We systematically searched the literature for studies comparing the results of endometrial sampling in women with postmenopausal bleeding with two different reference standards: blind dilatation and curettage (D&C) and hysteroscopy with histology. We assessed the quality of the detected studies by the QUADAS-2 tool. For each included study, we calculated the fraction of women in whom endometrial sampling failed. Furthermore, we extracted numbers of cases of endometrial cancer, atypical hyperplasia and endometrial disease that were identified or missed by endometrial sampling. We detected 12 studies reporting on 1029 women with postmenopausal bleeding: five studies with dilatation and curettage (D&C) and seven studies with hysteroscopy as a reference test. The weighted sensitivity of endometrial sampling with D&C as a reference for the diagnosis of endometrial cancer was 100% (range 100-100%) and 92% (71-100) for the diagnosis of atypical hyperplasia. Only one study reported sensitivity for endometrial disease, which was 76%. When hysteroscopy was used as a reference, weighted sensitivities of endometrial sampling were 90% (range 50-100), 82% (range 56-94) and 39% (21-69) for the diagnosis of endometrial cancer, atypical hyperplasia and endometrial disease, respectively. For all diagnosis studied and the reference test used, specificity was 98-100%. The weighted failure rate of endometrial sampling was 11% (range 1-53%), while insufficient samples were found in 31% (range 7-76%). In these women with insufficient or failed samples, an endometrial (pre) cancer was found in 7% (range 0-18%). In women with postmenopausal bleeding, the sensitivity of endometrial sampling to detect endometrial cancer and especially atypical hyperplasia and endometrial disease, including endometrial polyps, is lower than previously thought. Therefore, further diagnostic work-up for focal pathology is warranted, after a benign result of endometrial sampling.

van Hanegem N ，Prins MM ，Bongers MY ，Opmeer BC ，Sahota DS ，Mol BW ，Timmermans A ... -  《-》

Asymptomatic thickened endometrium in postmenopausal women: malignancy risk.

To assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding. Retrospective cohort (Canadian Task Force classification II-B). Academic medical center in the Midwestern United States. Over 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (>4 mm) and no bleeding. Flexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database. For the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5-15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively. Cancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted.

Famuyide AO ，Breitkopf DM ，Hopkins MR ，Laughlin-Tommaso SK ... -  《-》

Endometrial pathology in recurrent postmenopausal bleeding: observational study of 385 women.

Ghoubara A ，Sundar S ，Ewies AAA 《-》