Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy.

INTRODUCTION: Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work-up for postmenopausal bleeding showing reassuring histology or insufficient sampling. MATERIAL AND METHODS: All women presenting with postmenopausal bleeding were prospectively included from January 2009 to April 2011. Follow-up data were collected from patient charts and PALGA (Dutch Pathology Registry). Hazard ratios for endometrial cancer were determined by calculating standardized incidence ratios. RESULTS: A total of 668 women were included and 568 women were available for follow-up [median follow-up time 47 (range 7-63) months]. Women who presented with postmenopausal bleeding, endometrial thickness >4 mm and hyperplasia without atypia on biopsy at the first presentation showed a significantly increased risk (standardized incidence ratio 17.15, 95% confidence interval 1.96-61.93) of being diagnosed with endometrial cancer during the first four years of follow up compared with the age-specific population. All women that developed endometrial cancer after initial reassuring histology presented with recurrent postmenopausal bleeding. None of the women with endometrial thickness >4 mm and no or insufficient sample for histology at the first presentation developed endometrial cancer during the follow up. CONCLUSIONS: Although in general, women with endometrial hyperplasia without atypia are considered to have a low risk for cancer, we observed a significant long-term risk of endometrial cancer after postmenopausal bleeding. Whether additional diagnostics or a more stringent follow-up regimen would be cost-effective, needs to be studied.

Factors attributing to the failure of endometrial sampling in women with postmenopausal bleeding.

OBJECTIVE: To determine which doctor- and patient-related factors affect failure of outpatient endometrial sampling in women with postmenopausal bleeding, and to develop a multivariable prediction model to select women with a high probability of failed sampling. DESIGN: Prospective multicenter cohort study. SETTING: Three teaching hospitals in the Netherlands. POPULATION: Women presenting with postmenopausal bleeding with an indication for endometrial sampling. METHODS: Multivariable logistic regression was performed to evaluate the impact of doctor's training level and patient's characteristics on failure of sampling. MAIN OUTCOME MEASURES: Failure of endometrial sampling, classified as technical failure or insufficient tissue for diagnosis. RESULTS: In 74 (20.8%) of the 356 included women, sampling technically failed, and in 84 (29.8%) the amount of tissue was insufficient for diagnosis. Nulliparity [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.8-7.9] and advanced age (OR 1.03 per year, 95% CI 1.00-1.06) were associated with technical failure. Advanced age was associated with insufficient sampling (OR 1.04 per year, 95% CI 1.01-1.07), and endometrial thickness >12 mm decreased the chance of insufficient sampling (OR 0.3, 95%CI 0.1-0.8). The prediction model for total failure had an area under the ROC curve of 0.64 (95% CI 0.58-0.70). CONCLUSIONS: In women with postmenopausal bleeding, the failure rate of endometrial sampling is relatively high and is associated with nulliparity and advanced age. Endometrial thickness >12 mm decreased the chance of failure. A multivariable prediction model for total failure based on patient characteristics has a moderate capacity to discriminate between women at high or low risk of failure.

Current practice in the removal of benign endometrial polyps: a Dutch survey.

The purpose of this study is to evaluate the current practice of Dutch gynecologists in the removal of benign endometrial polyps and compare these results with the results of a previous study from 2003. In 2009 Dutch gynecologists were surveyed by a mailed questionnaire about polypectomy. Gynecologists answered questions about their individual performance of polypectomy: setting, form of anesthesia, method, and instrument use. The results were compared with the results from the previous survey. The response rate was 70% (585 of 837 gynecologists). Among the respondents, 455 (78%) stated to remove endometrial polyps themselves. Polyps were mostly removed in an inpatient setting (337; 74%) under general or regional anesthesia (247; 54%) and under direct hysteroscopic vision (411; 91%). Gynecologists working in a teaching hospital removed polyps more often in an outpatient setting compared with gynecologists working in a nonteaching hospital [118 (43%) vs. 35 (19%) p < 0.001]. These results are in accordance with the results from 2003. Compared to 2003 there was an increase in the number of gynecologists performing polypectomies with local or no anesthesia [211 (46%) vs. 98 (22%), p < 0.001]. An increase was also noted in the number of gynecologists using direct hysteroscopic vision [411 (91%) vs. 290 (64%), p < 0.001] and 5 Fr electrosurgical instruments [181 (44%) vs. 56 (19%), p < 0.001]. Compared to the situation in 2003, there is an increase in removal under direct hysteroscopic vision, with 5 Fr electrosurgical instruments, using local or no anesthesia. This implies there is progress in outpatient hysteroscopic polypectomy in the Netherlands.

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.

Diagnostic strategies for endometrial cancer in women with postmenopausal bleeding: cost-effectiveness of individualized strategies.

OBJECTIVE: To evaluate the cost-effectiveness of diagnostic strategies incorporating the diagnostic value of patient characteristics for endometrial carcinoma using prediction models. STUDY DESIGN: A decision analytic model was created to compare four diagnostic strategies for women with postmenopausal bleeding: the main outcome measures were 5 year survival, costs, and cost-effectiveness of three model based strategies compared to the strategy reflecting current practice. RESULTS: A strategy selecting women for endometrial biopsy based on their history only, dominated all other strategies (more effective, less cost). In a clinical scenario where transvaginal sonography (TVS) was assumed to be an integral part of the consultation without additional costs, a strategy selecting high-risk women for TVS became the most cost-effective strategy. CONCLUSIONS: Strategies taking into account the individual probability based on a prognostic model are less costly than the currently applied strategy for a similar effectiveness. The most cost-effective strategy depends on the clinical setting: in areas where TVS is performed by the consulting gynecologist without extra costs, selective TVS based on history is the most cost-effective strategy. When TVS is not readily available and therefore incurs extra costs, a risk selection based on patient characteristics is most cost-effective.