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Diagnostic workup for postmenopausal bleeding: a randomised controlled trial.

N van Hanegem1,2, M C Breijer3, S A Slockers4

  • 1Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands.

BJOG : an International Journal of Obstetrics and Gynaecology
|May 27, 2016
PubMed
Summary
This summary is machine-generated.

Hysteroscopy did not reduce recurrent postmenopausal bleeding (PMB) in women with a thickened endometrium and benign sampling. However, it effectively detected focal endometrial (pre)malignancy missed by initial sampling, warranting further investigation.

Keywords:
Endometrial carcinomaendometrial polypendometrial samplinghysteroscopy

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Area of Science:

  • Gynecologic Oncology
  • Reproductive Medicine
  • Diagnostic Imaging

Background:

  • Postmenopausal bleeding (PMB) with a thickened endometrium and benign endometrial sampling presents a diagnostic challenge.
  • Endometrial polyps are common in this population, but their role in recurrent bleeding and potential for malignancy requires clarification.
  • Current diagnostic pathways often involve hysteroscopy, but its effectiveness compared to expectant management is debated.

Purpose of the Study:

  • To evaluate hysteroscopy's effectiveness in detecting and treating endometrial polyps compared to expectant management in women with PMB.
  • To assess the impact of hysteroscopy on recurrent postmenopausal bleeding.
  • To determine the diagnostic yield of hysteroscopy for focal endometrial (pre)malignancy in women with initially benign sampling.

Main Methods:

  • A multicentre, randomized controlled trial involving 200 women with PMB, endometrial thickness >4 mm, and benign endometrial sampling.
  • Participants were randomized to either hysteroscopy (preceded by saline infusion sonography) or expectant management.
  • Primary outcome was recurrent PMB within one year; secondary outcomes included time to recurrent bleeding and detection of polyps and malignancy.

Main Results:

  • Recurrent bleeding within one year occurred in 15.3% of the hysteroscopy group versus 18.0% of the expectant management group (RR 0.85).
  • Hysteroscopy diagnosed polyps in 51% of women, with 6% showing evidence of endometrial (pre)malignancy.
  • Final pathology after hysterectomy revealed hyperplasia with atypia or endometrial cancer in six women initially having benign sampling.

Conclusions:

  • Operative hysteroscopy does not significantly reduce recurrent bleeding in women with PMB, thickened endometrium, and benign sampling.
  • Hysteroscopy is crucial for detecting focal endometrial (pre)malignancies that may be missed by blind endometrial sampling.
  • Further diagnostic workup, including hysteroscopy, is warranted in this patient group to rule out occult malignancies.