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How should we investigate women with postmenopausal bleeding?
1Department of Obstetrics and Gynaecology, Ninewells Hospital and Medical School, Dundee, Scotland.
Objective:
To evaluate the optimum method(s) of investigating women with postmenopausal bleeding.
Design:
Prospective study of 76 postmenopausal women.
Setting:
Teaching Hospital. Interventions. All women had pipelle endometrial biopsy in outpatient clinic. Prior to inpatient hysteroscopy and uterine curettage, each woman had pelvic ultrasonography to measure the endometrial thickness and to exclude ovarian pathology.
Results:
Pipelle biopsy was successful in 70% of cases and has a sensitivity of 70%. Hysteroscopy has superior diagnostic capabilities allowing direct visualisation of the endometrial cavity with directed biopsies. Endometrial thickness of > 5 mm used as an indicator of endometrial pathology compared to uterine curettage has a sensitivity of 83%, a specificity of 77%, and a positive predictive value of 54%. Ultrasound also detected five ovarian tumors, two of which were malignant and three missed by pelvic examination alone.
Conclusions:
We recommend the routine use of pelvic ultrasonography in all women with postmenopausal bleeding as it is an invaluable diagnostic tool in excluding ovarian pathology. In addition, sampling of the endometrial cavity, preferably with outpatient hysteroscopy, is mandatory for histological diagnosis. Overall, the combination of ultrasound and outpatient endometrial sampling would spare hospital admission for at least 60% of women with postmenopausal bleeding.