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ABSTRACT: To determine the incidence and significance of recurrent postmenopausal bleeding among women diagnosed with an endometrial thickness < or =4 mm after a first episode of postmenopausal bleeding.
Consecutive patients not using hormone replacement therapy (HRT) presenting with a first episode of postmenopausal bleeding and an endometrial thickness < or =4 mm at transvaginal ultrasonography (TVU) were managed expectantly. In case of recurrent bleeding, the patient was evaluated according to the hospital's local policy with TVU, office endometrial sampling, hysteroscopy or dilatation and curettage (D&C) or a combination of these tests. We evaluated the incidence of recurrent bleeding, potential risk factors for recurrent bleeding, and the diagnosis made after recurrent bleeding.
A total of 607 patients were registered with a first episode of postmenopausal bleeding, of whom 249 had an endometrial thickness < or =4 mm. Follow-up took place with a median of 174 weeks (range: 4-250 weeks). During follow-up, 25 of the 249 patients (10%; 95% CI: 6.6-14%) had recurrent bleeding. Median time until recurrence of bleeding was 49 weeks (range: 9-186 weeks). Two patients with recurrent bleeding turned out to have an endometrial carcinoma (8%; 95% CI: 2.2-25%), and 1 patient had a malignant melanoma. Time since menopause, age, body mass index, hypertension, diabetes and anticoagulants were not predictive for recurrent bleeding.
The recurrence rate after a first episode of postmenopausal bleeding managed expectantly is low and cannot be predicted by patient characteristics. Patients with recurrent bleeding should be re-evaluated, as they bear a considerable risk of carcinoma.
Acta Obstetricia Et Gynecologica Scandinavica 02/2008; 87(1):89-93. · 1.77 Impact Factor
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ABSTRACT: The objective is to assess among women with postmenopausal bleeding the relationship of age and time since menopause on one hand and the presence of endometrial cancer and atypical hyperplasia on the other hand. In a multicenter prospective cohort study, 614 women presenting with postmenopausal bleeding were included. Women underwent transvaginal sonography and, in cases where the endometrial thickness was >4 mm, endometrial sampling. Splines were used to assess the association between each of the continuous variables and (pre)malignancy of the endometrium. Subsequently, univariate and multivariate analysis were performed. The average age for women without (pre)malignancy was 61.7 years (SD 9.8). As malignant and premalignant cases were found to have similar age, these subgroups were merged in the analyses. Age was an independent predictor of (pre)malignancy. In women younger than 55 years, the odds ratio was 1.9 (95% CI: 1.1–3.3) for each year under 55 years of age and 1.03 (95% CI: 1.00–1.06) for each year over 55 years of age. The risk of (pre)malignancy of the endometrium was 4.9% in women less than 3 years postmenopausal versus 19.7% in women more than 20 years postmenopausal. However, in a multivariate analysis only age contributed to the prediction of risk. This study demonstrates that, in postmenopausal women with vaginal bleeding, the risk of (pre)malignancy of the endometrium is low in women under 50 years of age, increases considerably until 55 years of age, and rises only modestly with further advancing age. Future studies should explore whether these findings can be incorporated in the diagnostic work-up of women with postmenopausal bleeding.
International Journal of Gynecological Cancer 08/2007; 17(5):1118 - 1123. · 1.65 Impact Factor
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ABSTRACT: To assess the cost-effectiveness of transvaginal sonography (TVS) and saline infused sonography (SIS) in the diagnostic work-up of women with menorrhagia.
We performed a decision analysis in which we compared the percentage of patients treated successfully and cost of six strategies for the evaluation of menorrhagia: (0) hormonal treatment, (I) treatment of all patients with balloon ablation, (II) TVS and therapeutic hysteroscopy, (III) TVS, SIS and therapeutic hysteroscopy, (IV) SIS and therapeutic hysteroscopy, and (V) diagnostic hysteroscopy and therapeutic hysteroscopy. Hormonal treatment was considered to be the reference strategy to which the five strategies were compared. Data were obtained from the published literature. In order to evaluate the robustness of our results, we performed extensive sensitivity analyses, in which we varied sensitivity and specificity of TVS and hysteroscopy, the prevalence of intracavitary abnormalities, as well as costs of TVS and SIS.
We found that the strategy starting with SIS (IV) and the strategy with diagnostic hysteroscopy (V) revealed the highest number of patients treated successfully for menorrhagia. In terms of cost-effectiveness, SIS for all patients was superior over immediate diagnostic hysteroscopy for all patients. Strategies starting with TVS were less effective than the strategy starting with SIS.
We recommend SIS as the procedure of first choice in the work-up for women with menorrhagia.
International Journal of Gynecology & Obstetrics 11/2003; 83(1):45-52. · 2.05 Impact Factor
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ABSTRACT: To determine the value of transvaginal saline-infusion sonography of the uterus in patients with abnormal uterine blood loss in terms of avoiding hysteroscopy.
Prospective.
According to the protocol, transvaginal saline-infusion sonography was carried out on all consecutive patients with abnormal uterine blood loss (post-menopausal patients with an endometrial thickness of > or = 5 mm and all pre-menopausal patients with menorrhagia or metrorrhagia) in the St. Joseph hospital in Veldhoven, the Netherlands, during the period 1999-2001. If sonography did not provide an image suitable for assessment, or if intracavitary (pedunculated) lesions such as polyps or myomas were suspected, a planned therapeutic hysteroscopy was carried out. Patients indicated their perception of pain on a visual analogue scale.
Saline-infusion sonography of the uterus was performed in 457 patients (age: 40-69 years). In 32 patients (7%) it did not result in a representative image. In 138 (32%) of the remaining 425 patients, a pedunculated lesion was suspected. In 262 (59%) of the 457 patients, diagnostic efforts were restricted to ultrasonic examination. This was combined with endometrial aspiration in 161 (61%) of these patients. In total, hysteroscopy was carried out in 195 of the 457 patients (43%). There were no complications. Pain was scored as 'none-little' by 292 patients (64%), 'moderate' by 76 (17%) and 'a great deal' by 48 (10%) patients.
Saline-infusion sonography of the uterus is a safe diagnostic method in patients with abnormal uterine blood loss, which, in more than half the cases, can replace less well-tolerated diagnostic procedures.
Nederlands tijdschrift voor geneeskunde 03/2003; 147(11):502-6.
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[show abstract]
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ABSTRACT: The objective is to assess among women with postmenopausal bleeding the relationship of age and time since menopause on one hand and the presence of endometrial cancer and atypical hyperplasia on the other hand. In a multicenter prospective cohort study, 614 women presenting with postmenopausal bleeding were included. Women underwent transvaginal sonography and, in cases where the endometrial thickness was >4 mm, endometrial sampling. Splines were used to assess the association between each of the continuous variables and (pre)malignancy of the endometrium. Subsequently, univariate and multivariate analysis were performed. The average age for women without (pre)malignancy was 61.7 years (SD 9.8). As malignant and premalignant cases were found to have similar age, these subgroups were merged in the analyses. Age was an independent predictor of (pre)malignancy. In women younger than 55 years, the odds ratio was 1.9 (95% CI: 1.1-3.3) for each year under 55 years of age and 1.03 (95% CI: 1.00-1.06) for each year over 55 years of age. The risk of (pre)malignancy of the endometrium was 4.9% in women less than 3 years postmenopausal versus 19.7% in women more than 20 years postmenopausal. However, in a multivariate analysis only age contributed to the prediction of risk. This study demonstrates that, in postmenopausal women with vaginal bleeding, the risk of (pre)malignancy of the endometrium is low in women under 50 years of age, increases considerably until 55 years of age, and rises only modestly with further advancing age. Future studies should explore whether these findings can be incorporated in the diagnostic work-up of women with postmenopausal bleeding.
International Journal of Gynecological Cancer 17(5):1118-23. · 1.65 Impact Factor
