BACKGROUND: This study aimed to show the longitudinal use of routinely collected clinical data from history and ultrasound evaluation of the endometrium in developing an algorithm to predict the risk of endometrial carcinoma for postmenopausal women presenting with vaginal bleeding. METHODS: This prospective study collected data from 3047 women presenting with postmenopausal bleeding. Data regarding the presence of risk factors for endometrial cancer was collected and univariate and multivariate analyses were performed. RESULTS: Age distribution ranged from 35 to 97 years with a median of 59 years. A total of 149 women (5% of total) were diagnosed with endometrial carcinoma. Women in the endometrial cancer group were significantly more likely to be older, have higher BMI, recurrent episodes of bleeding, diabetes, hypertension, or a previous history of breast cancer. An investigator best model selection approach was used to select the best predictors of cancer, and using logistic regression analysis we created a model, 'Norwich DEFAB', which is a clinical prediction rule for endometrial cancer. The calculated Norwich DEFAB score can vary from a value of 0 to 9. A Norwich DEFAB value equal to or greater than 3 has a positive predictive value (PPV) of 7.78% and negative predictive value (NPV) of 98.2%, whereas a score equal to or greater than 5 has a PPV of 11.9% and NPV of 97.8%. CONCLUSION: The combination of clinical information with our investigation tool for women with postmenopausal vaginal bleeding allows the clinician to calculate a predicted risk of endometrial malignancy and prioritise subsequent clinical investigations.

We have developed a simple model based on patients' clinical characteristics in estimating the risk of endometrial cancer for postmenopausal women presenting with vaginal bleeding. The model shows reasonable discriminatory ability for women with cancer and without, with an area under the receiver operating characteristics curve of 0.73. This will allow clinicians to individualize the diagnostic pathway for women with postmenopausal vaginal bleeding.

Ketoacidosis is most often due to uncontrolled diabetes mellitus. Similar metabolic changes can occur with poor dietary intake of carbohydrates or prolonged fasting. Metabolic acidosis due to prolonged fasting is rarely described in the literature. We report a case of severe metabolic acidosis as a result of prolonged fasting in pregnancy.

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To our knowledge, this is the first population-based estimation of the incidence of genital tract bleeding and endometrial cancer among postmenopausal women in the United Kingdom. The results of this study showing the age-related differential diagnosis can be used to inform clinical practice when counselling postmenopausal women with vaginal bleeding.