Developing a robust and efficient pathway for the referral and investigation of women with post-menopausal bleeding using a cut-off of ≤4 mm for normal thickness

Abstract

The majority of women with post-menopausal bleeding (PMB) do not have endometrial cancer, and transvaginal ultrasound (TVUS) is accepted as the screening tool of choice to identify those at highest risk of malignancy. A new referral pathway was instigated in 2000, with patients only being referred to a gynaecologist following an abnormal TVUS result. An initial audit revealed a low positive predictive value for TVUS and a low incidence of detected malignancy. The cut-off value for a normal endometrium was increased from 3 mm to 4 mm in line with published data. This re7hyphen;audit evaluated the effectiveness of implemented changes and identified other areas for improvement. Of the 277 women referred during the study period, 193 had an abnormal or unseen endometrium and were subsequently seen by a gynaecologist. For patients without a histological diagnosis, clinical notes were reviewed and the hospital cancer database scrutinized for all endometrial cancers. Despite a 15.4% increase in referrals, only an additional 2.9% were assessed by gynaecologists. 14 cases of malignancy were identified with a mean endometrial thickness (ET) of 15.7 mm. Failed endometrial sampling was more prevalent with a minimally thickened endometrium. 80 patients with abnormal TVUS had no recorded histological diagnosis. Increasing the ET cut-off value has reduced unnecessary investigations in women at low risk of malignancy. No woman discharged back to her GP has been diagnosed with an endometrial malignancy within 1 year of initial referral. An algorithm has been proposed to further improve the investigation of women with PMB following an abnormal TVUS.

Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women

“…We identified 2398 studies, of which 129 were eligible for our analysis, with 40 790 unique patients, including 1 study that was eligible for both analyses (overlap of 45 women with endometrial cancers and 45 women with PMB) (eFigure 1 in the Supplement). Studies were published from January 1, 1977, through January 1, 2017, and most were cross-sectional and conducted in Northern (26 [20.2%]) and Southern Europe (24 [18.6%]).…”

“…In the 10 studies that included women with PMB and a minimum endometrial thickness (n = 2087), the pooled risk of endometrial cancer was 19% (95% CI, 14%-25%; τ 2 = 0.28). In 7 studies restricted to women with PMB and polyps (n = 2801), the pooled risk of endometrial cancer was 3% (95% CI, 3%-4%; τ 2 = 0).…”

“…For the analysis of the prevalence of PMB in women with endometrial cancer, we excluded 2 studies that selected cases based on stage at diagnosis; however, these studies were included in the stage-specific analysis. For the analysis of the risk of endometrial cancer among women with PMB, we conducted a secondary analysis in a subset of 10 studies that excluded women with measurements below a minimum endometrial thickness determined by TVUS (range, 4-5 mm) and a separate subset of 7 studies that evaluated the risk of endometrial cancer in women with polyps.…”

Health sector performance and efficiency in Ireland

“…Nonetheless, easier access to diagnostics may boost demand. Evidence suggests that protocols to regulate the use of tests and onward referral procedures strongly influences the effectiveness of care pathways (Williams et al, 2007). Systematic use of locally agreed protocols, to be followed by GPs and other actors in order to decide whether specific tests are required and how to access them, would help rationalise the use of existing diagnostic facilities, limit the risk of excessive take up and support effective planning.…”

Normal endometrial cells in cervical cytology: systematic review of prevalence and relation to significant endometrial pathology

“…In the UK, transvaginal ultrasound is used as the first-line procedure, followed by further investigation if the endometrial thickness is greater than 4 mm. 16,17 Most patients prefer to undergo endometrial assessment with hysteroscopy to rule out the risk of cancer. 18 However, the procedure has some associated complications, including uterine perforation.…”