Managing postmenopausal bleeding revisited: what is the best first line investigation and who should be seen within 2 weeks? A cross-sectional study of 326 women

ObjectivesThe management strategies of postmenopausal bleeding (PMB) vary between different centres. This study was conducted to (1) evaluate the performance of a “One Stop PMB Clinic” that uses trans-vaginal ultrasound scanning (TVS) ± Pipelle® endometrial biopsy (EB) as the first line investigation, and (2) identify the risk factors for endometrial cancer to help setting criteria to prioritize clinic slots.Study designA retrospective data review of 326 women seen in the period from 1 August 2005 until 31 August 2009 at Ipswich Hospital, UK.ResultsThe median primary referral interval was 30 days. The prevalence of endometrial cancer and atypical hyperplasia was 5.5% (n = 18) and 1.8% (n = 6), respectively. One case with endometrial thickness (ET) of <5 mm and negative Pipelle® EB was found to have cancer on a curettage specimen taken for persistent bleeding. Statistical analysis revealed an association between endometrial cancer and increased ET (p < 0.0001), increased age (p = 0.004) and multiple episodes of bleeding (p = 0.04). There was no evidence of an association with parity (p = 0.64) or severity of bleeding (p = 0.46). There was no case of endometrial cancer in HRT users.ConclusionTVS ± Pipelle® EB may be a safe first line investigation in managing PMB. Accepting that all investigations have a false negative rate, women with persistent bleeding should be re-investigated. Given the ever-increasing workload, the priority for urgent appointments may be given to the older women, non-users of HRT and those with multiple episodes rather than heavy bleeding.