Cost-effectiveness of strategies to evaluate postmenopausal bleeding.
OBJECTIVE
To identify an optimal evaluation strategy for patients of various ages and risks for endometrial cancer and for complex hyperplasia who present with a first episode of postmenopausal bleeding.


METHODS
We constructed a decision-analytic model to assess the life expectancy, effectiveness, cost, and cost-effectiveness of four options for the initial evaluation of postmenopausal bleeding: office endometrial biopsy, D&C, hysterectomy, and observation unless bleeding recurred. We considered patients at different ages and risks for cancer and for complex hyperplasia.


RESULTS
Life expectancy was similar for all four strategies, but overall expected costs varied markedly. Compared with the other procedures, office biopsy was the most cost-effective initial strategy, costing less than $41,000 per year of life saved for patients at moderate combined risk (ie, 10%) of cancer or complex hyperplasia. However, for patients at low risk (ie, 5%), even office biopsy was relatively costly in certain age groups, with costs as high as $205,000 per additional year of life saved for 80-year-old patients. Both D&C and hysterectomy were more costly and no more effective than office biopsy as initial evaluation strategies in all patient groups over a wide range of changes in baseline assumptions.


CONCLUSIONS
Office biopsy is always preferred over D&C or hysterectomy for the initial evaluation of patients with postmenopausal bleeding. However, one may consider delaying a biopsy unless and until bleeding recurs for patients who are at low risk (5% or less) for cancer and complex hyperplasia by clinical criteria.
Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham & Women's Hospital, Boston, Massachusetts.
S
S
Feldman
R S
RS
Berkowitz
A N
AN
Tosteson
D000368:Aged; D001706:Biopsy / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004107:Dilatation and Curettage / Q000191:economics; D016889:Endometrial Neoplasms / Q000150:complications / Q000191:economics* / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000191:economics; D008017:Life Expectancy; D008593:Menopause; D008875:Middle Aged; D012307:Risk Factors; D014592:Uterine Hemorrhage / Q000191:economics* / Q000209:etiology*