title: Role of hysteroscopy with endometrial biopsy to rule out endometrial cancer in postmenopausal women with abnormal uterine bleeding.
abstract: OBJECTIVE
  To compare the diagnostic accuracy of ultrasonographic endometrial thickness and outpatient hysteroscopy, to establish the most appropriate exam for the diagnosis of endometrial cancer in postmenopausal women with abnormal uterine bleeding (AUB). The secondary aim was to develop a multivariable approach considering clinical history as an added value for these diagnostic procedures.
  
  
  METHODS
  This prospective study was conducted on 220 consecutive postmenopausal patients with AUB, who underwent ultrasonographic evaluation of endometrial thickness, outpatient hysteroscopy and endometrial biopsy. Evaluation of sensitivity, specificity, positive and negative predictive value was performed. Receiver operator characteristic curve (ROC) was calculated to assess the global performance of ultrasonographic measurement of endometrial thickness and diagnostic hysteroscopy as tests for detecting endometrial cancer and atrophy.
  
  
  RESULTS
  Histological findings for <4 mm level revealed that atrophy was present in 48 (65%) and in 2 cases (2.7%) endometrial cancer was found; for > or = 4 mm values polyps and myomas were present in 86 (59%) and there were 11 (7.5%) endometrial cancer. Sensibility and specificity for trans-vaginal ultrasound, with a cut-off value > or = 4 mm, was 55.6% and 49.7% while positive predictive value was 83.3% and negative predictive value 98.1% (ROC curve 0.597). Hysteroscopy revealed sensitivity 100%, specificity 49.6%, positive predictive value 81.3% and negative predictive value 100% (ROC curve 0.993).
  
  
  CONCLUSIONS
  In conclusion, endometrial thickness <4 mm can miss malignancies but trans-vaginal ultrasound remains the first line diagnostic procedure in postmenopausal women without AUB, because it is not invasive and has high sensitivity for detecting endometrial cancer and other endometrial disease; according to our experience, outpatient hysteroscopy with biopsy is mandatory in all postmenopausal women with AUB.
authors.affiliation: Department of Gynaecology and Obstetrics, University of Padua, Padua, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Litta
authors.forename: Federica
authors.initials: F
authors.lastname: Merlin
authors.forename: Carlo
authors.initials: C
authors.lastname: Saccardi
authors.forename: Chiara
authors.initials: C
authors.lastname: Pozzan
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Sacco
authors.forename: Mara
authors.initials: M
authors.lastname: Fracas
authors.forename: Giampiero
authors.initials: G
authors.lastname: Capobianco
authors.forename: Salvatore
authors.initials: S
authors.lastname: Dessole
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D001284:Atrophy / Q000175:diagnosis; D001706:Biopsy; D004717:Endometrium / Q000473:pathology* / Q000503:physiopathology; D005260:Female; D006801:Humans; D015907:Hysteroscopy; D007889:Leiomyoma / Q000175:diagnosis; D008875:Middle Aged; D011127:Polyps / Q000175:diagnosis; D017698:Postmenopause; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012680:Sensitivity and Specificity; D014592:Uterine Hemorrhage / Q000209:etiology*; D014594:Uterine Neoplasms / Q000175:diagnosis*