title: Improving the existing diagnostic strategy by accounting for characteristics of the women in the diagnostic work up for postmenopausal bleeding.
abstract: OBJECTIVE
  The aim of this study was to evaluate whether the efficiency of the current diagnostic work up following postmenopausal bleeding could be improved by diagnostic strategies that take into account characteristics of the women in addition to the currently recommended transvaginal measurement of endometrial thickness to determine for subsequent histological assessment.
  
  
  METHODS
  Multicenter, prospective cohort study.
  
  
  METHODS
  A university hospital and seven teaching hospitals in the Netherlands.
  
  
  METHODS
  Consecutive women not using hormone replacement therapy, presenting with postmenopausal bleeding.
  
  
  METHODS
  Five hundred and forty women underwent transvaginal sonography, and in case of endometrial thickness (double layer) above 4 mm, subsequent endometrial sampling was performed. Presence of carcinoma was ruled out by the absence of abnormalities in histological specimen or by an uneventful follow up of at least 6 months.
  
  
  METHODS
  Probability of endometrial carcinoma was estimated by multivariable logistic regression models. For each diagnostic strategy, we calculated diagnostic accuracy (area under receiver operating characteristic curve [AUC]), negative predictive value (NPV) and the number of diagnostic procedures.
  
  
  RESULTS
  A strategy with transvaginal sonography alone with a fixed threshold incorrectly classified 0.7% of the women as nonmalignant (NPV: 99.3% [98.5-100%]), with 97% sensitivity and 56% specificity. A strategy integrating characteristics of the women with transvaginal sonography could result in less false reassurances (NPV: 99.6% [99.2-100%]), with only marginal decrease in diagnostic procedures, or a minor increase in false reassurances (NPV: 99.0% [98.3-100%]), with a substantial reduction (15-20%) in the procedures. AUCs associated with these strategies could improve from 0.76 (0.73-0.79) for transvaginal sonography alone to 0.90 (0.87-0.93) for the integrated strategy.
  
  
  CONCLUSIONS
  Taking into account the characteristics of the women could increase the efficiency of the diagnostic work up for postmenopausal bleeding.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, The Netherlands. b.c.opmeer@amc.uva.nl
authors.forename: B C
authors.initials: BC
authors.lastname: Opmeer
authors.forename: H C
authors.initials: HC
authors.lastname: van Doorn
authors.forename: A P M
authors.initials: AP
authors.lastname: Heintz
authors.forename: C W
authors.initials: CW
authors.lastname: Burger
authors.forename: P M M
authors.initials: PM
authors.lastname: Bossuyt
authors.forename: B W J
authors.initials: BW
authors.lastname: Mol
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D015992:Body Mass Index; D015331:Cohort Studies; D016889:Endometrial Neoplasms / Q000150:complications / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications; D008487:Medical History Taking; D008875:Middle Aged; D010298:Parity; D017698:Postmenopause; D011247:Pregnancy; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013959:Thyroid Diseases / Q000150:complications; D014463:Ultrasonography; D014592:Uterine Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology
chemical_list: D000925:Anticoagulants