title: Management of postmenopausal bleeding by general practitioners in a community setting: an observational study.
abstract: OBJECTIVE
  To evaluate the safety and effectiveness of a clinical pathway for investigation of postmenopausal bleeding (PMB), managed primarily by general practitioners. Women with an endometrial thickness (ET) ≥5mm on transvaginal ultrasound (TVUS) require either a pipelle biopsy in primary care or referral for specialist care.
  
  
  METHODS
  Data on 241 women with PMB were reviewed retrospectively over a 5-year follow-up period. Twenty-five women were excluded as they did not satisfy PMB clinical pathway criteria.
  
  
  RESULTS
  TVUS showed 121 women had an ET <5mm, 83 an ET ≥5mm, and 12 an endometrial polyp. In the women with ET ≥5mm, 38 had a pipelle biopsy performed in primary care, 36 were referred directly to secondary care, and 9 declined further investigations. Only 17 pipelle biopsies provided sufficient tissue, with the remaining 21 women referred to secondary care. Seven cases of endometrial cancer were identified, 4 by pipelle biopsy and 3 by hysteroscopy. Of the study cohort, 68% were managed solely by their general practitioner to the point of diagnosis, while 81% with an ET ≥5mm required management in secondary care at some stage. No further cases of endometrial cancer were identified in reviews of patient medical records and cancer registries.
  
  
  CONCLUSIONS
  Community-based investigation of PMB is an alternative model of care with no evidence of additional risks to the patient. Targeted education of general practitioners on pipelle biopsies is essential to maximise the effectiveness of the pathway.
authors.forename: Monique
authors.initials: M
authors.lastname: Stravens
authors.affiliation: Department of Obstetrics and Gynaecology, Christchurch Women's Hospital, Christchurch. monique.stravens@cdhb.health.nz.
authors.forename: Fali
authors.initials: F
authors.lastname: Langdana
authors.forename: John
authors.initials: J
authors.lastname: Short
authors.forename: Karyn
authors.initials: K
authors.lastname: Johnson
authors.forename: Bryony
authors.initials: B
authors.lastname: Simcock
authors.forename: Brett
authors.initials: B
authors.lastname: Shand
authors.forename: Graham
authors.initials: G
authors.lastname: McGeoch
authors.forename: Peter
authors.initials: P
authors.lastname: Sykes
mesh_terms: D004717:Endometrium / Q000000981:diagnostic imaging* / Q000473:pathology*; D005260:Female; D058005:General Practitioners; D006801:Humans; D008875:Middle Aged; D009520:New Zealand; D017698:Postmenopause; D012189:Retrospective Studies; D014463:Ultrasonography; D014592:Uterine Hemorrhage / Q000209:etiology / Q000473:pathology*