Postmenopausal bleeding: Cost-effective evaluation

Abstract

To the Editors: The article by Weber et al. (Weber AM, Belinson JL, Bradley DL, Piedmonte MR. Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. Am J Obstet Gynecol 1997;177:924-9) asserting that vaginal ultrasonography may represent the best first-choice investigation costwise compared with endometrial biopsy in the evaluation of women with postmenopausal bleeding made interesting reading. Curettage is accepted as the standard for the evaluation of postmenopausal bleeding, especially if preceded by hysteroscopy, and there is evidence that office endometrial biopsy is probably as good,1Feldman S Berkowitz RS Tosteson ANA Cost effectiveness of strategies to evaluate post menopausal bleeding.Obstet Gynecol. 1993; 81: 968-975PubMed Google Scholar, 2Goldchmit R Katz Z Blickstein I Caspi B Dgani R The accuracy of endometrial Pipelle sampling with and without sonographic measurement of endometrial thickness.Obstet Gynecol. 1993; 82: 727-730PubMed Google Scholar provided endometrial thickness by ultrasonography is >5 mm. From their algorithms, 72% of women in the endometrial biopsy arm had a definite diagnosis after the biopsy, with only 28% needing a second evaluation by way of ultrasonography and a further 10% of this 28% going on to hysteroscopy and curettage. In the ultrasonography arm, 55% of the women had abnormal findings and required endometrial biopsy, which was diagnostic in 90% of this 55%. Hence about 30% more women required both ultrasonography and endometrial biopsy in the ultrasonography arm of the algorithm compared with the endometrial biopsy arm before a diagnosis could be made. Second, twice as many women required hysteroscopy and curettage in the ultrasonography arm compared with the endometrial biopsy arm. This 30% reevaluation rate in the ultrasonography arm with endometrial biopsy represents serious cost implications, which more than offset the $14 to $20 savings made per patient using the marginally cheaper vaginal ultrasonography as a first test over endometrial biopsy, given the hundreds of thousands of women who undergo these evaluations every year. This is evident when the necessary repeat visits by the patients are taken into consideration. Weber et al. unfortunately did not cost these repeat hospital visits, neither did they cost time taken off work by patients for repeat visits as well as patient inconvenience and transport. The two procedures are complementary and it is possible to cut costs by performing ultrasonography first on women with postmenopausal bleeding (which will also assess pathologic features in the pelvis) and then endometrial biopsy at the same visit on those cases not resolved by ultrasonography. By adopting this approach, only a minimum number of patients will require a second visit or hysteroscopy and NO LABEL6/8/90539 NO LABEL6/8/90539