By Frederick R. Jelovsek, M.D.
The most common presenting symptom of endometrial (uterine) cancer is
abnormal uterine bleeding. Most of the time it is categorized as
postmenopausal bleeding
since the age range of endometrial cancer is usually over age 50. On the
other hand, of all postmenopausal bleeding, only 5-10% is due to cancer
or its precursors. Traditionally, a D&C in the hospital was the gold
standard method to rule out cancer. It was replaced by endometrial
biopsy over the last 15-20 years. Now there has been a recent trend to
avoiding endometrial biopsy, an invasive and somewhat painful procedure,
by using vaginal probe ultrasound to initially evaluate women with postmenopausal
bleeding. If the thickness of the endometrial stripe is less than 5 mm, the
chances of cancer are less than 1%. What is not clear is whether the
strategy of doing an ultrasound first is cost-effective since over half the patients
will still need a biopsy.
-
A. Weber and others, Vaginal ultrasonography versus endometrial biopsy in
women with postmenopausal bleeding, Am J Obstet Gynecol 1997;177:924-9,
did a study to try to determine whether an endometrial biopsy should be the
primary procedure or ultrasound. Any strategy of diagnostic work-up
depends upon the diagnostic accuracy and the costs of each procedure. Accuracy estimates
will have a range from various studies and costs will vary at each doctor's office
or hospital. For example, endometrial biopsy may only be accurate 62-82% of the time and
non-diagnostic the rest of the time. Vaginal ultrasound may vary in cost from $60-$100 or
more. The most optimal strategy will thus be very dependent upon which numbers
are used in the calculation. In this study, the authors varied the numbers and tested
many different combinations.
Their conclusion was that the algorithm using vaginal ultrasound as the initial
procedure usually was the most cost effective, $218-$231 versus $238-$246 for biopsy
first algorithm. They even present formulae so practitioners can calculate the best
strategy based upon local costs and estimates of diagnostic accuracy.
I was impressed that there actually was very little difference between the two
approaches. Either one could be used depending upon convenience and cost. The
strategy using vaginal ultrasound first is less painful for almost 50%
of women so it makes sense to adopt that approach (first do no harm).
Women with postmenopausal bleeding
| | office endometrial biopsy | | | | vaginal ultrasound | |
|
| 72% diagnostic | | 28% nondiagnostic | | 45% normal | | 55% abnormal |
|
| no further evaluation | | vaginal ultrasound | | no further evaluation | | office endometrial biopsy |
| | 90% normal | 10% abnormal | | | 90% diagnostic | 10% nondiagnostic |
| | no further evaluation | hysteroscopy D&C | | | no further evaluation | hysteroscopy D&C |
| | | | | |
| 
