The diagnostic work-up of women with postmenopausal bleeding

In this thesis we describe the diagnostic work-up that can be used to diagnose or exclude endometrial cancer in women with postmenopausal bleeding. Despite the many studies investigating this, there is no consensus in literature. The diagnostic steps vary in different guidelines, depending on the structure of patient flow in different settings and healthcare systems, as well as the availability of specific procedures. One important question in this thesis is if we can reassure women with a benign result of endometrial sampling. Is it (cost-)effective to diagnose and remove endometrial polyps to prevent recurrent bleeding? And is it necessary to diagnose and remove a polyp to detect a possible endometrial (pre)cancer? From the randomised trial described in this thesis, we can conclude that in women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Yet, hysteroscopy detected focal endometrial (pre) cancer in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic work-up is warranted to detect focal (pre)cancers missed by endometrial sampling. Furthermore, we can conclude that the diagnostic accuracy of endometrial sampling is lower that we thought based on previous literature. We have also looked into the value of predictionmodels, which we could use to select women with a high risk of endometrial cancer for further diagnostic work-up based on their patient-characteristics. We can conclude that until now, no predictionmodels are available which can select women based on their characteristics, without on the other hand missing women with endometrial cancer