Scripties UMCG - Rijksuniversiteit Groningen
English | Nederlands

Leidt implementatie van de nieuwe richtlijn postmenopauzaal bloedverlies tot betere uitkomsten? Een retrospectieve cohortstudie naar de richtlijn diagnostiek van postmenopauzaal bloedverlies van de Nederlandse vereniging van Obstetrie en Gynaecologie (NVO

(2017) Zoellner, L.S. (Lizzy-Sara)

Objective: Postmenopausal bleeding is known to be caused by a malignancy in about 10% of cases, which indicates the need for adequate diagnosis of this symptom. Previous research has shown the probability of polyps being (pre)malignant more often than assumed, possibly causing the missing of up to 6% of (pre)malignancy’s by using the designed guideline for diagnosis of postmenopausal bleeding from 2003. Because of this report and the fast development of diagnostic tests, a new guideline was developed in November 2015, advising additional testing with a Gel Instillation Sonography (GIS) or hysteroscopy for patients who present with an endometrial thickness of 4 mm or more and a normal endometrial aspiration biopsy. This new diagnostic guideline might be accompanied by higher costs, more complications, such as perforations or infections, and higher burdening for both patient and doctor. The discussion concerning the efficiency of the new guideline deserves attention. The goal of this study is to examine whether the increase of additional testing in women with postmenopausal bleeding following the new diagnostic guideline of November 2015, will lead to a decrease in the number of missed (pre)malignancy’s. Furthermore the extent to which both guidelines where followed will be investigated, in addition to the level of burdening of patients and doctors that both methods induce.
Study design: In this retrospective observational cohort study patients were included that presented with postmenopausal bleeding between January 1st of 2015 and December 31th of 2016. Excluded were patients with previous postmenopausal bleeding within one year prior and patients that underwent an uterus extirpation. The group from 2015 (OR-group), when the old guideline from 2003 was used, consisted of 337 women. In 2016 (NR-group), after introduction of the new guideline, 344 women were included.
Results: In this study 681 patients were included. The baseline characteristics were not significantly different between both groups. (Pre)malignancy’s were found with 11 (3,3%) patients in the OR-group, vs 14 (4,1%) in the NR-group; RR 1,2468 and 95%CI: 0,5743 to 2,7071 (p = 0,685). A GIS was performed in 4,3% of patients in the OR-group, compared to 27,7 in the NR-group (p-value 0,00). Also, 15,7% of patients in the OR-group received a hysteroscopy, in contrast to 43,4% in the NR-group (p-value 0,00). The average number of consultations per patient in the OR-group was 2,31, compared to 2,94 in the NR-group. The guideline was followed in 254 (75%) patients of the OR-group and 253 (74%) patients of the NR-group. In 51 (15%) cases in the OR-group, the diagnostic pathway was more extensive than the guideline advised, while in the NR-group 77 (22%) patients received less testing than the guidelines recommended. In the OR-group 9 (2,7%) complications were seen, compared to 17 (5%) in the NR-group. Noticed was that in the OR-group 84 (25%) benign intracavitary abnormalities were found, compared to 102 (31%) in the NR-group (p-value 0,002).
Conclusions: This study confirms that the new guideline leads to an increase of diagnostic tests, which might lead to detection of more pathology. However, contradicting the expectations, we did not find an increase in detected (pre)malignancy’s. Although this study has it’s restrictions because of its retrospective nature, the findings do stimulate re-evaluation of the new guideline in clinical practice on a larger scale. In a time of rising health care costs, we must carefully consider the costs and benefits

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