Ultrasound in the management of women with post-menopausal bleeding

Abstract: The aim of this thesis was to investigate how ultrasound can be used in the diagnostic work-up of women with post-menopausal bleeding (PMB) to optimise and individualise their management. The thesis is based on six studies comprising post-menopausal women with (Study I-VI) and without (Study VI) abnormal bleeding. The clinical value of conventional ultrasound, with or without saline infusion (hydrosonography), and of power Doppler ultrasound, was determined, and the performance of different endometrial biopsy techniques was compared and correlated with sonographic findings. Re-bleeding and endometrial growth were common during a follow-up period of 12 months in women with PMB and endometrium < 5 mm, irrespective of whether dilatation and curettage (D&C) was carried out or not. Endometrial pathology was only found in women with endometrial growth to >/= 5 mm. If these women are managed by ultrasound follow-up, endometrial sampling should be performed if the endometrium grows to a thickness of >/= 5 mm, and perhaps also in cases of re-bleeding. Endorette® (a simple endometrial sampling device) and D&C had similar diagnostic value in women with PMB and endometrium < 7 mm, whereas D&C was superior to Endorette® in women with endometrium >/= 7 mm. However, in another study on women with PMB and endometrium >/= 5 mm, we found that D&C failed to diagnose about half of the focal lesions in the uterine cavity that were removed by operative hysteroscopy. Thus, the presence or absence of focal lesions should determine the diagnostic procedure. Hydrosonography was found to be as good as hysteroscopy with regard to detecting focal lesions, but neither method was accurate enough in discriminating benign from malignant lesions. Distension difficulties at hydrosonography were more common in women with endometrial cancer and should therefore raise a suspicion of malignancy. A multivariate logistic regression model including clinical information, conventional ultrasound variables, and power Doppler variables seems to be superior to endometrial ultrasound morphology in correctly diagnosing endometrial cancer in cases where the endometrium measures 5-15 mm. The reproducibility of endometrial measurements allows reliable discrimination between post-menopausal women with endometrium < 5 mm and >/= 5 mm.