Diagnostic workup for postmenopausal bleeding: a randomised controlled trial

N. van Hanegem*, M. C. Breijer, S. A. Slockers, M. H. Zafarmand, P. M.A.J. Geomini, R. Catshoek, J. M.A. Pijnenborg, L. F. van der Voet, F. P.H.L.J. Dijkhuizen, G. C.R. van Hoecke, N. Reesink-Peters, S. Veersema, M. H.A. van Hooff, P. J.M. van Kesteren, J. A. Huirne, B. C. Opmeer, M. Y. Bongers, B. W.J. Mol, A. Timmermans

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

45 Citations (Scopus)


Objective: To evaluate the effectiveness of hysteroscopy for the detection and treatment of endometrial polyps versus expectant management in women with postmenopausal bleeding (PMB), a thickened endometrium and benign endometrial sampling. Design: Multicentre, randomised controlled trial. Setting: Three academic hospitals and nine non-academic teaching hospitals in the Netherlands. Population: Women with PMB, an endometrial thickness >4 mm and benign result from endometrial sampling. Methods: Women were randomised to either further diagnostic workup by hysteroscopy (preceded by saline infusion sonography) or expectant management. Main outcomes: The primary outcome measure was recurrence of PMB within a year after randomisation. Secondary outcome measures were time to recurrent bleeding and recurrent bleeding after more than 1 year. In the hysteroscopy group, the presence of polyps and the results of their histology were registered. Results: Between January 2010 and October 2013, 200 women were randomised; 98 to hysteroscopy and 102 to expectant management. Within 1 year a total of 15 women (15.3%) in the hysteroscopy group experienced recurrent bleeding, versus 18 (18.0%) in the expectant management group (relative risk 0.85 (95% CI 0.46–1.59). In the hysteroscopy group, 50/98 (51%) polyps were diagnosed of which 6/98 (6%) showed evidence of endometrial (pre)malignancy; final pathology results after hysterectomy showed three women with hyperplasia with atypia and three women with endometrial cancer. Conclusion: In women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Hysteroscopy detected focal endometrial (pre)malignancy in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic workup is warranted to detect focal (pre)malignancies, missed by blind endometrial sampling. Tweetable abstract: In women with PMB, hysteroscopy does not reduce recurrent bleeding but is warranted to detect focal malignancy.

Original languageEnglish
Pages (from-to)231-240
Number of pages10
JournalBJOG: An International Journal of Obstetrics and Gynaecology
Issue number2
Early online date26 May 2016
Publication statusPublished - Jan 2017


  • Endometrial carcinoma
  • endometrial polyp
  • endometrial sampling
  • hysteroscopy


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