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Developing a robust and efficient pathway for the referral and investigation of women with post-menopausal bleeding using a cut-off of 4 mm for normal thickness

¹ Department of Radiology, Good Hope Hospital, Rectory Road, Sutton Coldfield B75 7RR, Departments of ² Radiology and ³ Histopathology, Birmingham Women's Health Care Trust, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK

Correspondence: Dr Josephine McHugo, Consultant Radiologist, Radiology Department, Birmingham Women's Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK. E-mail: jo.mchugo{at}bwhct.nhs.uk

The majority of women with post-menopausal bleeding (PMB) do not have endometrial cancer, and transvaginal ultrasound (TVUS) is accepted as the screening tool of choice to identify those at highest risk of malignancy. A new referral pathway was instigated in 2000, with patients only being referred to a gynaecologist following an abnormal TVUS result. An initial audit revealed a low positive predictive value for TVUS and a low incidence of detected malignancy. The cut-off value for a normal endometrium was increased from 3 mm to 4 mm in line with published data. This re7hyphen;audit evaluated the effectiveness of implemented changes and identified other areas for improvement. Of the 277 women referred during the study period, 193 had an abnormal or unseen endometrium and were subsequently seen by a gynaecologist. For patients without a histological diagnosis, clinical notes were reviewed and the hospital cancer database scrutinized for all endometrial cancers. Despite a 15.4% increase in referrals, only an additional 2.9% were assessed by gynaecologists. 14 cases of malignancy were identified with a mean endometrial thickness (ET) of 15.7 mm. Failed endometrial sampling was more prevalent with a minimally thickened endometrium. 80 patients with abnormal TVUS had no recorded histological diagnosis. Increasing the ET cut-off value has reduced unnecessary investigations in women at low risk of malignancy. No woman discharged back to her GP has been diagnosed with an endometrial malignancy within 1 year of initial referral. An algorithm has been proposed to further improve the investigation of women with PMB following an abnormal TVUS.

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