Patients’ preferences in the evaluation of postmenopausal bleeding

Sir, I read with interest the article by the Timmerans et al. who implied that we should be more aggressive in the investigation of women with postmenopausal bleeding. While I agree that endometrial cancer can be detected in double-layer endometrial thickness of less than 4 mm.1,2 I do not share their view that we should be more aggressive in the more frequent use of invasive testing for the investigation postmenopausal bleeding. Dr Timmerans study was based on the assumption that there was a 1% chance of having endometrial cancer missed using the current practice of a cutoff of 4 mm on double-layer endometrial thickness beyond which invasive testing should be offered. Unfortunately, she did not tell us of the number of endometrial cancers, which were missed, in her unit during 2004 using the above practice. The mention of cancer is sufficiently disturbing to the nonmedical population and as such will lead to demands that may be medically unsound. I submit, therefore, that the request by women for more invasive testing was based on (a) the counselling they received and (b) their experience of having little or no complication from the hysteroscopy may be unaware that a number of complications are possible with hysteroscopy: complications related to the anaesthesia and complications related to the procedure. If there was a major complication from the hysteroscopy, their willingness to require more invasive testing would be less pronounced. It was unclear how the endometrium was sampled in this study. I wonder whether transvaginal ultrasound measured endometrial thickness and Pipelle endometrial biopsy would not be sufficient because unlike colposcopy there are no specific features that can suggest a malignancy on hysteroscopy and the detection rate of endometrial cancer in postmenopausal women is 99.6% with a Pipelle endometrial biopsy.3 j