Australian and New Zealand Journal of Obstetrics and Gynaecology 2014; 54: 597–599
DOI: 10.1111/ajo.12259
Short Communication
Risks and benefits of hysteroscopy and endometrial sampling as a standard procedure for assessing serendipitous findings of endometrial thickening in postmenopausal women Benjamin ASTON1 and Edward WEAVER2 1
Princess Alexandra Hospital, Wooloongabba, and 2Department of Obstetrics and Gynaecology, Nambour General Hospital, University of Queensland, Nambour, Queensland, Australia
A retrospective study was undertaken of 35 asymptomatic postmenopausal women undergoing hysteroscopy, dilatation and curettage (H D&C) for an incidental finding of thickened endometrium to assess the rate of significant pathological findings, cost per finding and complication rate of any procedures performed. This study found one case of endometrial adenocarcinoma (1/35; 3%) at an estimated cost per significant finding of $507,116 with an estimated 11.6 complication events per finding. Key words: asymptomatic, endometrial neoplasms, endometrial thickness, hysteroscopy, postmenopause.
Introduction The uterus is currently the most common location for malignant neoplasia of the genital tract in Australia.1 Uterine malignancies usually arise in postmenopausal women. The use of transvaginal ultrasound (TVS) to assess endometrial thickness (ET) is of key significance in the investigative process for malignancy risk. An endometrial thickness 4 mm).
Correspondence: Dr Benjamin Aston, Medical Officer, Princess Alexandra Hospital, 199 Ipswich Rd, Wooloongabba, Qld 4102, Australia. Email: [email protected] Received 6 June 2014; accepted 15 August 2014.
The associated healthcare cost relevant to these women was investigated, determining the cost per finding of clinically significant pathology.
Material and Methods Charts for women who underwent H D&C (hysteroscopy, dilatation and curettage) during the 24 months, between 1 July 2011 and 30 June 2013, within the Sunshine Coast Health District hospitals (Nambour General, Gympie, Caloundra, Qld, Australia) were reviewed with approval from the Human Research and Ethics Committee of the Prince Charles Hospital Brisbane. Postmenopausal gynaecologically asymptomatic women with an incidental finding of thickened endometrium (>4 mm) on TVS within this group were identified. ET was determined on TVS by measuring the thickest section of both endometrial layers combined. These studies were performed at a variety of hospital-based and private imaging centres. Relevant data for the study were extracted from hospital records. A total of 301 charts were reviewed. Thirty-five women were included and 266 were excluded. Reasons for exclusion included: postmenopausal bleeding (n = 238), post-coital bleeding (n = 4), vaginal discharge (n = 6), insufficient information available (n = 8) and other (n = 10). Comprehensive costing analysis was performed by the finance department of the Sunshine Coast health service on 30 representative women to calculate the mean cost per hospitalisation. This analysis included both direct and indirect costs incurred by: operating theatre, anaesthetics, medical labour, medical supplies, allied
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
597
B. Aston and E. Weaver
health, pathology, medical imaging and pharmacy. More specific details of the modelling used for costing were not available. Mean and Standard Deviation (SD) calculations of the data were performed using Excel (Microsoft Office 2007, Microsoft, USA).
Results The mean ET on TVS was 9.01 mm (5–18.1 mm; SD 3.54). Twenty-one cases of ET were found to have a normal uterine cavity, 11 were polyps, two were simple hyperplasia without atypia, and one was a finding of adenocarcinoma. Clinical characteristics of these women are shown in Table 1. Thirty-four women (34/35; 97%) had nonsinister histological findings, with one patient (1/ 35; 3%) having a finding of adenocarcinoma. The mean cost per hospitalisation was $2614 ($1363– $4677; SD $829). The mean admission length was 1.26 days (1–6; SD 0.89), giving a mean cost per hospital day of $2075. There were 4 (4/35; 11.4%) complications, requiring eight hospital inpatient days for management, with an associated cost of $16,600. These complications included uterine perforation (n = 2), severe laryngeal spasm (n = 1) and seven days of postoperative vaginal bleeding (n = 1). These results, although on a smaller scale compared with previous studies of Ribeiro3 and Gambacciani,4 are consistent with relatively rare findings of significant pathology in asymptomatic postmenopausal women with ET. Combining data from Ribeiro and Gambacciani for women who met the inclusion criteria for this study with the present data set gathered here, a patient pool can be generated. These data are shown in Table 2.
The combined data show a finding of one adenocarcinoma per 194 procedures (3/582; 0.52%). At an average cost of $2614 per procedure, this gives a cost of $507,116 per malignancy. Findings of endometrial hyperplasia (simple or complex) occurred at a rate of 1 per 48.5 procedures, giving a cost of $126,779 per finding. Complications were not reported in the two comparable studies by Ribeiro3 and Gambacciani.4 However, Lev-Sagie5 reported complications at 3.6% (3/82) when performing H D&C + polypectomy. Combining the data of our study and that of Lev-Sagie provides a complication rate of 7/117 cases (6%). Total complications therefore equate to 11.6 complication events per finding of adenocarcinoma and 2.9 complication events per finding of hyperplasia.
Discussion The 4–5 mm ET threshold used in symptomatic postmenopausal women may not be applicable to women without bleeding, for the exclusion of intrauterine pathology.6 Intrauterine pathologies in asymptomatic postmenopausal women are common (13%, Dreisler et al.6) and are most frequently benign polyps5,7 requiring no treatment. Additionally, endometrial cancer presents with uterine bleeding in 90% of cases, and in 75% of women is at an early stage.8 The one woman found to have endometrial adenocarcinoma in our study was ultimately surgically staged as stage 1 with favourable histology. Gerber et al.9 demonstrated there was no prognostic advantage gained investigating asymptomatic women with increased ET, compared with investigations initiated within eight weeks of the onset of vaginal bleeding. Identification rates of
Table 1 Patient characteristics, categorised by operative and histological diagnoses
Age (years) Years since menopause BMI (kg/m2) Endometrial thickness (mm) Parity Type II diabetes mellitus Tamoxifen use Hormone replacement therapy
All n = 35 Mean (SD)
Normal/Atrophic n = 21 Mean (SD)
69.9 (7.8) 19.8 (8.94) 26.5 (6.8) 9.02 (3.8) 2.7 (1.7) 2 2 8
69.9 (8.7) 19.2 (10.3) 26.3 (6.3) 8.73 (3.8) 3.0 (2.0) 1 2 8
Polyp n = 11 Mean (SD)
Simple hyperplasia n=2 Mean (SD)
68.7 (5.4) 19.1 (5.1) 27.4 (8.4) 8.17 (2.9) 2.1 (1.3) 1 0 0
70.5 23.5 21.7 11.5 2.5 0 0 0
(9.1) (7.7) (2.5) (6.3) (0.7)
Adenocarcinoma n=1 Mean 83 31 31.23 15 2 0 0 0
Table 2 Pooled histological data from comparative studies for women meeting inclusion criteria for this study Ribeiro et al.3 Cohort size (n) Histological finding of adenocarcinoma on endometrial sampling (n) Histological finding of hyperplasia (simple or complex) on endometrial sampling (n)
598
Gambacciani et al.4
This study
Combined total
399 1
148 1
35 1
582 3
1
9
2
12
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Asymptomatic endometrial thickening
endometrial cancer in this study are less than a recently published study which had a detection rate of 1 case per every 106 investigations performed.10 A cut-off of 5 mm for hysteroscopy in asymptomatic women has a sensitivity and specificity for detecting focal pathology of 56.0% (36.6–73.7) and 88.0% (81.3–92.5), respectively.6 This suggests a substantial risk of overtreatment with the associated consequences. No cases of cancer or hyperplasia were identified with an ET
DOI: 10.1111/ajo.12259
Short Communication
Risks and benefits of hysteroscopy and endometrial sampling as a standard procedure for assessing serendipitous findings of endometrial thickening in postmenopausal women Benjamin ASTON1 and Edward WEAVER2 1
Princess Alexandra Hospital, Wooloongabba, and 2Department of Obstetrics and Gynaecology, Nambour General Hospital, University of Queensland, Nambour, Queensland, Australia
A retrospective study was undertaken of 35 asymptomatic postmenopausal women undergoing hysteroscopy, dilatation and curettage (H D&C) for an incidental finding of thickened endometrium to assess the rate of significant pathological findings, cost per finding and complication rate of any procedures performed. This study found one case of endometrial adenocarcinoma (1/35; 3%) at an estimated cost per significant finding of $507,116 with an estimated 11.6 complication events per finding. Key words: asymptomatic, endometrial neoplasms, endometrial thickness, hysteroscopy, postmenopause.
Introduction The uterus is currently the most common location for malignant neoplasia of the genital tract in Australia.1 Uterine malignancies usually arise in postmenopausal women. The use of transvaginal ultrasound (TVS) to assess endometrial thickness (ET) is of key significance in the investigative process for malignancy risk. An endometrial thickness 4 mm).
Correspondence: Dr Benjamin Aston, Medical Officer, Princess Alexandra Hospital, 199 Ipswich Rd, Wooloongabba, Qld 4102, Australia. Email: [email protected] Received 6 June 2014; accepted 15 August 2014.
The associated healthcare cost relevant to these women was investigated, determining the cost per finding of clinically significant pathology.
Material and Methods Charts for women who underwent H D&C (hysteroscopy, dilatation and curettage) during the 24 months, between 1 July 2011 and 30 June 2013, within the Sunshine Coast Health District hospitals (Nambour General, Gympie, Caloundra, Qld, Australia) were reviewed with approval from the Human Research and Ethics Committee of the Prince Charles Hospital Brisbane. Postmenopausal gynaecologically asymptomatic women with an incidental finding of thickened endometrium (>4 mm) on TVS within this group were identified. ET was determined on TVS by measuring the thickest section of both endometrial layers combined. These studies were performed at a variety of hospital-based and private imaging centres. Relevant data for the study were extracted from hospital records. A total of 301 charts were reviewed. Thirty-five women were included and 266 were excluded. Reasons for exclusion included: postmenopausal bleeding (n = 238), post-coital bleeding (n = 4), vaginal discharge (n = 6), insufficient information available (n = 8) and other (n = 10). Comprehensive costing analysis was performed by the finance department of the Sunshine Coast health service on 30 representative women to calculate the mean cost per hospitalisation. This analysis included both direct and indirect costs incurred by: operating theatre, anaesthetics, medical labour, medical supplies, allied
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
597
B. Aston and E. Weaver
health, pathology, medical imaging and pharmacy. More specific details of the modelling used for costing were not available. Mean and Standard Deviation (SD) calculations of the data were performed using Excel (Microsoft Office 2007, Microsoft, USA).
Results The mean ET on TVS was 9.01 mm (5–18.1 mm; SD 3.54). Twenty-one cases of ET were found to have a normal uterine cavity, 11 were polyps, two were simple hyperplasia without atypia, and one was a finding of adenocarcinoma. Clinical characteristics of these women are shown in Table 1. Thirty-four women (34/35; 97%) had nonsinister histological findings, with one patient (1/ 35; 3%) having a finding of adenocarcinoma. The mean cost per hospitalisation was $2614 ($1363– $4677; SD $829). The mean admission length was 1.26 days (1–6; SD 0.89), giving a mean cost per hospital day of $2075. There were 4 (4/35; 11.4%) complications, requiring eight hospital inpatient days for management, with an associated cost of $16,600. These complications included uterine perforation (n = 2), severe laryngeal spasm (n = 1) and seven days of postoperative vaginal bleeding (n = 1). These results, although on a smaller scale compared with previous studies of Ribeiro3 and Gambacciani,4 are consistent with relatively rare findings of significant pathology in asymptomatic postmenopausal women with ET. Combining data from Ribeiro and Gambacciani for women who met the inclusion criteria for this study with the present data set gathered here, a patient pool can be generated. These data are shown in Table 2.
The combined data show a finding of one adenocarcinoma per 194 procedures (3/582; 0.52%). At an average cost of $2614 per procedure, this gives a cost of $507,116 per malignancy. Findings of endometrial hyperplasia (simple or complex) occurred at a rate of 1 per 48.5 procedures, giving a cost of $126,779 per finding. Complications were not reported in the two comparable studies by Ribeiro3 and Gambacciani.4 However, Lev-Sagie5 reported complications at 3.6% (3/82) when performing H D&C + polypectomy. Combining the data of our study and that of Lev-Sagie provides a complication rate of 7/117 cases (6%). Total complications therefore equate to 11.6 complication events per finding of adenocarcinoma and 2.9 complication events per finding of hyperplasia.
Discussion The 4–5 mm ET threshold used in symptomatic postmenopausal women may not be applicable to women without bleeding, for the exclusion of intrauterine pathology.6 Intrauterine pathologies in asymptomatic postmenopausal women are common (13%, Dreisler et al.6) and are most frequently benign polyps5,7 requiring no treatment. Additionally, endometrial cancer presents with uterine bleeding in 90% of cases, and in 75% of women is at an early stage.8 The one woman found to have endometrial adenocarcinoma in our study was ultimately surgically staged as stage 1 with favourable histology. Gerber et al.9 demonstrated there was no prognostic advantage gained investigating asymptomatic women with increased ET, compared with investigations initiated within eight weeks of the onset of vaginal bleeding. Identification rates of
Table 1 Patient characteristics, categorised by operative and histological diagnoses
Age (years) Years since menopause BMI (kg/m2) Endometrial thickness (mm) Parity Type II diabetes mellitus Tamoxifen use Hormone replacement therapy
All n = 35 Mean (SD)
Normal/Atrophic n = 21 Mean (SD)
69.9 (7.8) 19.8 (8.94) 26.5 (6.8) 9.02 (3.8) 2.7 (1.7) 2 2 8
69.9 (8.7) 19.2 (10.3) 26.3 (6.3) 8.73 (3.8) 3.0 (2.0) 1 2 8
Polyp n = 11 Mean (SD)
Simple hyperplasia n=2 Mean (SD)
68.7 (5.4) 19.1 (5.1) 27.4 (8.4) 8.17 (2.9) 2.1 (1.3) 1 0 0
70.5 23.5 21.7 11.5 2.5 0 0 0
(9.1) (7.7) (2.5) (6.3) (0.7)
Adenocarcinoma n=1 Mean 83 31 31.23 15 2 0 0 0
Table 2 Pooled histological data from comparative studies for women meeting inclusion criteria for this study Ribeiro et al.3 Cohort size (n) Histological finding of adenocarcinoma on endometrial sampling (n) Histological finding of hyperplasia (simple or complex) on endometrial sampling (n)
598
Gambacciani et al.4
This study
Combined total
399 1
148 1
35 1
582 3
1
9
2
12
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Asymptomatic endometrial thickening
endometrial cancer in this study are less than a recently published study which had a detection rate of 1 case per every 106 investigations performed.10 A cut-off of 5 mm for hysteroscopy in asymptomatic women has a sensitivity and specificity for detecting focal pathology of 56.0% (36.6–73.7) and 88.0% (81.3–92.5), respectively.6 This suggests a substantial risk of overtreatment with the associated consequences. No cases of cancer or hyperplasia were identified with an ET
