通过在绝经后出血的诊断检查中考虑女性的特征来改进现有的诊断策略。

Improving the existing diagnostic strategy by accounting for characteristics of the women in the diagnostic work up for postmenopausal bleeding.

作者信息

Opmeer B C, van Doorn H C, Heintz A P M, Burger C W, Bossuyt P M M, Mol B W J

机构信息

Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, The Netherlands.

出版信息

BJOG. 2007 Jan;114(1):51-8. doi: 10.1111/j.1471-0528.2006.01168.x.

DOI:10.1111/j.1471-0528.2006.01168.x

PMID:17233860

Abstract

OBJECTIVES

The aim of this study was to evaluate whether the efficiency of the current diagnostic work up following postmenopausal bleeding could be improved by diagnostic strategies that take into account characteristics of the women in addition to the currently recommended transvaginal measurement of endometrial thickness to determine for subsequent histological assessment.

DESIGN

Multicenter, prospective cohort study.

SETTING

A university hospital and seven teaching hospitals in the Netherlands.

SAMPLE

Consecutive women not using hormone replacement therapy, presenting with postmenopausal bleeding.

METHODS

Five hundred and forty women underwent transvaginal sonography, and in case of endometrial thickness (double layer) above 4 mm, subsequent endometrial sampling was performed. Presence of carcinoma was ruled out by the absence of abnormalities in histological specimen or by an uneventful follow up of at least 6 months.

MAIN OUTCOME MEASURES

Probability of endometrial carcinoma was estimated by multivariable logistic regression models. For each diagnostic strategy, we calculated diagnostic accuracy (area under receiver operating characteristic curve [AUC]), negative predictive value (NPV) and the number of diagnostic procedures.

RESULTS

A strategy with transvaginal sonography alone with a fixed threshold incorrectly classified 0.7% of the women as nonmalignant (NPV: 99.3% [98.5-100%]), with 97% sensitivity and 56% specificity. A strategy integrating characteristics of the women with transvaginal sonography could result in less false reassurances (NPV: 99.6% [99.2-100%]), with only marginal decrease in diagnostic procedures, or a minor increase in false reassurances (NPV: 99.0% [98.3-100%]), with a substantial reduction (15-20%) in the procedures. AUCs associated with these strategies could improve from 0.76 (0.73-0.79) for transvaginal sonography alone to 0.90 (0.87-0.93) for the integrated strategy.

CONCLUSION

Taking into account the characteristics of the women could increase the efficiency of the diagnostic work up for postmenopausal bleeding.

摘要

目的

本研究旨在评估，除目前推荐的经阴道测量子宫内膜厚度以确定后续组织学评估外，考虑女性特征的诊断策略是否能提高绝经后出血现行诊断检查的效率。

设计

多中心前瞻性队列研究。

地点

荷兰的一家大学医院和七家教学医院。

样本

连续的未使用激素替代疗法且出现绝经后出血的女性。

方法

540名女性接受经阴道超声检查，若子宫内膜厚度（双层）超过4mm，则进行后续子宫内膜取样。通过组织学标本无异常或至少6个月的平稳随访排除癌症存在。

主要观察指标

通过多变量逻辑回归模型估计子宫内膜癌的概率。对于每种诊断策略，我们计算诊断准确性（受试者操作特征曲线下面积[AUC]）、阴性预测值（NPV）和诊断程序数量。

结果

仅采用经阴道超声且设定固定阈值的策略将0.7%的女性错误分类为非恶性（NPV：99.3%[98.5 - 100%]），灵敏度为97%，特异度为56%。将女性特征与经阴道超声相结合的策略可减少错误的安心判断（NPV：99.6%[99.2 - 100%]），诊断程序仅略有减少，或者错误的安心判断略有增加（NPV：99.0%[98.3 - 100%]），但程序大幅减少（15 - 20%）。与这些策略相关的AUC可从仅经阴道超声的0.76（0.73 - 0.79）提高到综合策略的0.90（0.87 - 0.93）。