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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.

The risk of recurrent postmenopausal bleeding in women whose endometrial thickness after a first episode was 4 mm or less could have major implications for management. If the recurrence rate is low, follow-up by transvaginal ultrasonography (TVU) would suffice. In contrast, a high recurrence rate (or the diagnosis of malignancy at follow-up) would call for immediate endometrial sampling. The investigators, from 7 university-affiliated teaching hospitals in The Netherlands, practiced expectant management for consecutive patients not on hormone replacement therapy who presented with a first episode of postmenopausal bleeding and were found to have a thin endometrium. Of 607 women with a first episode of postmenopausal bleeding, 249 had an endometrial thickness of 4 mm or less. During a median follow-up of approximately 3.25 years, 25 of these 249 women (10%) had recurrent bleeding. The median interval before bleeding recurred was 49 weeks. Two patients with recurrent bleeding proved to have endometrial carcinoma and another had malignant melanoma. Recurrent bleeding appeared not to correlate with age, time since menopause, body mass index, hypertension, diabetes, or anticoagulant therapy. Whether or not endometrial sampling was carried out in the office at initial presentation did not influence the findings. There was, however, a significant difference in recurrent bleeding between patients who underwent hysteroscopy and/or dilatation and curettage at initial workup (5/21) and those who did not (20/208). The hazard rate ratio was 2.8, with a 95% confidence interval of 1.05 to 7.5. These findings endorse the use of TVU as an initial measure in women with postmenopausal bleeding. It is, however, vital that patients who are managed expectantly be reevaluated and have endometrial sampling should bleeding recur.