Gynaecological oncology: Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies

OBJECTIVE

To determine the most cost-effective outpatient testing strategy for diagnosing endometrial cancer in women with postmenopausal bleeding (PMB).

DESIGN

Decision analysis modelling.

POPULATION

Women with postmenopausal bleeding.

METHODS

A decision analytic model was constructed to reflect current service provision, which evaluated 12 diagnostic strategies using endometrial biopsy (EB), ultrasonography (USS) (4- and 5-mm endometrial thickness cutoff) and hysteroscopy. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from published literature and cost estimates from local and NHS sources.

MAIN OUTCOME MEASURES

The cost per additional life year gained (pound/LYG) was determined and compared for each diagnostic strategy, and sensitivity analyses were performed.

RESULTS

Compared with carrying out no initial investigation, a strategy based on initial diagnosis with USS using a 5-mm cutoff was the least expensive (11,470 pound/LYG). Initial investigation with EB or USS using a 4-mm cutoff was comparably cost-effective (less than 30,000 pound/LYG versus USS with a 5-mm cutoff) at their most favourable diagnostic performance and at disease prevalence of 10% or more. The strategies involving initial evaluation with test combinations or hysteroscopy alone were not cost-effective.

CONCLUSIONS

Women presenting for the first time with PMB should undergo initial evaluation with USS or EB.

Efficacy of laparoscopic excision of visually diagnosed peritoneal endometriosis in the treatment of chronic pelvic pain

OBJECTIVE

To determine the efficacy of laparoscopic excision of visually diagnosed endometriosis in the treatment of chronic pelvic pain.

STUDY DESIGN

Sixty-two women with chronic pelvic pain and who underwent laparoscopic excision of visually diagnosed peritoneal lesions suggestive of endometriosis returned postal questionnaires. The main outcomes measures were change in pelvic pain symptoms measured on a continuous and ordinal scale and patient satisfaction following treatment. Secondary outcomes were quality of life, time off work and use of health service resources.

RESULTS

42/62 (68%) women with an average follow up time of 13 months (range 6-38 months) returned completed outcome questionnaires. The mean amount of pelvic pain was reduced following surgery compared to immediately prior to treatment, regardless of the nature of the pain (P<0.05). Overall, 67% (95% CI 50-80%) of women reported improvement in pain symptoms and 71% (95% CI 55-84%) were satisfied with the results of treatment. Satisfaction with treatment was comparable whether the visual diagnosis of peritoneal endometriosis was confirmed histologically or not (62% versus 64%, P=1.0).

CONCLUSION

Laparoscopic excision of visually diagnosed endometriosis appears to be efficacious in the treatment of women with chronic pelvic pain. The launch of a long-term randomised controlled trial to confirm these provisional results is now required.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy and prolonged bleeding, pain, pressure symptoms and subfertility but are mostly benign. The traditional method of treatment has been surgery as long term medical therapies have not shown to be effective. Uterine artery embolization (UAE - complete occlusion of both the uterine arteries with particulate emboli) has been reported to be an effective and safe alternative in the treatment of menorrhagia and other fibroid-related symptoms in women not desiring future fertility, but thus far this evidence is based on case controlled studies and case reports.

OBJECTIVES

To review the benefits and/or harms from randomised controlled trials (RCTs) of uterine artery embolization (UAE) versus other interventions for symptomatic uterine fibroids.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched 10 August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, Issue 3, 2004), MEDLINE (January 1966 to November 2005) and EMBASE (January 1980 to November 2005). We also contacted authors of potential ongoing studies.

SELECTION CRITERIA

RCTs of UAE versus any medical or surgical therapy for symptomatic uterine fibroids.

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) assessed the trials and extracted the data independently. They also contacted the investigators of eligible RCTs for unpublished data.

MAIN RESULTS

Three trials were included in this review. Two RCTs compared UAE with abdominal hysterectomy in 234 women. Although the follow-up period was intended for two years, the available published results was only for six months follow-up. The second trial included 63 women comparing UAE with myomectomy in women who wished to preserve their fertility. The minimum follow-up reported was six months with a mean of 17 (+/- 9.3) months. The clinical success rate measured by improvement in fibroid-related symptoms e.g. menstrual loss was at least 85% in the UAE group from both trials. The mean dominant fibroid volume decreased by 30 to 46% in two trials. UAE significantly reduces length of hospital stay compared to surgery for either hysterectomy or myomectomy. Women undergoing UAE resumed routine activities sooner than those undergoing surgery. UAE was associated with a higher rate of minor post procedural complications such as vaginal discharge, post puncture haematoma and post embolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge, compared with hysterectomy. There were no major complication differences between the two groups. Three women in the myomectomy trial had elevated FSH levels post UAE indicating possible ovarian dysfunction.

AUTHORS' CONCLUSIONS

UAE offers an advantage over hysterectomy with regards to a shorter hospital stay and a quicker return to routine activities. There is no evidence of benefit of UAE compared to surgery (hysterectomy / myomectomy) for satisfaction. The higher minor complications rate after discharge in the UAE group as well as the unscheduled visits and readmission rates require more longer term follow-up trials to comment on its effectiveness and safety profile. There is currently an ongoing trial (REST, U. K.) and EMMY trial yet to report on the long term follow up, the results of which are awaited with interest.

Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)--a systematic enquiry and overview

Levonorgestrel releasing-intrauterine systems (LNG-IUS) were originally developed as a method of contraception in the mid 1970s. The only LNG-IUS approved for general public use is the Mirena LNG-IUS, which releases 20 mcg of levonorgestrel per day directly in to the uterine cavity. However, new lower dose (10 and 14 mcg per day) and smaller sized LNG-IUS (MLS, FibroPlant-LNG) are currently under clinical development and investigation. Research into the non-contraceptive uses of LNG-IUS is rapidly expanding. In the UK, LNG-IUS is licensed for use in menorrhagia and to provide endometrial protection to perimenopausal and postmenopausal women on estrogen replacement therapy. There is limited evidence to suggest that LNG-IUS may also be beneficial in women with endometriosis, adenomyosis, fibroids, endometrial hyperplasia and early stage endometrial cancer (where the patient is deemed unfit for primary surgical therapy). This systematic enquiry and overview evaluates the quality of evidence relating to the non-contraceptive therapeutic uses of LNG-IUS in gynaecology.

The management of endometrial hyperplasia: an evaluation of current practice

OBJECTIVE

To identify current management practices and evaluate subsequent outcomes of treatment for women diagnosed with endometrial hyperplasia.

STUDY DESIGN

All women with a histological diagnosis of endometrial hyperplasia at the Birmingham Women's Hospital were identified between October 1998 and September 2000. A retrospective case note review was performed for each woman using a standardised data abstraction sheet. Baseline characteristics including clinical presentation and treatment strategy were obtained. Results of subsequent endometrial tissue examinations were used to assess histological response to treatment and the need and indication for hysterectomy was used to assess clinical response.

RESULTS

There were 351 women diagnosed with endometrial hyperplasia during the study period of which 84% presented with symptoms of abnormal uterine bleeding and 54% were postmenopausal. Complex endometrial hyperplasia was the most common diagnosis accounting for 60% of all cases. Eighty percent of women with atypical endometrial hyperplasia were treated by hysterectomy compared with 30% without evidence of cytological atypia (relative hysterectomy rate of 2.6, 95% CI 2.0-3.3). Hysterectomy was avoided in 138/172 (80%, 95% CI 74-86%) women managed conservatively during the study period. Overall 35/108 (36%, 95% CI 27-46%) of women managed conservatively had persistent or progressive disease identified (mean follow up 36 months). 20/143 (14%) women initially diagnosed with endometrial hyperplasia who subsequently underwent hysterectomy were found to have endometrial cancer, the majority of whom had been diagnosed with atypical disease (14/20, 70%).

CONCLUSION(S)

The majority of women with atypical endometrial hyperplasia were managed by hysterectomy and the substantial risk of diagnostic under-call supports this approach to treatment. In contrast, there is no consensus regarding the initial management of women with endometrial hyperplasia without cytological atypia.

Antibiotic treatment of bacterial vaginosis in pregnancy: multiple meta-analyses and dilemmas in interpretation

There is considerable evidence to show an association between genital tract infections, such as bacterial vaginosis (BV), and preterm delivery (PTD). Meta-analyses to date have shown screening and treating BV in pregnancy does not prevent PTD. This casts doubt on a cause and effect relationship between BV and PTD. However, the meta-analyses reported significant clinical, methodological and statistical heterogeneity of the included studies. We therefore undertook a repeat meta-analysis, included recently published trials, and applied strict criteria on data extraction. We meta-analysed low and high-risk pregnancies separately. We found that screening and treating BV in low-risk pregnancies produced a statistically significant reduction in spontaneous PTD (RR 0.73; 95% CI 0.55-0.98). This beneficial effect was not observed in high-risk or combined risk groups. The differences in antibiotic sensitivity between high and low risk groups may suggest differing causal contributions of the infectious process to PTD. The evidence, along with prior knowledge of differing predisposing factors and prognosis between these risk groups, supports the hypothesis that PTD in high and low risk pregnant women are different entities and not linear extremes of the same syndrome.

The accuracy of maternal anthropometry measurements as predictor for spontaneous preterm birth—a systematic review

OBJECTIVE

To assess the accuracy with which antenatal maternal anthropometric measurements predict the risk spontaneous preterm birth.

STUDY DESIGN

(1) DATA SOURCES: Studies were identified without language restrictions from MEDLINE, EMBASE, PASCAL, BIOSIS, the Cochrane Library, MEDION, National Research Register, SCISEARCH and Conference Papers, and manual searching of bibliographies of known primary and review articles, and contact with authors. (2) STUDY SELECTION AND DATA EXTRACTION: Studies were selected if they used antenatal maternal anthropometric features (pre-pregnancy weight, maternal pregnancy weight gain and maternal height) to predict spontaneous preterm birth. Two reviewers independently selected studies and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables of the maternal anthropometric test results with spontaneous preterm birth as the reference standard. (3) DATA SYNTHESIS: Heterogeneity assessments were carried out to aid the decision regarding pooling of the accuracy results. Likelihood ratios for positive (LR+) and negative (LR-) test results were calculated, and summary estimates were produced in absence of heterogeneity of the accuracy results.

RESULTS

There were eight primary accuracy articles that met the selection criteria, which included a total of 122,647 asymptomatic women. There were six studies on pre-pregnancy weight where five measured the body mass index (BMI) and one used an arbitrary measure. There were four studies on the adequacy of pregnancy weight gain and two studies on maternal height as a predictor for the risk of preterm birth. One article contributed three studies, while two articles provided two studies each. The commonest reference standard used was birth before 37 weeks' gestation. None of the studies fulfilled the ideal test accuracy study criteria. There was heterogeneity in the accuracy results of pre-pregnancy BMI but not in the adequacy of weight gain. All three maternal anthropometric features were poor predictors of preterm labour. Pre-pregnancy BMI is a poor predictor of preterm birth before 37 weeks' gestation (LR+ that ranged from 0.96 (95% confidence interval (CI) 0.66-1.40) to 1.75 (95% CI 1.33-2.31)) as are the adequacy of pregnancy weight gain (summary LR+ of 1.81, 95% CI 1.45-2.30) and short maternal height (LR+ of 1.79 (95% CI 1.27-2.52).

CONCLUSION

Routine antenatal maternal anthropometric measurements are not useful in predicting the risk of preterm birth before 37 weeks' gestation. Further studies should address their use in combination with other test but need to use a more clinically appropriate reference standard of preterm birth, such as birth before 32-34 weeks' gestation, and improve on the quality of study design.

Determining the quality of educational climate across multiple undergraduate teaching sites using the DREEM inventory

BACKGROUND

Our obstetrics and gynaecology undergraduate teaching module allocates 40-50 final year medical students to eight teaching hospital sites in the West Midlands region. Based on student feedback and concerns relating to the impact of new curriculum changes, we wished to objectively assess whether the educational environment perceived by students varied at different teaching hospital centres, and whether the environment was at an acceptable standard.

METHODS

A Dundee Ready Education Environment (DREEM) Questionnaire, a measure of educational environment, was administered to 206 students immediately following completion of the teaching module.

RESULTS

The overall mean DREEM score was 139/200 (70%). There were no differences in the education climate between the teaching centres.

CONCLUSION

Further research on the use of DREEM inventory, with follow up surveys, may be useful for educators to ensure and maintain high quality educational environments despite students being placed at different teaching centres.

The accuracy of risk scores in predicting preterm birth--a systematic review

This review aims to determine the accuracy with which published risk scores predict spontaneous preterm birth in pregnant women. Studies were identified without language restrictions through nine different databases (up to June 2002), and manual searching of bibliographies of known primary and review articles. Two reviewers selected studies independently and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables of the results of risk scoring with spontaneous preterm birth as the reference standard. Heterogeneity was assessed and its reasons were explored. Summary estimates of accuracy were produced within clinically appropriate subgroups. There were 19 primary accuracy articles that met the selection criteria, including a total of 67390 women. There are 12 different risk-scoring systems, the one developed by Creasy being the most commonly evaluated. Quality features of an ideal study, such as blinding and consecutive enrolment, were frequently missing from the included studies, no study fulfilled all criteria for high quality study, and there was heterogeneity between their accuracy estimates. The reference standard most often used was birth before 37 weeks' gestation. The point estimates for the likelihood ratios (LRs) varied widely among the studies. LRs for an abnormal score (LR+) ranged from 1.0 (95% confidence interval (CI) 0.6-1.4) to 38.8 (95% CI 23.5-63.9) while that for a normal score (LR-) ranged from 0.1 (95% CI 0.02-0.6) to 1.2 (95% CI 0.9-1.6). In otherwise asymptomatic women, risk scoring in early pregnancy has a wide range of accuracy in predicting spontaneous preterm birth before 37 weeks' gestation. The evidence is of a relatively poor quality and lacks clinically important reference standards.

Accuracy of absence of fetal breathing movements in predicting preterm birth: a systematic review

OBJECTIVE

To determine the accuracy with which the absence of fetal breathing movements on ultrasound examination predicts spontaneous preterm birth in women with threatened preterm labor.

METHODS

Data sources included Medline, Embase, Pascal, Biosis, Cochrane Library, Medion, National Research Register, SciSearch, conference papers, and manual searching of bibliographies of known primary and review articles. A study was selected if it used absence of fetal breathing movements on ultrasound to predict spontaneous preterm birth in women with threatened preterm labor but before advanced cervical dilatation. Two reviewers independently selected studies and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables with birth within 48 h and within 7 days of testing as the reference standards. Likelihood ratios for a positive test (LR+) and negative test (LR-) were calculated as a measure of accuracy.

RESULTS

There were eight studies, which included a total of 328 women, evaluating the accuracy of absence of fetal breathing movements in predicting spontaneous preterm birth in women with threatened preterm labor. There were differences in the methodological quality among the included studies. All were lacking in one or more item that make up an ideal test accuracy study. For women presenting with threatened preterm labor, meta-analysis showed a summary LR+ of 14.80 (95% CI, 6.30-34.79) with a corresponding summary LR- of 0.46 (95% CI, 0.36-0.58) for predicting preterm birth within 7 days, and summary LR+ of 7.84 (95% CI, 1.12-54.99) and summary LR- of 0.25 (95% CI, 0.13-0.48) for predicting preterm birth within 48 h of testing.

CONCLUSION

Absence of fetal breathing movements has the potential to be a useful test in predicting preterm birth both within 7 days and within 48 h of testing. However, the available studies were deficient in their sample size and quality of methodology. Future research should be undertaken to evaluate this technology and to address the methodological deficiencies.

The accuracy of various tests for bacterial vaginosis in predicting preterm birth: a systematic review

OBJECTIVE

To determine the accuracy with which various types of tests for bacterial vaginosis predict spontaneous preterm birth in pregnant women.

DATA SOURCES

Studies were identified without language restrictions through nine different databases, and manual searching of bibliographies of known primary and review articles.

STUDY SELECTION AND DATA EXTRACTION

There are four different bacterial vaginosis testing methods: Gram staining tests using either Nugent's or Spiegel's criteria, and gas liquid chromatography are laboratory based, and the fourth method uses clinical (Amsel's) criteria to diagnose bacterial vaginosis. Two reviewers independently selected studies and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables of the bacterial vaginosis test results with spontaneous preterm birth as the reference standard.

DATA SYNTHESIS

Data on asymptomatic women and women with symptoms of threatened preterm labour were analysed separately. Data were pooled to produce summary estimates of likelihood ratios for positive (LR+) and negative (LR-) test results for the various types of tests.

RESULTS

There were 18 primary articles, involving altogether 17,868 women. There was unexplained heterogeneity in the meta-analyses of the accuracy results, which requires caution in their interpretation. Meta-analyses of studies testing asymptomatic women in the second trimester showed that clinical criteria had a LR+ of 0.98 (95% confidence interval 0.59 to 1.6) and a LR- of 1.00 (0.93 to 1.1), Gram staining (Nugent's criteria) had a LR+ of 1.6 (1.4 to 1.9) and a LR- of 0.9 (0.8 to 0.9), and Gram staining (Spiegel's criteria) had a LR+ of 2.4 (1.4 to 4.9) and a LR- of 0.81 (0.64 to 1.0). Among symptomatic women, Gram staining (Spiegel's criteria) had a LR+ of 1.3 (1.0 to 1.6) and LR- of 0.9 (0.7 to 1.0).

CONCLUSION

There was a lack of difference in the accuracy of the various bacterial vaginosis tests for predicting preterm birth in both asymptomatic and symptomatic women of threatened preterm labour.

Patient anxiety and experiences associated with an outpatient ?one-stop? ?see and treat? hysteroscopy clinic

BACKGROUND

"One-stop" outpatient hysteroscopy clinics have become well established for the investigation and treatment of women with abnormal uterine bleeding. However, the advantages of these clinics may be offset by patient factors such as anxiety, pain, and dissatisfaction. This study aimed to establish patients' views and experiences of outpatient service delivery in the context of a one-stop diagnostic and therapeutic hysteroscopy clinic, to determine the amount of anxiety experienced by these women and compare this with other settings, and to determine any predictors for patient preferences.

METHODS

The 20-item State-Trait Anxiety Inventory was given to 240 women attending a one-stop hysteroscopy clinic: to 73 consecutive women before their appointment in a general gynecology clinic and to 36 consecutive women attending a chronic pelvic pain clinic. The results were compared with published data for the normal female population, for women awaiting major surgery, and for women awaiting a colposcopy clinic appointment. In addition, a questionnaire designed to ascertain patients' views and experiences was used. Logistic regression analysis was used to delineate the predictive values of diagnostic or therapeutic hysteroscopy, and to determine their effect on the preference of patients to have the procedure performed under general anesthesia in the future.

RESULTS

Women attending the hysteroscopy clinic in this study reported significantly higher levels of anxiety than those attending the general gynecology clinic (median, 45 vs 39; p = 0.004), but the levels of anxiety were comparable with those of women attending the chronic pelvic pain clinic (median, 45 vs 46; p = 0.8). As compared with the data from the normal female population (mean, 35.7) and those reported for women awaiting major surgery (mean, 41.2), the levels of anxiety experienced before outpatient hysteroscopy clinic treatment were found to be higher (mean, 45.7). Only women awaiting colposcopy (6-item mean score, 51.1 +/- 13.3) experienced significantly higher anxiety scores than the women awaiting outpatient hysteroscopy (6-item mean score, 47.3 +/- 13.9; p = 0.002). Despite their anxiety, most women are satisfied with the outpatient hysteroscopy "see and treat" service. High levels of anxiety, particularly concerning pain but not operative intervention, were significant predictors of patients desiring a future procedure to be performed under general anesthesia.

CONCLUSIONS

Outpatient hysteroscopy is associated with significant anxiety, which increases the likelihood of intolerance for the outpatient procedure. However, among those undergoing operative therapeutic procedures, dissatisfaction was not associated with the outpatient setting.

Endometriosis and the neoplastic process

Endometriosis is a frequent disorder that commonly presents with infertility and pelvic pain. Although the precise aetiology of endometriosis is unclear, it is generally considered to involve multiple genetic, environmental, immunological, angiogenic and endocrine processes. Genetic factors have been implicated in endometriosis but the susceptibility genes remain largely unknown. Although endometriosis is a benign disorder, recent studies of endometriosis suggest endometriosis could be viewed as a neoplastic process. Evidence to support this hypothesis includes the increased susceptibility to develop ovarian clear-cell and endometrioid cancers in the presence of endometriosis, and molecular similarities between endometriosis and cancer. In this article we discuss (i) the evidence suggesting that endometriosis might be viewed as a neoplastic process, and (ii) the implications of this hypothesis for elucidating the pathogenesis of endometriosis and developing novel methods of diagnostic classification and individualised treatments.

On-line monitoring for control of a pilot-scale sequencing batch reactor using a submersible UV/VIS spectrometer

A submersible UV/VIS spectrometer was used to monitor a pilot-scale sequencing batch reactor (SBR). The instrument utilises the whole UV/VIS range between 200 and 750 nm. With just one single instrument nitrate, organic matter and suspended solids can be measured simultaneously. The spectrometer is installed directly in the reactor, measures in real-time, and is equipped with an auto-cleaning system using pressured air. The paper shows the calibration results for measurements in the SBR tank, time series for typical SBR cycles, and proposes possible ways for optimisation of the operation by using these measurements.

Position for women during second stage of labour

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting) or lying down have advantages for women delivering their babies.

OBJECTIVES

To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the cervix).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (16 April 2003).

SELECTION CRITERIA

Trials that used randomised or quasi-randomised allocation and appropriate follow up and compared various positions assumed by pregnant women during the second stage of labour.

DATA COLLECTION AND ANALYSIS

We independently assessed the trials for inclusion and extracted the data.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 19 included trials (5764 participants) was variable. Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: reduced duration of second stage of labour (10 trials: mean 4.29 minutes, 95% confidence interval (CI) 2.95 to 5.64 minutes) - this was largely due to a considerable reduction in women allocated to the use of the birth cushion; a small reduction in assisted deliveries (18 trials: relative risk (RR) 0.84, 95% CI 0.73 to 0.98); a reduction in episiotomies (12 trials: RR 0.84, 95% CI 0.79 to 0.91); an increase in second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39); increased estimated blood loss greater than 500 ml (11 trials: RR 1.68, 95% CI 1.32 to 2.15); reduced reporting of severe pain during second stage of labour (1 trial: RR 0.73, 95% CI 0.60 to 0.90); fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98).

REVIEWER'S CONCLUSIONS

The tentative findings of this review suggest several possible benefits for upright posture, with the possibility of increased risk of blood loss greater than 500 ml. Women should be encouraged to give birth in the position they find most comfortable. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent trials' data are available, women should be allowed to make informed choices about the birth positions in which they might wish to assume for delivery of their babies.

Effect of paper quality on the response rate to a postal survey: a randomised controlled trial. ISRCTN 32032031

BACKGROUND

Response rates to surveys are declining and this threatens the validity and generalisability of their findings. We wanted to determine whether paper quality influences the response rate to postal surveys

METHODS

A postal questionnaire was sent to all members of the British Society of Gynaecological Endoscopy (BSGE). Recipients were randomised to receiving the questionnaire printed on standard quality paper or high quality paper.

RESULTS

The response rate for the recipients of high quality paper was 43/195 (22%) and 57/194 (29%) for standard quality paper (relative rate of response 0.75, 95% CI 0.33-1.05, p = 0.1

CONCLUSION

The use of high quality paper did not increase response rates to a questionnaire survey of gynaecologists affiliated to an endoscopic society.

Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review

This review investigates the accuracy with which transvaginal cervical sonography predicts spontaneous preterm birth. Published studies were identified without language restrictions through nine different databases and manual searching of bibliographies of known primary and review articles. Studies were selected if they undertook antenatal transvaginal sonographic cervical assessment among a population of pregnant women with known gestational age of delivery. There were 46 primary articles, which included a total of 31,577 women, consisting of 33 studies in asymptomatic and 13 studies in symptomatic women. Data were extracted for the studies' characteristics and quality. Accuracy data were used to form 2 x 2 contingency tables for various cervical length measurements with birth before 32, 34 and 37 weeks' gestation as the reference standards. Data were stratified according to singleton or twin pregnancy, gestational age at testing, cervical length threshold, and the various reference standards, and were pooled to produce summary estimates of likelihood ratios (LRs). Our review showed that transvaginal cervical sonography identifies women who are at higher risk of spontaneous preterm birth, although there was a wide variation amongst studies with respect to gestational age at testing, definition of threshold of abnormality and definition of reference standard. The most commonly reported sub-group was testing of asymptomatic women at < 20 weeks' gestation using a threshold cervical length of 25 mm with spontaneous preterm birth before 34 weeks' gestation as the reference standard. The summary LR+ for this group was 6.29 (95% CI, 3.29-12.02), with corresponding LR- of 0.79 (95% CI, 0.65-0.95). Both cervical length measurement and funneling, whether alone or in combination, appear to be useful (depending on the threshold chosen to define the abnormality) in predicting spontaneous preterm birth in asymptomatic women. For symptomatic women there was a paucity of data, although the degree of funneling appeared to be predictive of spontaneous preterm birth.

Probability analysis for diagnosis of endometrial hyperplasia and cancer in postmenopausal bleeding: an approach for a rational diagnostic workup

OBJECTIVE

To develop an analytical approach to estimate the probability of endometrial hyperplasia and cancer in women with postmenopausal bleeding, using a combination of patient history and tests.

METHODS

A prospectively collected database of 428 postmenopausal women investigated for abnormal uterine bleeding in an outpatient rapid access clinic was used. The probability of disease was estimated using multivariable logistic regression models considering a combination of age and the use of hormone replacement therapy (HRT) and tests (ultrasound and hysteroscopy) in keeping with the actual clinical process.

RESULTS

The prevalence or prior probability of endometrial cancer in the sample studied was 4.4%. Hysteroscopy alone performed better than ultrasound alone. In all patients, a negative hysteroscopy reduced the probability of cancer to 1.3%. In women less than 60 years of age who use HRT, a negative hysteroscopy further reduced this probability to 0.1%. Overall, a positive hysteroscopy raised the probability of cancer to 38.9%. However, in women over 60 years of age not using HRT, a positive hysteroscopy increased this probability to 59.4%. Combining ultrasound results with hysteroscopy did not meaningfully alter the diagnostic probability.

CONCLUSION

The combination of information obtained from patient history and tests allows generation of specific disease probabilities in postmenopausal bleeding. This type of multivariable analysis puts diagnostic information gained from history and other tests into a perspective that reflects actual clinical practice.