Case-control study of risk factors for partial molar pregnancy

OBJECTIVE

The purpose of our study was to identify risk factors for partial molar pregnancy from a woman's general, reproductive, and dietary history.

STUDY DESIGN

Sixty-five women with pathologically confirmed partial molar pregnancy were interviewed, and their experiences were compared with those of 130 age-matched control women who had successfully completed a pregnancy with delivery of a live infant at the same hospital during the same calendar period.

RESULTS

Multivariate analysis revealed that exposures which independently and significantly predicted increased risk for partial molar pregnancy included irregular cycles, pregnancy histories including only male infants among prior live births, and oral contraceptive use for > 4 years. Dietary factors previously postulated for complete molar pregnancy including protein, fat, vitamin A, or carotene were found not to be related to risk for partial molar pregnancy.

CONCLUSION

Epidemiologic patterns for complete and partial molar pregnancies appear to differ somewhat; risk for partial mole is associated with reproductive history but not dietary factors.

Overexpression of the protein tyrosine phosphatase, nonreceptor type 6 (PTPN6), in human epithelial ovarian cancer

Our current understanding of human ovarian tumorigenesis is limited by the lack of a discrete precursor lesion as well as a limited knowledge of the steps in tumor progression. Since the alterations in the regulation of the tyrosyl residues on various cellular proteins appear to be an important pathway in neoplastic transformation, it is possible that changes in the expression of the proteins that control tyrosine phosphorylation (i.e., tyrosine kinases and phosphatases) may play a role in ovarian cancer development. Protein tyrosine phosphatase, nonreceptor type 6 (PTPN6), contains two src homology 2 domains and is expressed primarily in hematopoietic and epithelial cells. Using Northern blot and immunoblotting analysis, we showed that both the PTPN6 transcripts and proteins were overexpressed two- to four-fold in 7 of the 8 ovarian epithelial carcinoma cell lines studied. In addition, we showed that there was also a two- to threefold increase in expression of the PTPN6 transcript in 10 of 11 (91%) invasive ovarian epithelial cancer tissues examined. These observations suggest that the PTPN6 gene is potentially of etiologic relevance to a majority of ovarian cancers.

Characterization of human ovarian surface epithelial cells immortalized by human papilloma viral oncogenes (HPV-E6E7 ORFs)

Primary human ovarian surface epithelial (HOSE) cells were immortalized by a retroviral vector (LXSN-16E6E7) expressing HPV-E6E7 open reading frames (ORF). Immortalizations of primary ovarian epithelial cells were achieved in three of three attempts. Detailed analysis was carried out in one line, HOSE 6-3, selected on the basis of its epithelial morphology. The immortalized line (HOSE 6-3) was nontumorigenic in nude mice when examined at subculture number 20. Cytogenetic analysis confirmed its human origin and detailed karyotypic analysis revealed a mixed karyotype made up of about 60% of diploid and 40% of near-tetraploid cells. Clonal chromosomal aberration was observed in a subpopulation of cells involving a ring chromosome number 9. Immunofluorescence and two-dimensional gel electrophoresis revealed the presence of vimentin and several species of cytokeratin (K7, K8, K18, K19). The profile of the cytoskeletal filaments of HOSE 6-3 cells is largely identical with that of normal ovarian epithelial cells before immortalization. The immortalized ovarian epithelial cells have a lower sensitivity to TGF-beta 1 inhibition compared to normal ovarian epithelial cells. The immortalized line, HOSE 6-3, has altered growth properties including a higher proliferation rate, plating efficiency, and saturation density. The establishment of a continuous line of human ovarian epithelial cells may provide an in vitro model for study of carcinogenesis in human ovarian cancers.

Detailed deletion mapping of chromosome 6q in borderline epithelial ovarian tumors

We have used PCR amplification of tandem repeats and Southern blot analysis to study the pattern of allelic loss at chromosome 6q in borderline ovarian tumors and compared that with invasive ovarian carcinomas. DNA from 46 borderline ovarian tissues, 20 invasive ovarian tumor tissues, together with corresponding uninvolved (control) tissues was used. The invasive tumors demonstrated the highest percentage of loss of heterozygosity (13 of 45 informative cases, 29%) at the 6q25-27 locus site. In contrast, the borderline ovarian tumors showed only an 11% frequency of loss of heterozygosity (3 of 26). Our results display a sharp contrast in the pattern of loss of heterozygosity between invasive and borderline ovarian tumors and suggest that allelic loss at chromosome 6q may not be involved in the development of borderline ovarian tumors.

Predicting endometrial cancer among older women who present with abnormal vaginal bleeding

We studied 203 women ages 49 or over who presented with abnormal vaginal bleeding and who underwent either endometrial biopsy or dilation and curettage at the Brigham and Women's Hospital. Using information from the clinical history, we predicted their risk for endometrial cancer (36 patients) or complex endometrial hyperplasia (16 patients). Factors independently associated with endometrial cancer/complex hyperplasia included age 70 or older (OR = 9.1, P = 0.0001), diabetes (OR = 3.7, P = 0.02), and nulliparity (OR = 2.7, P = 0.02). After adjusting for age, menopause was borderline significant (OR = 2.6, P = 0.07). Our data estimated a risk of endometrial cancer/complex hyperplasia of 87% for a woman possessing all of these factors, and a risk of less than 3% if she had none of them. Our model provides an inexpensive, simple means for assessing the risk of endometrial cancer and complex hyperplasia in the post- or perimenopausal woman with abnormal bleeding.

Evidence for a multifocal origin of papillary serous carcinoma of the peritoneum

Histopathological evidence suggests that papillary serous carcinoma of the peritoneum (PSCP) may be multifocal in origin. Utilizing a PCR based method to detect tandem repeat polymorphisms in formalin fixed tissue, loss of heterozygosity at eight loci on chromosomes 1, 3, 4, and 17 was studied in six cases of PSCP. Loss of heterozygosity was assessed at between 5 and 11 tumor sites/patient. Allelic losses at 4 loci (1q32-qter, 3p14.3-21.1, 17q12, 17q21.3-23) were noted. Three cases demonstrated a different pattern of allelic loss at various anatomic sites within the same patient. In an additional case, a mutation of the p53 gene, detected by quantitative PCR followed by single-strand conformation polymorphism analysis, was detected in only 2 of 5 tumor sites. The pattern of allelic loss and the mutational pattern of the p53 gene varied at tumor sites within the same patient in 4 of 6 cases of PSCP. These findings are consistent with histopathological evidence that PSCP is multifocal in origin.

Two-year follow-up of 263 patients with post/perimenopausal vaginal bleeding and negative initial biopsy

Patients with post- or perimenopausal bleeding (PMB) whose initial endometrial biopsy or dilation and curettage (D&C) reveals benign or insufficient tissue may eventually be diagnosed with endometrial cancer or complex endometrial hyperplasia. We studied 286 consecutive patients with PMB who had either an endometrial biopsy or D&C at Brigham and Women's Hospital during November 1990 to April 1991 and reviewed their subsequent specimens after a minimum of 23 months of follow-up. Of the initial 286 patients with PMB, 6 (2%) had endometrial cancer on their index biopsy, 17 (6%) had complex hyperplasia, and 201 (70%) had other benign findings. Sixty-two (22%) had "tissue insufficient for diagnosis." Excluding the 23 with cancer/complex hyperplasia, there were 263 patients in the cohort, 86 of whom (33%) had further endometrial sampling during the follow-up period. Of these, four (2%) were subsequently found to have a uterine malignancy (2 of the benigns, 2 of the insufficients) and five (2%) were subsequently found to have complex hyperplasia. Of the four patients subsequently found to have cancer, two had stage I adenocarcinoma, one had stage IV adenocarcinoma, and one had stage I high-grade stromal sarcoma.

Pseudomyxoma peritonei: a review of 23 cases

OBJECTIVE

To review the experience at the Massachusetts General and Brigham and Women's Hospitals with 23 women treated for pseudomyxoma peritonei between 1961 and 1991.

METHODS

Patients were identified retrospectively from the tumor registry at the Massachusetts General and Brigham and Women's Hospitals, and all charts were reviewed. The median follow-up interval was 2.5 years (range 3 months to 31 years).

RESULTS

The mean age at diagnosis was 58 years (range 26-76). Pseudomyxoma peritonei was found in association with ten (44%) ovarian tumors of borderline malignancy, nine (39%) ovarian cystadenocarcinomas, and four (17%) appendiceal cystadenocarcinomas. Three patients had synchronous tumors in the ovary and appendix. All patients underwent surgical staging and cytoreduction. Eleven patients received postoperative therapy and, of these, nine developed a recurrence; 12 patients received no further therapy and, of these, three developed a recurrence. However, these groups were not pathologically comparable. With respect to survival, of the ten patients with borderline malignancies, seven had no evidence of disease, one was alive with disease, and two died of disease. For the nine patients with ovarian cystadenocarcinomas, three had no evidence of disease, one was alive with disease, and five died of disease (median time to death 18 months). For the four patients with appendiceal carcinomas, two had no disease, one was alive with disease, and one died with disease. Among all 23 patients, 12 (52%) developed a recurrence, with a range of time to first recurrence of 3 months to 19 years. Eight women required at least one additional laparotomy because of accumulation of gelatinous material.

CONCLUSIONS

Although pseudomyxoma peritonei is associated with borderline and well-differentiated tumors, recurrence is common and the prognosis after recurrence is guarded. Involvement of the appendix is common; therefore, appendectomy is indicated when pseudomyxoma is encountered. To date, surgery has been the only effective therapy for this disease, and adjuvant therapy has not been shown conclusively to be of benefit.

Psychological, social and sexual effects of gestational trophoblastic disease on patients and their partners

The psychological, social and sexual effects of gestational trophoblastic disease in both patients and their partners are reviewed. The results suggest that despite the favorable prognosis of this disease, mood disturbances, sexual disturbances and fertility concerns can persist in both patients and their partners. Recommendations are made concerning providing supportive care to meet the needs of patients and their partners.

Pulmonary metastases of gestational trophoblastic tumor. Risk factors for early respiratory failure

Between January 1980 and December 1990, 75 (57.3%) of 131 patients with metastatic gestational trophoblastic tumor had pulmonary metastases detected on plain chest roentgenography at the King Faisal Specialist Hospital and Research Centre. Pulmonary involvement was commonly extensive, with 32 (42.7%) patients having > 10 pulmonary metastases and 45 (60%) patients having a pulmonary lesion > 5 cm in diameter. Greater than 50% lung opacification, mediastinal involvement and pleural effusion were present in 25 (33.3%), 25 (33.3%) and 36 (48%) patients, respectively. Eight (10.7%) patients developed early respiratory failure requiring mechanical ventilation within one month of presentation. The development of early respiratory failure was significantly associated with the presence of dyspnea, anemia, clinical pulmonary hypertension, cyanosis, > 50% lung opacification, mediastinal involvement and bilateral pleural effusion. Because all patients requiring mechanical ventilation died, the use of extracorporeal perfusion should be considered in patients with early respiratory failure.

Current management of complete and partial molar pregnancy

Molar pregnancy is composed of two separate entities, partial (PHM) and complete (CHM), which are distinct in terms of epidemiology, genetics, histopathology, clinical presentation and risk of persistent gestational trophoblastic tumor (GTT). The most common presenting symptom in patients with CHM is vaginal bleeding. Approximately half the patients with CHM show signs of exuberant trophoblastic growth, with uterine enlargement and high levels of human chorionic gonadotropin (hCG). In contrast, patients with PHM usually present as though they have an incomplete or missed abortion, with bleeding, small uteri and low hCG levels. Cytogenetically, all chromosomal material in CHM is derived from the male. Hence, no fetal parts are identified. In PHM, dispermy results in a triploid conceptus, in which an abnormal fetus is present and ultimately dies. The diagnosis of CHM is usually confirmed by sonography when a vesicular pattern is noted. The ultrasound pattern in PHM is less consistent and depends on careful measurement of the gestational sac. Patients with CHM with marked trophoblastic hyperplasia, elevated hCG levels and enlarged uteri can develop significant medical complications, which should be recognized early and treated aggressively. These include acute respiratory distress syndrome, hyperthyroidism, preeclampsia and theca lutein cysts. All molar pregnancies should be evacuated promptly following a definitive diagnosis. If the patient no longer wishes to preserve her fertility, a hysterectomy will reduce the risk of developing nonmetastatic GTT. Following evacuation, careful hCG monitoring is mandatory since it is the most reliable and sensitive method for the early detection of GTT.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cytokines on epidermal growth factor receptor expression by malignant trophoblast cells in vitro

Trophoblastic cells abundantly express epidermal growth factor (EGF) receptors, which, when activated by EGF or transforming growth factor-alpha, can influence cellular growth and metabolism. Various lymphocyte and macrophage cytokines have been found to influence the proliferation of human choriocarcinoma (CCA) cells in vitro. In the current study we investigated the possibility that certain cytokine effects are mediated by changes in EGF receptor expression. JEG-3 human CCA cells were incubated with varying concentrations of interleukin 1-alpha (IL-1 alpha), interleukin 1-beta (IL-1 beta), interleukin 2, gamma-interferon, granulocyte-macrophage colony stimulating factor and tumor necrosis factor-alpha (TNF), and the expression of EGF receptor was measured by radioimmunoassay using a murine monoclonal antibody with specificity for the EGF receptor. Proliferative or growth suppressive effects of the cytokines were assessed by quantitative analysis of the DNA in the cell culture wells. Macrophage-derived cytokines IL-1 alpha, IL-1 beta and TNF significantly suppressed cell growth; this was associated with a significant increase in EGF receptor expression. The other cytokines had no significant effect on either EGF receptor expression or cell growth. We also studied the expression of EGF mRNA in JEG-3, Jar and BeWo CCA cell lines. By reverse transcription followed by polymerase chain reaction, low levels of EGF mRNA were detected in all three cell lines. Therefore, EGF may be synthesized by JEG-3, Jar and BeWo CCA cell lines to participate in an autocrine growth pathway. Our findings support the concept that cytokines may act as paracrine mediators of autocrine processes involved in CCA cell growth regulation by modulating growth factor receptor expression.

Subsequent pregnancy experience in patients with gestational trophoblastic disease. New England Trophoblastic Disease Center, 1965-1992

We reviewed the subsequent pregnancy outcome in patients with partial mole, complete mole and persistent gestational trophoblastic tumor treated at the New England Trophoblastic Disease Center from June 1, 1965, to December 31, 1992. Such patients can be assured that they can anticipate a normal future reproductive outcome. However, when a patient has had a molar pregnancy, she is at increased risk (1%) of developing molar disease in a subsequent conception.

Clinical features of multiple conception with partial or complete molar pregnancy and coexisting fetuses

The estimated incidence of twin pregnancy consisting of hydatidiform mole and a coexisting fetus is 1 per 22,000-100,000 pregnancies. Since 1965, nine patients with this entity have been treated at the New England Trophoblastic Disease Center (NETDC), Boston. One patient had a partial hydatidiform mole coexisting with a normal placenta and fetus. The other eight patients had twin pregnancies with a complete hydatidiform mole (CHM) and coexisting fetus. We compared the clinical outcomes in these 8 patients and 14 additional published case reports of multiple gestations composed of CHM and coexisting fetuses with a group of 71 patients with singleton CHM treated at NETDC. Twelve of the 22 patients (55%) with CHM and coexisting fetuses developed persistent gestational trophoblastic tumor, requiring chemotherapy. Five of these patients developed metastases requiring multiple cycles of chemotherapy to achieve remission. The presenting symptoms of multiple conception with CHM and coexisting fetuses were similar to those in patients with a singleton conception and complete mole. However, as compared to singleton CHM, patients having a multiple conception with CHM and coexisting fetuses were diagnosed at a later gestational age, had higher preevacuation beta-human chorionic gonadotropin levels and had a greater propensity to develop persistent tumor. These data indicate that patients with multiple conceptions consisting of CHM and coexisting fetuses are at high risk of developing persistent gestational trophoblastic tumor.

Brain metastases of gestational trophoblastic tumor

Brain involvement by gestational trophoblastic tumor (GTT) was diagnosed by computed tomography in 23 (17%) of 131 patients with metastatic GTT at King Faisal Specialist Hospital and Research Centre between January 1980 and December 1990. All 23 patients had concurrent lung involvement, and 20 presented with neurologic symptoms. There were three treatment groups: Group A--methotrexate, actinomycin-D, chlorambucil and brain irradiation; group B--cisplatin, VP-16, actinomycin-D and intrathecal methotrexate; and group C--palliative therapy and other chemotherapy. While no patients in groups A or C survived, 4 (57%) of 7 patients in group B achieved complete, sustained remission. Serum:cerebrospinal fluid beta-human chorionic gonadotropin ratios were measured in 9 patients and were < 60 in only 4 patients. The clinical features of patients with brain metastases are reviewed in detail.

Cytokine regulation of trophoblast steroidogenesis

Activated monocytes and lymphocytes secrete cytokines that act as autocrine and paracrine mediators to promote and regulate local immune processes. These cell types are abundant at the maternal-fetal interface, and cytokines may play a role in pregnancy maintenance or failure. The purpose of this study was to determine the effects of selected monocyte- and lymphocyte-derived cytokines on trophoblast progesterone and estradiol production. JEG-3 choriocarcinoma cells were cultured in supplemented medium alone or in various concentrations of selected recombinant monocyte or lymphocyte cytokines. The cytokines were evaluated both individually and in combination. After 48 h of incubation, the culture supernatant was aspirated and stored at -20 C. Samples were then analyzed for steroid concentration by specific RIAs. Specific interleukin-1 (IL-1)-and tumor necrosis factor (TNF)-neutralizing antibodies were evaluated for their ability to abrogate the cytokine's observed stimulatory effect. To evaluate the physiological relevance of the progesterone-stimulating effect observed with monocyte-derived cytokines, JEG-3 cells were incubated with activated monocyte supernatant or directly cocultured with activated monocytes, and supernatants from these cultures were analyzed for progesterone levels. The monocyte cytokines [IL-1 alpha (5 U/mL), IL-1 beta (5 U/mL), and TNF alpha (1000 U/mL) significantly stimulated trophoblast progesterone production (nanograms per mL): JEG-3 control, 4.1 +/- 0.5; IL-1 alpha, 7.8 +/- 0.9; IL-1 beta, 8.8 +/- 0.5; and TNF alpha 7.2 +/- 0.8 (P < 0.05). Neither the monocyte nor the lymphocyte cytokines altered trophoblast estradiol production. Activated monocyte supernatant and direct JEG-3-monocyte cocultures also significantly stimulated trophoblast progesterone production in vitro. The stimulatory effect of the monocyte-derived cytokines was specific, as demonstrated by neutralization assay. The increased trophoblast progesterone production was not due to enhanced cellular proliferation, but to enhance cellular steroidogenesis, as measured by quantitative DNA analysis. The lymphocyte cytokines (IL-2, interferon-gamma, and granulocyte-macrophage colony-stimulating factor had no effect on trophoblast progesterone production. We conclude that monocyte IL-1 alpha, IL-1 beta, and TNF alpha may regulate trophoblast progesterone production through paracrine effects. Monocyte-trophoblast interactions may be significant in normal pregnancy as well as pregnancy disorders.

Molecular cloning of differentially expressed genes in human epithelial ovarian cancer

A DNA-fingerprinting approach has been adapted to detect differentially expressed genes in human ovarian carcinoma. This method is based on the use of arbitrary primers to generate fingerprints from total RNA isolated from normal ovarian epithelial cells and ovarian carcinoma cells by polymerase chain reaction (PCR). Using this method, we cloned two cDNA fragments (DOC-1 and DOC-2) which were present in normal ovarian surface epithelial cells but consistently absent in all of the ovarian cancer cell lines from the differential display. In addition, we also identified a cDNA fragment (LF4.0) which is overexpressed in most of the tumor cell lines and tumor tissues in comparison to the normal ovarian surface epithelial cells. The differential expression of the genes in the tumor cell lines as well as in the tumor tissues was also confirmed by Northern analysis. The clone DOC-2, which is a 800-bp cDNA fragment, has one open reading frame suggesting that the gene may be translated. Assuming that this frame is the sense strand, we generated both sense and antisense riboprobe for in situ mRNA hybridization. Only the antisense DOC-2 riboprobe revealed a hybridization signal which was restricted to the human surface ovarian epithelium. The potential functional roles of these genes is now under investigation.

Natural history of twin pregnancy with complete hydatidiform mole and coexisting fetus

OBJECTIVE

To investigate the clinical features and natural history of twin conceptions consisting of complete hydatidiform mole and a coexisting fetus.

METHODS

Since 1973, eight well-documented cases of twin pregnancy with complete hydatidiform mole and coexisting fetus have been treated at the New England Trophoblastic Disease Center (NETDC). The clinical features of these eight patients were compared to 71 patients with singleton complete hydatidiform mole treated at the NETDC and with the published experience of other investigators. Flow cytometric analysis of DNA content was performed in addition to histologic inspection to assist in confirming the diagnosis of twin pregnancy with complete hydatidiform mole and coexisting fetus.

RESULTS

Five of the eight patients in this series developed persistent gestational trophoblastic tumor requiring chemotherapy. Three of these five patients developed metastases requiring multi-agent chemotherapy to achieve remission. The presenting symptoms of twin pregnancy with complete hydatidiform mole and coexisting fetus were similar to those in patients with a singleton complete mole. However, compared to singleton complete molar gestation, a twin pregnancy with complete mole and coexisting fetus was diagnosed at a later gestational age, had higher preevacuation beta-hCG levels, and had a greater propensity to develop persistent gestational trophoblastic tumor.

CONCLUSION

Our findings indicate that patients with complete hydatidiform mole and coexisting fetus are at high risk for developing persistent gestational trophoblastic tumor.

The effects of cytokines on human chorionic gonadotropin (hCG) production by a trophoblast cell line

The present study was conducted to investigate the effects of cytokines on human chorionic gonadotropin (hCG) and its alpha- and beta-subunit release as well as protein synthesis in a trophoblast cell line. The human choriocarcinoma cell line, Jar, was used as a trophoblast model. Jar cells were incubated for 24 h with varying concentrations (5 x 10(-4)-40 micrograms/ml) of the following cytokines: Il-1, Il-2, Il-3, Il-4, Il-5, Il-6, IFN-gamma, tumor necrosis factor (TNF)-alpha, M-CSF and GM-CSF. Supernatants were assayed for hCG and its alpha- and beta-subunits by immunoradiometric methods. Cytotoxic effects were assessed by trypan blue staining. Protein synthesis was measured by [3H]leucine incorporation. The cytokines Il-1 and TNF-alpha significantly stimulated hCG release. The other cytokines had no significant effect on hCG production. Protein synthesis by the Jar cells was not significantly affected by either Il-1 or TNF-alpha. However, IFN-gamma (40 micrograms/ml) significantly suppressed protein synthesis by the Jar cells. Trophoblast viability in the presence of TNF-alpha (10 micrograms/ml) and IFN-gamma (40 micrograms/ml) was only 40% and 50%, respectively. These results suggest that cytokines may be important regulators of trophoblast function. Il-I appears to have a stimulatory effect on trophoblast hCG release, while TNF-alpha and IFN-gamma appear to have cytotoxic effects on trophoblast cells.

Screening for ovarian cancer: the preliminary experience of a familial ovarian cancer center

Women with a family history of ovarian cancer represent a high-risk group for the development of epithelial ovarian cancer. From July 1990 through December 1992, 386 women with a first-degree or multiple second-degree relatives with confirmed ovarian cancer were enrolled in a study to assess the utility of screening with transvaginal sonography, color flow doppler, and CA125. The mean age of the group was 41; 85% were premenopausal and 89/384 (23%) had 2 or more relatives with ovarian cancer. An initial ultrasound examination was abnormal in 89/384 (23%), 89% of whom were premenopausal. A persistent ovarian mass was detected in 15 patients and all were surgically proven to be benign. Mean CA125 levels were significantly higher and more variable in pre- vs postmenopausal women. CA125 was > or = 35 U/ml in 42/386 (11%) (36-232 U/ml). All but one of these women were premenopausal and 50% subsequently normalized. Two patients who were surgically explored for a rising CA125 had normal ovaries. An additional 19 patients have undergone prophylactic oophorectomy with no consistent histopathologic abnormality identified. These data demonstrate the difficulty inherent in screening a predominantly premenopausal population and do not clearly establish the efficacy of these modalities in the early detection of ovarian cancer.

Cost-effectiveness of strategies to evaluate postmenopausal bleeding

OBJECTIVE

To identify an optimal evaluation strategy for patients of various ages and risks for endometrial cancer and for complex hyperplasia who present with a first episode of postmenopausal bleeding.

METHODS

We constructed a decision-analytic model to assess the life expectancy, effectiveness, cost, and cost-effectiveness of four options for the initial evaluation of postmenopausal bleeding: office endometrial biopsy, D&C, hysterectomy, and observation unless bleeding recurred. We considered patients at different ages and risks for cancer and for complex hyperplasia.

RESULTS

Life expectancy was similar for all four strategies, but overall expected costs varied markedly. Compared with the other procedures, office biopsy was the most cost-effective initial strategy, costing less than $41,000 per year of life saved for patients at moderate combined risk (ie, 10%) of cancer or complex hyperplasia. However, for patients at low risk (ie, 5%), even office biopsy was relatively costly in certain age groups, with costs as high as $205,000 per additional year of life saved for 80-year-old patients. Both D&C and hysterectomy were more costly and no more effective than office biopsy as initial evaluation strategies in all patient groups over a wide range of changes in baseline assumptions.

CONCLUSIONS

Office biopsy is always preferred over D&C or hysterectomy for the initial evaluation of patients with postmenopausal bleeding. However, one may consider delaying a biopsy unless and until bleeding recurs for patients who are at low risk (5% or less) for cancer and complex hyperplasia by clinical criteria.