Clinical pathway for evaluating women with abnormal uterine bleeding

Abnormal uterine bleeding is one of the most common gynecologic complaints, generating one-fifth of all visits to the gynecologist and accounting for up to one-fourth of hysterectomies performed in the United States each year. A careful evaluation of this condition is important because endometrial cancer is diagnosed in 10% of postmenopausal women with abnormal bleeding and is a plausible possibility in premenopausal women who present with this symptom. The authors have developed a cost-efficient, risk-based clinical pathway for evaluation of abnormal uterine bleeding. This article is a report of 1000 patients with abnormal uterine bleeding who were seen at the Women's Care Clinic in Denver over a 3-year period and who were managed using this protocol. The women were grouped according to menopausal status (570 premenopausal and 430 postmenopausal) and the presence of risk factors for endometrial cancer, including obesity (43%), nulligravidity (12%), history of anovulation (27%), diabetes (14%), hypertension (15%), or tamoxifen therapy. Patients with one or more of these characteristics were considered high-risk for endometrial cancer and underwent endometrial biopsy. The clinical pathways followed for premenopausal and postmenopausal women are presented in Figures 1 and 2. Four hundred thirty women (44%) were successfully treated medically and did not require endometrial biopsy. The remaining 530 women had endometrial biopsy performed, and 250 of these (90 premenopausal and 160 postmenopausal) were also evaluated with ultrasonography. Biopsy results revealed 40 women with simple hyperplasia, 5 with atypical hyperplasia, and 5 with endometrial cancer. Overall, endometrial biopsy was avoided in nearly 50% of the patients. Physician compliance with the protocols was greater with high-risk patients (77% overall and 88% in postmenopausal patients) than with low-risk patients (42%).