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.