Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy.

BACKGROUND The objective was to determine how postmenopausal bleeding (PMB) is managed in Sweden today, and to relate the findings to a new evidence-based algorithm for the management of PMB. METHODS A questionnaire regarding the role of ultrasound and the use of different endometrial biopsy methods in the management of PMB was sent to all 61 gynecologic departments in Sweden. RESULTS Fifty-nine of the 61 departments (97%) satisfactorily answered the questionnaire. Ultrasound was either always (n = 54, 92%) or most commonly (n = 5, 8%) used in the diagnostic work-up of PMB. In women with endometrial thickness < or =4 mm, 18 of the departments (31%) routinely sampled the endometrium; 12 (15%) followed the women with ultrasound; three (5%) did both sampling and follow-up with ultrasound; and the remaining 29 (49%) used expectant management (i.e. no biopsy or routine follow-up). In women with endometrium > or =5 mm, hydrosonography was performed routinely in two departments (3%), occasionally in 37 departments (63%), and never in 20 departments (34%). In women with endometrium > or =5 mm, endometrial biopsy was obtained routinely by Endorette/Pipelle in 39 departments (66%), while in 26 departments (44%) operative hysteroscopy was never performed. CONCLUSION More than one-third of the gynecologic departments in Sweden never perform hydrosonography to rule out focal lesions or operative hysteroscopy for the removal of such lesions. Hydrosonography and hysteroscopy have a central role in the new guidelines for the management of PMB. Therefore, a need exists to broaden the use of hydrosonography and hysteroscopy.