• Paul P Smith, Siobhan O'Connor, Janesh Gupta, and T Justin Clark.
• Birmingham Women's Hospital, Birmingham, United Kingdom. Electronic address: paul.smith@doctors.net.uk.
• J Minim Invasive Gynecol. 2014 Sep 1; 21 (5): 799-803.

Study ObjectiveTo estimate the prevalence of genital tract diseases in women with initial and recurrent postmenopausal bleeding (PMB) to help inform diagnostic pathways.DesignProspective cohort study (Canadian Task Force classification: II-2).SettingLarge urban teaching hospital.PatientsOf 1938 consecutive women with postmenopausal bleeding, 106 (5%) were investigated for a recurrent episode after having normal findings of previous investigations.InterventionsAll women underwent pelvic examination and ultrasound scanning. An endometrial biopsy was performed when endometrial thickness was >4 mm in women with a first episode of PMB, with recourse to outpatient hysteroscopy after correlation between clinical and pathologic findings. All women with a recurrent PMB episode underwent endometrial biopsy and outpatient hysteroscopy.Measurements And Main ResultsThe risk of having endometrial cancer or hyperplasia with atypia was significantly less in women with recurrent PMB (9%) as compared with those with a first episode of PMB (8%) (p = .002), but were significantly more likely to have benign endometrial polyps (28%) compared with women with a first episode of PMB (19%) (relative risk, 1.47; 95% confidence interval, 1.07-2.02; p = .02).ConclusionRecurrent PMB results in less likelihood of premalignant and malignant endometrial disease; however, in 1 of 4 women PMB is caused by endometrial polyps. First-line investigation in women with recurrent PMB should be tests that have high accuracy for enabling diagnosis of focal diseases, such as outpatient hysteroscopy or saline infusion sonography.Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.

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