Performance of ultrasound and rates of guideline-concordant care in a diverse postmenopausal bleeding cohort.

BACKGROUND: Professional society guidelines endorse the use of ultrasound to evaluate an initial episode of postmenopausal bleeding, with endometrial sampling reserved for patients with an endometrial thickness exceeding 4 mm. However, the data supporting this ultrasound-based approach are derived from cohort studies with minimal racial and ethnic diversity. OBJECTIVE: This study aimed to evaluate rates of adequate endometrial visualization, prompt guideline-concordant care, and identify risk factors for lack of timely indicated sampling in a multi-institutional cohort of patients who underwent ultrasound to evaluate postmenopausal bleeding. STUDY DESIGN: Patients aged ≥45 years who underwent transvaginal ultrasound for an initial coding-based diagnosis of postmenopausal bleeding were eligible for this retrospective cohort study. Ultrasound findings of the endometrium were classified as thin (endometrium ≤4 mm), thick (endometrium >4 mm), or inadequate (endometrium not completely visualized). Associations between clinicodemographic factors, ultrasound findings, and follow-up patterns were analyzed. We defined care as guideline-concordant if patients with a thin endometrium on the index ultrasound did not undergo biopsy, or if those with a thick or inadequately visualized endometrium received indicated endometrial sampling within 3 months after the index ultrasound. We analyzed outcomes using univariable and multivariable logistic regressions. RESULTS: A total of 3614 patients were included in the study (48.4% non-Hispanic White, 28.5% non-Hispanic Black, 9.6% Hispanic, 3.0% Asian, and 10.4% other/missing). Rates of inadequate ultrasound examination varied between racial/ethnic cohorts (non-Hispanic White 5.9%, non-Hispanic Black 18.8%, Hispanic 12.7%, and Asian 9.2%). Uterine fibroids were present in 71.5% (737/1031) of non-Hispanic Black patients, as opposed to 43.3% (757/1750) of non-Hispanic White patients, and were strongly associated with lower odds of adequate ultrasound (odds ratio, 0.29 [95% confidence interval, 0.23-0.38]; P<.001). Rates of endometrial sampling were 53.5% (209/391) after an inadequate ultrasound and 75.3% (1329/1765) after a thickened endometrium finding. Guideline-concordant care rates were 85.7% for non-Hispanic White (1500/1750), 78.0% for non-Hispanic Black (804/1031), 83.6% for Hispanic (290/347), and 82.7% for other/unknown (402/83) patients. Compared with non-Hispanic White patients, non-Hispanic Black patients were less likely to receive guideline-concordant care (adjusted odds ratio, 0.64 [95% confidence interval, 0.52-0.78]). CONCLUSION: Non-Hispanic Black patients with postmenopausal bleeding have a higher rate of inadequate ultrasound examination due to fibroids and are less likely to receive prompt guideline-concordant care. An ultrasound-based workup of postmenopausal bleeding risks delays in endometrial cancer diagnoses and may contribute to racial disparities in outcomes. A universal biopsy approach for postmenopausal bleeding may be considered to decrease variation in and improve guideline-concordant care.

Duke Scholars

Author Evan Robert Myers Obstetrics and Gynecology, Women's Community & Population He ...

Author Laura Jean Havrilesky Obstetrics and Gynecology, Gynecologic Oncology