This study has highlighted the complexity of the investigation pathways travelled by women referred for abnormal bleeding. Decision-making about investigation and understanding would be clarified if postmenopausal women were studied separately from premenopausal women with menstrual bleeding problems. For postmenopausal women exclusion of cancer is a main objective, so once investigation has been completed discharge follows, but in the woman with abnormal menstrual bleeding, even if serious pathology is excluded, the original presenting symptoms require management.
About 60% of premenopausal women with abnormal bleeding reported that their symptoms were not much improved at 10 months. Research is needed to understand this phenomenon, and to explore ways to integrate patient factors into optimising evaluation and treatment in these cases. The significance of benign pathologies in this group also requires clarification.
Given the relatively small differences observed in cost-effectiveness, there is justification for allowing other issues (such as clinician preferences and womens perspectives) to influence decisions as to the investigation method. The clinicians expressed interest in the Tao brush being made available for their use. Its introduction would have resource implications, in particular the training of pathology staff. The Tao brush is superior in obtaining adequate samples, so it should be considered the method of choice for postmenopausal women, or at least be readily available as a back-up technique where Pipelle sampling has failed.
At the time of investigation ultrasound was much more acceptable to women than hysteroscopy and biopsy, but hysteroscopy was not more unpleasant to women than biopsy. Women having hysteroscopy were pleased to have had the investigation and women having this randomisation option were least likely to have wanted more investigation, whereas those having biopsy only wished that they had had more investigation.
There is scope to make better use of patient factors to inform decisions as to the most efficient and acceptable method of investigation for an individual woman. Additional analyses, using data available as a result of this study, will contribute to this agenda.