Summary
Open access to transvaginal sonography offered a relevant contribution to the diagnostic and therapeutic management of women with abnormal vaginal bleeding in primary care. Among the GPs’ variety of working hypotheses expressed as possible causes of abnormal bleeding, the majority implied ‘no structural pathology’. The agreement between normal sonographic findings and GP’s working hypotheses ‘no structural pathology’ was 50/65. The agreement between sonographic fibroids and the working hypothesis ‘fibroids’ was 14/24. In 23/89 patients, sonography yielded findings suggestive of intracavitary abnormalities. Sonographic findings allowed GPs to carry out actual management, mainly in terms of well-founded watchful waiting or drug therapy in 57/89 patients, and an increased referral rate for 27/89 patients. In a relatively high proportion of patients (23/89), anomalies amenable to hysteroscopic treatment were revealed. In addition, some problems revealed by ultrasonography could be dealt with in primary care, for example, displaced IUCD.
Strength and limitations
For the first time, this study allows an insight into both the underlying pathology and the contribution of sonography to management of women of reproductive age who consult their GPs for abnormal vaginal bleeding. Some limitations of the study need to be addressed here.
First, the question arises as to whether the patients included are representative of those encountered in primary care. The possibility of selection bias in this study, induced by participating GPs who may have included only those patients in whom underlying pathology was suspected, cannot be excluded entirely. However, the patients included in the study seem to reflect a typical general practice population, as only 9/89 of them were initially considered for referral to a gynaecologist. The included patients showed a variety of bleeding patterns, which were very similar to those found in another study performed in general practice by Shapley et al.4 This confirms that the study population reflects normal general practice. Further confirmation of this is provided by Emanuel et al, who found a normal uterine cavity in 63% of patients referred for abnormal uterine bleeding.15 In the present study, a normal uterine cavity was found in 74% (66/89) of patients, a sufficiently higher prevalence than was found in referred patients. In the Netherlands, the proportion of women aged 18–45 years taking oral contraception is much higher (41%]16 than the 16% (14/89) seen in the present study population. This may be explained by the fact that the use of oral contraceptives reduces and probably even prevents the occurrence of heavy and irregular bleeding, thus reducing the probability of its users being entered into the study.17 Compared with the general Dutch population, the present study population contained more patients of non-Western ethnicity. These were mainly black women from Surinam and the Netherlands Antilles, a population well known for its high prevalence of fibroids.18
Secondly, in the Netherlands, gynaecological ultrasound scans are usually done by gynaecologists, as in the present study, rather than by ultrasonographers. Therefore, some effect of inflating the actual referral number cannot be completely ruled out. The participating gynaecologists filled in a standardised sonography form and were instructed to refer the patient back to their GP for further management. In practice, gynaecologists advocate additional diagnostic work-up and removal of intracavitary abnormalities such as submucous fibroids and endometrial polyps.10,19 It might have been difficult for the GP not to refer. On the other hand, all patients contacted their GP for management after the ultrasound scan, and 5/23 patients with intracavitary abnormalities were not referred. The researchers did not ask the GPs to explain the motivation behind their management. Reasons for first-line treatment instead of referral might be mild symptoms, the patient’s preference, or GP-related factors and preferences.20 Since the study was performed, the actual advocated management on abnormal bleeding has not been changed in more recent guidelines in the Netherlands.21
Third, despite vaginal sonography being generally accepted as a useful first-line diagnostic procedure, its accuracy varies depending on the type of uterine abnormality. In diagnosing intracavitary abnormalities in particular, transvaginal sonography is not considered as being the gold standard, but is generally accepted as being the first diagnostic step.10,12,13 Obviously, the diagnostic accuracy of vaginal sonography was beyond the scope of the present study.
Apart from the impact of sonographic findings on GPs’ management of patients, some other important observations were made. A remarkably high number of displaced copper IUCDs was found — in 5/10 patients who had one. Displaced IUCDs are quite common, and apart from causing abnormal bleeding, are thought to be less effective in preventing pregnancies. A recent study reported that displaced copper IUCDs occurred in 29% of patients during an observation period up to 60 months.22 GPs should be aware of partial IUCD expulsion as a cause of abnormal vaginal bleeding, a complication that is easily detected by ultrasonography.
Comparison with existing literature
Some guidelines on abnormal vaginal bleeding recommend initial symptom-based medical treatment without further investigations.5,10 However, more information about normal sonographic findings may confirm the GP’s diagnosis and may imply a solid argument for prescribing medical therapy to well-informed patients in general practice.20,23–25 Sonography is a safe procedure that is well-tolerated by patients.26 Nonetheless, vaginal sonography is an intimate procedure that might cause distress and discomfort for some women. Therefore, adequate information about the procedure is required.27,28
To date, little is known about the cost-effectiveness of diagnostic procedures in patients with abnormal uterine bleeding.29 Julian et al carried out a prospective non-randomised comparative study of a GP-led integrated care pathway and a consultant-led one-stop menstrual clinic for referred patients with menorrhagia.30 After 8 months, there was no difference in treatment between the two groups, except for fewer outpatient appointments in the GP-led care pathway. In the present study, open-access sonography resulted in an increased number of referred patients who, outside this study, would have stayed under primary care. Obviously, some of these women would probably have been referred anyway, albeit at a later stage. The consequences of this change in management in terms of cost-effectiveness deserve further evaluation.
Giving GPs open access to transvaginal sonography revealed the disagreement between their working hypotheses and sonographic findings. The contribution of this study to the management of women with normal scans is that GPs were able to reassure their patients with more confidence. It was also beneficial to those women with findings amenable to gynaecological treatment, who, because of the additional information from sonography, were referred more efficiently and without undue delay. This is especially important for those women with intracavitary abnormalities, amenable for hysteroscopic resection, which cannot be suspected and detected by any other means. In addition, some problems revealed by sonography could be solved in primary care, for example displaced IUCDs.
