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Evaluation of postmenopausal bleeding
868 Letters
1. “True” blood pressure should be the same in the sitting, supine, and lateral positions. The closest that we can normally get to this (i.e., blood pressure measured directly from the radial artery) is in agreement.3 2. Indirect measurement of blood pressure from the uppermost arm in the recumbent lateral position will give a lower value than supine or sitting blood pressure (assumed to be a hydrostatic effect) and should be avoided. 3. Blood pressure measured with the cuff on the dependent arm in the lateral position is close to supine or sitting blood pressure,1, 2 and this arm should be used to allow comparisons with blood pressure performed in other positions. I hope that Goldkrand and Jackson would agree with the first two points and would be grateful if they could present data from their indirect measurements to confirm or refute the third point. S. Michael Kinsella, MD St. Michael’s Hospital, Southwell Street, Bristol, United Kingdom BS2 8EG REFERENCES
1. Kinsella SM, Spencer JAD. Blood pressure measurement in the lateral position. Br J Obstet Gynaecol 1989;96:1110-2. 2. Kinsella SM, Black AMS. Reporting of “hypotension” after epidural analgesia during labour. Effect of choice of arm and timing of baseline readings. Anesthesia 1998;53:131-5. 3. Clark SL, Cotton DB, Pivarnik JM, Lee W, Hankins GDV, Benedetti TJ, et al. Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol 1991;164:883-7.
6/8/89125
Reply To the Editors: I thank Kinsella for the letter. The first premise is correct. Although Kinsella recommends the radial artery, certainly the aortic arch blood pressure is the same in all positions. The radial artery is a close approximation but still subject to its position vis à vis the heart. The second premise is correct. Our data (not published with the article) demonstrated that in each case the arm above the heart had a lower blood pressure (mean arterial pressure [MAP] 78 mm Hg) than the arm below the heart did (MAP 94 mm Hg). There was reasonable concordance of the indirect blood pressure in the sitting versus the supine position, but this correlated better to the lateral position in the lower arm than in the upper arm. This would conform with supposition No. 3 that there is a relationship between these arms. Our data support, or at least approximate what Kinsella has proposed. When we did our direct aortic arch blood pressure measurements, we found that the supine position (MAP 88 mm Hg) correlated well with the MAP in the aortic arch (MAP 80 mm Hg), but in the lateral position it was the mean of both arms (MAP 86 mm Hg) that correlated best with the central blood pressure (MAP 87 mm Hg).
April 1998 Am J Obstet Gynecol
Our study was to determine the true central blood pressure and this correlated best with the mean of the upper and lower arm in the left lateral position, although the MAP in the supine position also correlated well. What has been touted in obstetrics is the use of the left lateral position to improve a patient’s blood pressure. The question of whether this is really physiologically true is not because the physicians have used the upper rather than the dependent arm, but that they have received reassurance that perhaps the patient was better when indeed she was not. John W. Goldkrand, MD Department of Obstetrics and Gynecology, Memorial Medical Center, P.O. Box 23089, Savannah, GA 31403 6/8/89124
Evaluation of postmenopausal bleeding To the Editors: I read with great interest the article by Weber et al. (Weber AM, Belinson JL, Bradley LD, Piedmonte MR. Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. Am J Obstet Gynecol 1997;177:924-9), a comparative cost analysis of the evaluation of postmenopausal bleeding. The conclusion of the authors was that primarily screening with vaginal ultrasonography rather than by performing an office endometrial biopsy was more cost effective. The cost benefit, though, was marginal at approximately $12 per patient. As the proportion of the female population in our society increases, this marginal benefit may have substantial overall savings to society in health care dollars. I believe the authors underestimated the actual cost benefit. The algorithm proposed by Weber et al. assumes that a diagnostic test (both the office endometrial biopsy and vaginal ultrasonographic examination) have 100% sensitivity. The point at which “no further evaluation” is necessary must also include that the “diagnostic test” may be in error and that the underlying problem (hyperplasia or cancer) will continue to be symptomatic and require more evaluation. A corrected algorithm using the authors’ estimates of the results of the testing is presented in Fig. 1. The authors quote multiple sources in the text of their Comment section that 0.8% of women with postmenopausal bleeding with an endometrial thickness ≤4 mm have an endometrial cancer. The literature on the false-negative rate of office endometrial biopsy in postmenopausal women consists mostly of small series. One of the studies referenced by the authors showed that 4% of women with a normal biopsy specimen proved to have hyperplasia.1 Thus, with use of 0.8% and 4% false-negative rates for vaginal ultrasonography and office endometrial biopsy, respectively, the cost-effectiveness can be recalculated. It can be assumed that a patient who has had a normal office endometrial biopsy specimen with continued bleeding would have a hysteroscopy-curettage and
Letters 869
Volume 178, Number 4 Am J Obstet Gynecol
Fig. 1. Corrected algorithm of result of testing. US, Ultrasonography; D&C, curettage.
that a women who had a normal ultrasonography would first have an office biopsy if symptoms persisted, as shown in Fig. 1. If we use the authors’ estimates of costs ($200 for an office endometrial biopsy, $72 for an endovaginal ultrasonography, and $868 for a hysteroscopy-curettage), the total cost of an evaluation with office endometrial biopsy first is $271.20 and vaginal ultrasonography first, $237.60. The cost savings is actually more than twice what the authors originally estimated. If the false-negative rate of the endometrial biopsy was only 1%, the costs would be $252.45 and $224.65, respectively, a savings just slightly more than the authors’ original estimate. These figures do not take into account any extra cost that may be incurred because of any delay in diagnosis and treatment of the underlying disease process.
Additionally, the false-negative rate of the tests may be different when used in combination compared with individually. Further studies will be necessary to evaluate the diagnostic accuracy of the two tests in conjunction. Mitchell D. Creinin, MD Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA 15213-3180 REFERENCE
1. Dijkhuizen FPHLJ, Brolmann HAM, Potters AE, Bongers MY, Heintz APM. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996;87:345-9.
6/8/89972
1. “True” blood pressure should be the same in the sitting, supine, and lateral positions. The closest that we can normally get to this (i.e., blood pressure measured directly from the radial artery) is in agreement.3 2. Indirect measurement of blood pressure from the uppermost arm in the recumbent lateral position will give a lower value than supine or sitting blood pressure (assumed to be a hydrostatic effect) and should be avoided. 3. Blood pressure measured with the cuff on the dependent arm in the lateral position is close to supine or sitting blood pressure,1, 2 and this arm should be used to allow comparisons with blood pressure performed in other positions. I hope that Goldkrand and Jackson would agree with the first two points and would be grateful if they could present data from their indirect measurements to confirm or refute the third point. S. Michael Kinsella, MD St. Michael’s Hospital, Southwell Street, Bristol, United Kingdom BS2 8EG REFERENCES
1. Kinsella SM, Spencer JAD. Blood pressure measurement in the lateral position. Br J Obstet Gynaecol 1989;96:1110-2. 2. Kinsella SM, Black AMS. Reporting of “hypotension” after epidural analgesia during labour. Effect of choice of arm and timing of baseline readings. Anesthesia 1998;53:131-5. 3. Clark SL, Cotton DB, Pivarnik JM, Lee W, Hankins GDV, Benedetti TJ, et al. Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol 1991;164:883-7.
6/8/89125
Reply To the Editors: I thank Kinsella for the letter. The first premise is correct. Although Kinsella recommends the radial artery, certainly the aortic arch blood pressure is the same in all positions. The radial artery is a close approximation but still subject to its position vis à vis the heart. The second premise is correct. Our data (not published with the article) demonstrated that in each case the arm above the heart had a lower blood pressure (mean arterial pressure [MAP] 78 mm Hg) than the arm below the heart did (MAP 94 mm Hg). There was reasonable concordance of the indirect blood pressure in the sitting versus the supine position, but this correlated better to the lateral position in the lower arm than in the upper arm. This would conform with supposition No. 3 that there is a relationship between these arms. Our data support, or at least approximate what Kinsella has proposed. When we did our direct aortic arch blood pressure measurements, we found that the supine position (MAP 88 mm Hg) correlated well with the MAP in the aortic arch (MAP 80 mm Hg), but in the lateral position it was the mean of both arms (MAP 86 mm Hg) that correlated best with the central blood pressure (MAP 87 mm Hg).
April 1998 Am J Obstet Gynecol
Our study was to determine the true central blood pressure and this correlated best with the mean of the upper and lower arm in the left lateral position, although the MAP in the supine position also correlated well. What has been touted in obstetrics is the use of the left lateral position to improve a patient’s blood pressure. The question of whether this is really physiologically true is not because the physicians have used the upper rather than the dependent arm, but that they have received reassurance that perhaps the patient was better when indeed she was not. John W. Goldkrand, MD Department of Obstetrics and Gynecology, Memorial Medical Center, P.O. Box 23089, Savannah, GA 31403 6/8/89124
Evaluation of postmenopausal bleeding To the Editors: I read with great interest the article by Weber et al. (Weber AM, Belinson JL, Bradley LD, Piedmonte MR. Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. Am J Obstet Gynecol 1997;177:924-9), a comparative cost analysis of the evaluation of postmenopausal bleeding. The conclusion of the authors was that primarily screening with vaginal ultrasonography rather than by performing an office endometrial biopsy was more cost effective. The cost benefit, though, was marginal at approximately $12 per patient. As the proportion of the female population in our society increases, this marginal benefit may have substantial overall savings to society in health care dollars. I believe the authors underestimated the actual cost benefit. The algorithm proposed by Weber et al. assumes that a diagnostic test (both the office endometrial biopsy and vaginal ultrasonographic examination) have 100% sensitivity. The point at which “no further evaluation” is necessary must also include that the “diagnostic test” may be in error and that the underlying problem (hyperplasia or cancer) will continue to be symptomatic and require more evaluation. A corrected algorithm using the authors’ estimates of the results of the testing is presented in Fig. 1. The authors quote multiple sources in the text of their Comment section that 0.8% of women with postmenopausal bleeding with an endometrial thickness ≤4 mm have an endometrial cancer. The literature on the false-negative rate of office endometrial biopsy in postmenopausal women consists mostly of small series. One of the studies referenced by the authors showed that 4% of women with a normal biopsy specimen proved to have hyperplasia.1 Thus, with use of 0.8% and 4% false-negative rates for vaginal ultrasonography and office endometrial biopsy, respectively, the cost-effectiveness can be recalculated. It can be assumed that a patient who has had a normal office endometrial biopsy specimen with continued bleeding would have a hysteroscopy-curettage and
Letters 869
Volume 178, Number 4 Am J Obstet Gynecol
Fig. 1. Corrected algorithm of result of testing. US, Ultrasonography; D&C, curettage.
that a women who had a normal ultrasonography would first have an office biopsy if symptoms persisted, as shown in Fig. 1. If we use the authors’ estimates of costs ($200 for an office endometrial biopsy, $72 for an endovaginal ultrasonography, and $868 for a hysteroscopy-curettage), the total cost of an evaluation with office endometrial biopsy first is $271.20 and vaginal ultrasonography first, $237.60. The cost savings is actually more than twice what the authors originally estimated. If the false-negative rate of the endometrial biopsy was only 1%, the costs would be $252.45 and $224.65, respectively, a savings just slightly more than the authors’ original estimate. These figures do not take into account any extra cost that may be incurred because of any delay in diagnosis and treatment of the underlying disease process.
Additionally, the false-negative rate of the tests may be different when used in combination compared with individually. Further studies will be necessary to evaluate the diagnostic accuracy of the two tests in conjunction. Mitchell D. Creinin, MD Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Hospital, 300 Halket St., Pittsburgh, PA 15213-3180 REFERENCE
1. Dijkhuizen FPHLJ, Brolmann HAM, Potters AE, Bongers MY, Heintz APM. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996;87:345-9.
6/8/89972