***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A study was conducted to compare transvaginal ultrasound ( TVS ) , saline infusion sonography ( SIS ) and outpatient hysteroscopy for examining the uterine cavity in women with postmenopausal bleeding and unscheduled bleeding on hormone replacement therapy ( HRT ) . Fourty Subjects agreed to undergo TVS , SIS and hysteroscopy in addition to endometrial sampling . The abnormalities detected by each imaging method were recorded together with the discomfort ( visual analogue scale ) . Thirty women completed all three imaging procedures . In 18 cases TVS suggested an abnormal cavity .  SIS  and  hysteroscopy  were of similar efficacy in clarifying the nature of this , and confirmed an abnormality in 12 cases ( 40 % ) . TVS was significantly less painful than the other procedures ( p < 0.001 ) .  SIS and hysteroscopy were associated with pain scores similar to endometrial sampling . These findings justify the need for a large r and omised trial of TVS , SIS , hysteroscopy and endometrial sampling , in order to develop the most appropriate strategy for investigating postmenopausal bleeding and unscheduled bleeding on HRT Women with postmenopausal bleeding should be evaluated efficiently to exclude endometrial carcinoma Objective . To develop and test a risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women at risk of intrauterine malignancy . Methods . We prospect ively studied 624 postmenopausal women with vaginal bleeding and endometrial thickness > 4 mm undergoing diagnostic hysteroscopy .  Patient characteristics and endometrial assessment of women with or without endometrial cancer were compared . Then , a risk-scoring model , including the best predictors of endometrial cancer , was tested . Univariate , multivariate , and ROC curve analysis were performed . Finally , a split-sampling internal validation was also performed . Results . The best predictors of endometrial cancer were recurrent vaginal bleeding ( odds ratio ( OR ) = 2.96 ) , the presence of hypertension ( OR = 2.01 ) endometrial thickness > 8 mm ( OR = 1.31 ) , and age > 65 years ( OR = 1.11 ) . These variables were used to create a risk-scoring model ( RHEA risk-model ) for the prediction of intrauterine malignancy , with an area under the curve of 0.878 ( 95 % CI 0.842 to 0.908 ; P < 0.0001 ) . At the best cut-off value ( score ≥ 4 ) , sensitivity and specificity were 87.5 % and 80.1 % , respectively . Conclusion . Among symptomatic postmenopausal women with endometrial thickness > 4 mm , a risk-scoring model including patient characteristics and endometrial thickness showed a moderate diagnostic accuracy in discriminating women with or without endometrial cancer . Based on this model , a decision algorithm was developed for the management of such a population We conducted this study to test the hypothesis that transvaginal ultrasonography and color Doppler imaging of the uterine arteries are complementary methods in the assessment of patients with postmenopausal bleeding . Sixty-seven patients were studied . Seventeen suffered from endometrial carcinoma , 12 from benign endometrial lesions ( six polyp , six hyperplasia ) and 38 had no organic pathology .  Transvaginal ultrasonography was found to be superior to CDI in the detection of pathologic conditions of the endometrium , but neither method can distinguish benign lesions from their malignant counterparts . CDI does not give additional information over that obtained by transvaginal ultrasonography in the assessment of patients with postmenopausal bleeding , and the limitations of both methods in the differentiation of endometrial carcinoma from benign lesions need to be recognized In this prospect i ve study , 139 patients , 83 premenopausal patients with abnormal uterine bleeding and 56 postmenopausal patients either with metrorrhagia ( 33 ) or a suspect sonographic finding ( 23 ) , were examined preoperatively with transvaginal sonography ( TVS ) and saline contrast hysterosonography ( SCHS ) . The histological results , obtained by hysteroscopy , were compared with the preoperative findings . Uterine pathology ( benign polyps , submucous fibroids , endometrial hyperplasia and carcinoma ) was found in 74.7 % and 76.8 % of the pre- and postmenopausal patients , respectively . TVS and  SCHS  are very sensitive at diagnosing uterine pathology , the latter being more specific and enabling better surgical management and a reduction in unnecessary interventions OBJECTIVE To evaluate the role of one-stop clinic for early diagnosis and management of women with postmenopausal bleeding by means of transvaginal ultrasonography , outpatient hysteroscopy and endometrial biopsy . STUDY DESIGN A prospect i ve analysis was performed on 522 women with postmenopausal bleeding who were referred directly to the gynecology outpatient clinic for evaluation of postmenopausal bleeding . Endometrial thickness of 6 mm , as measured by a transvaginal scan , was considered the cutoff limit for further investigation by hysteroscopy and endometrial biopsy . RESULTS One hundred ninety-one women were using hormone replacement therapy . Thirty-two were taking tamoxifen .  Outpatient  hysteroscpoy  was performed in 157 ( 71.3 % ) cases . Thirty-seven ( 16.8 % ) cases had general anesthesia for hysteroscopy . Twenty-four ( 11 % ) cases had only an endometrial sample obtained . Twenty-one cases of endometrial carcinoma , 20 of endometrial hyperplasia , 4 of cervical carcinoma and 5 of other genital tract malignancies along with several benign pathologies , including submucosal myomas , were detected . Seven ( 2.3 % ) cases of endometrial thickness below the cutoff limit had recurrent bleeding due to benign conditions . CONCLUSION A one-stop clinic is effective for early diagnosis of genital tract malignancy in a majority of patients with postmenopausal bleeding and significantly help in reducing the hospital waiting list PURPOSE To assess the accuracy of hysterosonography ( HSG ) and its role in diagnostic confidence and therapeutic clinical decision making among referring physicians caring for patients with postmenopausal bleeding ( PMB ) . MATERIAL S AND METHODS One hundred twenty-three patients with PMB underwent transvaginal ultrasonography ( US ) and HSG .  They were examined for cancer , polyp , leiomyoma , and hyperplasia . Physicians assessed the effect of the studies on diagnostic confidence and care , including  biopsy , dilation and curettage , hysteroscopy , hormone manipulation , and /or patient reassurance .  Abnormality was proved with histopathologic evaluation , and normality , with 6-month follow-up . RESULTS In 10 patients , HSG was unsuccessful , and in 15 , follow-up was incomplete ; this left 98 patients .  Endometrial polyps were seen in 46 ( 47 % ) patients ; leiomyoma , in 11 ( 11 % ) ; cancer , in four ( 4 % ) ; hyperplasia , in eight ( 8 % ) ; and normal findings , in 29 ( 30 % ) . Our calculations yielded a sensitivity of 98 % and a specificity of 88 % . In 86 ( 88 % ) patients , US added certainty to the diagnosis ; in 78 ( 80 % ) , it result ed in a change in patient treatment . CONCLUSION HSG and transvaginal US in patients with PMB improves diagnostic accuracy , clinical decision making , and the clinician 's diagnostic certainty . In patients with benign causes of PMB , the absence of abnormality at HSG and a normal endometrial biopsy result may eliminate the need for further studies OBJECTIVE The purpose of this study was to use transvaginal ultrasonographic measurements to find the thickness of the endometrium below which the risk of endometrial abnormality in women with postmenopausal bleeding is low . STUDY DESIGN This multicenter study was carried out at eight clinics in four Nordic countries . The study included 1168 women with postmenopausal bleeding scheduled for curettage Before the curettage was performed  , the thickness of the endometrium was measured with transvaginal ultrasonography . The measurement included both endometrial layers ( double-layer technique ) . The transvaginal ultrasonographic measurement was compared with the histopathologic diagnosis of the curettage specimens . RESULTS In women with atrophic endometrium the mean endometrial thickness ( + /- SD ) was 3.9 + /- 2.5 mm . The corresponding figures for women with endometrial cancer were 21.1 + /- 11.8 mm . No malignant endometrium was thinner than 5 mm . In 30 women ( 2.8 % ) it was not possible to measure the thickness of the endometrium ; one of these women had endometrial cancer . The 95 % confidence limit for the probability of excluding endometrial abnormality was 5.5 % when the endometrial thickness was < or = 4 mm as measured by transvaginal ultrasonography . CONCLUSION The risk of finding pathologic endometrium at curettage when the endometrium is < or = 4 mm as measured by transvaginal ultrasonography is 5.5 % . Thus in women with postmenopausal bleeding and an endometrium < or = 4 mm it would seem justified to refrain from curettage OBJECTIVE This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was < /=4 mm in women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy . STUDY DESIGN Transvaginal ultrasonography was performed in 361 women aged > /=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy .  If endometrial thickness was < /=4 mm , a Papanicolaou cervical smear was performed and the woman was reexamined with transvaginal ultrasonography after 4 and 12 months . Subjects were also instructed to return if they had recurrent bleeding , in which case transvaginal ultrasonography was performed and an endometrial biopsy specimen was obtained . Women with an endometrial thickness > /=5 mm underwent either curettage or endometrial biopsy . RESULTS One hundred sixty-three women had an endometrial thickness < /=4 mm . In this group one endometrial cancer that was missed by ultrasonography was diagnosed by cervical cytologic examination and two adnexal malignancies were diagnosed by ultrasonography . Endometrial malignancy was diagnosed in 0.6 % of the women with an endometrial thickness < /=4 mm . Endometrial biopsy was performed because of recurrent bleeding in 6.1 % of cases and because of endometrial thickening in 8.1 % . No cancer or hyperplasia was subsequently diagnosed among the women with an endometrial thickness < /=4 mm . Endometrial cancer was diagnosed in 18.7 % of the women with an endometrial thickness > /=5 mm . The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20 . 2 % . CONCLUSION If the false-negative rate of endometrial biopsy techniques is taken into account , then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is < /=4 mm . A r and omized prospect i ve study is necessary to verify this finding Background Abnormal uterine bleeding ( AUB ) is one of the most common debilitating menstrual problems and has remained one of the most frequent indications for hysterectomy in developing countries . Approximately in 40 % of hysterectomy specimens , no definite organic pathology could be established . The problem is common worldwide but causes may vary from one region to another . This study may help gynecologists in our population to improve their therapeutic strategies by promoting minimally invasive uterus sparing modalities such as endometrial ablation and hysteroscopic resection of early proliferative lesions . Methods It was a prospect i ve , cross-sectional study conducted at Liaquat National Hospital from 15th January 2010 till 14th July 2011 over a period of 18 months . Women who underwent dilatation and curettage for endometrial sampling with complaints of AUB were included in the study and histopathologic spectrum was determined . Results Polymenorrhea was the most common presenting pattern ( 30 % , 72/241 ) with reproductive age women being the most susceptible ( 49.3%,119/241 ) . The commonest histopathological spectrum was normal menstrual pattern ( 34 % , 82/241 ) and the commonest pathology was hormonal imbalance ( 27 % , 65/241 ) , followed by endometrial polyp ( 14 % , 34/241 ) , chronic endometritis ( 12 % , 28/241 ) , atrophic endometrium ( 6 % , 15/241 ) , endometrial hyperplasia ( 5 % , 12/241 ) , and endometrial carcinoma ( 2 % , 5/241 ) . Chronic endometritis was commonly seen in reproductive age ( 18 % , 21/119 ) ; h 
    Output:
    
Conclusions and Relevance Early detection strategies focused on women with PMB have the potential to capture as many as 90 % of endometrial cancers ; however , most women with PMB will not be diagnosed with endometrial cancer .