9.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

9.2 Key points for audit

• Comparison of diagnosis predicted by hysteroscopy or ultrasound with definitive pathology
• Long term outcomes of false negative investigations
• Acceptability of outpatient procedures and requirements for analgesia
• Occurrence of false reassurance (i.e. cancers found after failure to investigate).

9.3 Recommendations for future research

The following have been identified as important areas requiring further research:

• The epidemiology of different risk categories of women presenting with PMB in primary care and the prognostic significance, if any, of different patterns of bleeding
• Epidemiological and economic modelling of the costs and benefits of adopting different cut-off values for TVUS
• The significance of the recurrence of post-menopausal bleeding following negative investigations and the time interval at which investigations should be repeated if post-menopausal bleeding continues
• The cost-effectiveness of different sequences of investigation
• The extent of inter-observer variation for all diagnostic techniques
• The optimal setting and method for outpatient procedures such as hysteroscopy and endometrial sampling
• The extent and characteristics of incidental findings with transvaginal ultrasonography for post-menopausal bleeding and subsequent costs and benefits to both patients and the NHS.

It is worth emphasising that there is currently a large quantity of poorly conducted research, and that future studies should aim to employ a more rigorous methodology.