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Published:December 19, 2016DOI:https://doi.org/10.1016/j.ajog.2016.12.013
      Thank you for raising these comments in your letter to the editor.
      • Giannella L.
      • Paganelli S.
      Abnormal uterine bleeding in premenopausal women and the role of body mass index.
      Although likelihood ratios (LRs) are usually calculated based on the qualities of a diagnostic test and used when deciding whether to order one,
      • Grimes D.A.
      • Schulz K.
      Refining clinical diagnosis with likelihood ratios.
      we understand the temptation to extrapolate the idea of LRs to decision making around risk factors. We accept that LR of 1-2 for body mass index ≥30 kg/m2 only minimally increases the likelihood of having endometrial hyperplasia or cancer in this population (Figure). However, risk factors currently used in the decision to perform endometrial biopsy in premenopausal women with abnormal uterine bleeding include age, irregular menstrual cycle, and infertility; using our data, LRs for these factors are similarly low. We challenge other researchers in this area to continue to develop a greater understanding of risk factors in premenopausal women, to better target invasive diagnostic testing.
      Figure thumbnail gr1
      FigureUsing likelihood ratios to modulate risk of disease
      Wise and Farquhar. Limits to likelihood ratios. Am J Obstet Gynecol 2017.
      With respect to the comment that the risk of atypical hyperplasia is very low (1.3%) and rarely requires biopsy, we note that the population included in that review
      • Pennant M.E.
      • Mehta R.
      • Moody P.
      • et al.
      Premenopausal abnormal uterine bleeding and risk of endometrial cancer.
      was premenopausal women with abnormal bleeding. This is very helpful for primary care practitioners, and fills a gap in the literature. However, in our population of women seen in secondary care, 36% were already taking hormonal medical therapy; the prevalence of disease was 4.9%, and these women at higher risk warrant invasive testing.

      References

        • Giannella L.
        • Paganelli S.
        Abnormal uterine bleeding in premenopausal women and the role of body mass index.
        Am J Obstet Gynecol. 2017; 216: 533
        • Grimes D.A.
        • Schulz K.
        Refining clinical diagnosis with likelihood ratios.
        Lancet. 2005; 365: 1500-1505
        • Pennant M.E.
        • Mehta R.
        • Moody P.
        • et al.
        Premenopausal abnormal uterine bleeding and risk of endometrial cancer.
        BJOG. 2017; 124: 404-411

      Linked Article

      • Abnormal uterine bleeding in premenopausal women and the role of body mass index
        American Journal of Obstetrics & GynecologyVol. 216Issue 5
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          We read with great interest the article by Wise et al1 comparing the incidence of complex endometrial hyperplasia (EH) or cancer in premenopausal women with abnormal uterine bleeding and body mass index (BMI) ≥30 vs <30 kg/m2. They showed that a BMI ≥30 strongly associated with EH or cancer, and concluded that “BMI should be the first stratification in the decision to perform endometrial biopsy.”1
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