POGS CPG Abnormal Uterine Bleedine

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These have been developed following the consensus meeting of clinicians and scientists in Washington1. frequency. frequency. based primarily on the independent WHO analysis2. DEFINITION OF TERMS Statement 1 Abnormal uterine bleeding (AUB) encompasses any significant deviation from normal frequency. and also on other published population data3-6. Fraser IS (2007) What do we mean by abnormal uterine bleeding and dysfunctional uterine bleeding? Gynecol Forum 12:2. C) (Modified from the Consensus Meeting of Clinicians and Scientists (2007) by Frasier IS. Munro MG.0 4. duration and volume or amount) are outlined below. (III. intermenstrual bleeding. 3-5.) Clinical Dimensions of Menstruation Descriptive and Menstrual Cycle Terms Frequency of menses (days) Frequent Normal Infrequent Regularity of menses (cycle to cycle Absent variation over 12 months.0 < 4. regularity. Broder M.I. References: d" . premenarcheal or postmenopausal bleeding. C) Reference: 1. Critchley HOD. heavy or light menstrual periods. Statement 2 The normal limits for the four main clinical dimensions of menstruation and the menstrual cycle (regularity. heaviness (volume or amount) and duration of menstrual bleeding. Hum Reprod. duration and flow) are set on the basis of medians and 95% confidence intervals. irregular menstrual cycles. in days) Regular Irregular Duration of flow (days) Prolonged Normal Shortened Volume of monthly blood loss (ml) Heavy Normal Light Normal Limits (5th-95th percentiles) < 24 24-38 > 38 Variation of 2 to 20 days Variation > 20 days > 8. AUB may include short or long (but regular) menstrual cycles. 1-9.5-8. It is used to describe all abnormal menstrual signs and symptoms arising from the uterine corpus. with or without any recognizable pathology.5 > 80 5-80 <5 Supporting Statements: Suggested normal limits for the four main clinical dimensions of menstruation and the menstrual cycle (regularity. Based on these limits. Normal limits for menstrual parameters in the mid-reproductive years (III. 5. It is a term used when the disorder involves primarily the endometrial molecular mechanisms (ovulatory DUB) or the hypothalamic-pituitary-ovarian axis (anovulatory DUB). C) Supporting Statements: The most common clinically significant disturbance in uterine bleeding is abnormally heavy bleeding. Critchley HOD. London: RCOG Press. Disorders of the menstrual cycle. Frasier IS. Cameron IT and Maclean AB (eds). be abandoned1-2. 57-65. Thus. Munro MG. (GPP) Supporting Statements: DUB is commonly used to describe abnormally heavy or irregular bleeding without recognizable organic pathology1-2. It is usually used to describe a symptom. In: O’Brien PMS. prolonged and/or heavy bleeding. London: RCOG Press. 141-52. Nilsson L and Rybo G (1966) Menstrual blood loss: a population study. In: O’Brien PMS. (III. The term menorrhagia is used to describe such heavy bleeding. 1-9. Treloar AE.3 e" . 320-351. p. 77-126. but some clinicians use it as a diagnosis. Behn BG and Brown BW (1967) Variation of the human menstrual cycle through reproductive life.339. Ovulatory DUB is described as having regular cycles with heavy bleeding. Munro MG. Statement 4 Dysfunctional uterine bleeding (DUB) is defined as excessive bleeding of uterine origin that is not due to complications of pregnancy or to any systemic or local pelvic pathology. Cameron IT and Maclean AB (eds). DUB usually connotes anovulatory cycles. Boynton RE. Contraception 55. it is recommended that this term. Fraser IS and Inceboz US (2000) Defining disturbances of the menstrual cycle. 141-52. Hogdahl AM. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation (1997) Menstrual bleeding patterns in untreated women. National Institute for Health and Clinical Excellence (NICE). 2. Heavy menstrual bleeding (2007). Statement 3 It is recommended that the term menorrhagia be discarded and replaced by the term “heavy menstrual bleeding”. London. 3. Frasier IS. It has been used as a diagnosis of exclusion. Snowden R and Christian B (eds) (1983) Patterns and Perceptions of Menstruation (A World Health Organization international study). metrorrhagia and menometrorrhagia. 3. anovulatory DUB is characterized by irregular.1. The current popular term for heavy menstruation is heavy menstrual bleeding3. Acta Obstet Gynecol Scand 45. DUB is further differentiated into ovulatory and anovulatory DUB. Int J Fertil 12. Critchley HOD. Croom Helm. Fraser IS and Inceboz US (2000) Defining disturbances of the menstrual cycle. On the other hand. while in USA. References: 1. Disorders of the menstrual cycle. but its exact use is variable. 4. 2. Hallberg L. along with other terms such as hypermenorrhea. Belsey EM and Pinol AP. 6. In Europe. Broder M (2007) Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. 1-9. Broder M (2007) Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. 1.2. diagnoses) • “old DUB” includes the following – coagulopathies (congenital and acquired). Munro MG. FIGO 2009 Congress Interactive Session on AUB. Statement 5 AUB includes both DUB and bleeding from organic causes. 2. Fraser IS et al. In: Shearman RP. Hum Reprod 5: 637-8. 2. Crosignani PG and Rubin B (1990) Dysfunctional uterine bleeding.5 It occurs more frequently in anovulatory women. South Africa. J Am Board Fam Med. 578-98. Cape Town International Convention Center. Edinburgh: Churchill Livingstone. Fraser IS (1985) The dysfunctional uterus. Kennedy CM. References: 1. 6 October 2009. inflammation. vasoactive regulators) The Technical Working Group for the POGS 2009 Clinical Practice Guidelines on Abnormal Uterine Bleeding concurs with the FIGO recommendation. SA Fam Pract 49(8): 32-33. 19: 590-602. Ely JW.The recent FIGO 2009 Congress recommended that the term DUB should be discarded. Textbook of clinical reproductive endocrinology. 3. f" .3. Clark EC and Bowdler NC (2006) Abnormal uterine bleeding: a management algorithm. References: 1. 3-5. The justifications for abolishing the term ‘DUB’ are as follows4: • A diagnosis of exclusion and admission of our ignorance about local mechanisms • Terminology used very differently in different countries (symptoms. disturbances of local hemostasis. Statement 6 Acute AUB is characterized by significant blood loss that results in hypovolemia (hypotension or tachycardia) or shock.dysmenorrhea and dysfunctional uterine bleeding. signs. 4. (III. emergency and operating room resources. References: 1. Acute uterine bleeding unrelated to pregnancy. Lindeque BG (2007) Clinical approach to a patient with abnormal uterine bleeding. 12(2): 1114. the etiology is described as organic. (GPP) Supporting Statements: Acute uterine bleeding ranges from modestly heavy menstrual bleeding to excessively heavy bleeding associated with hypovolemic shock. ovulatory disorders and endometrial dysfunction (infection. Gynaecol Forum 2007. Fraser IS (2007) What do we mean by abnormal uterine bleeding and dysfunctional uterine bleeding? Gynecol Forum 12:2. C) Supporting Statements: When AUB is due to systemic causes or disorders of the reproductive tract.4 Acute uterine bleeding requires urgent or emergent medical intervention that more often leads to frequent use of urgent care. ed. The absence of organic pathology makes the cause of bleeding as dysfunctional1-2. 75: 127-32. Speroff L. and/or frequency and has been present for the majority of the last six (6) months. 4.499. FIGO 2009 Congress Interactive Session on AUB. J Clin Endocrinol Metab 1992. Fraser IS et al. South Africa.575-9. regularity. or all of these factors may result in heavier menstruation. Casey ML. South Africa. Glass RH. Organic Causes a. Reproductive Tract Disease i. (GPP) References: 1. Baltimore: Lippincott Williams & Wilkins 1999. Cape Town International Convention Center. 6 October 2009. Abnormal Uterine Bleeding (AUB) Etiology of Abnormal Uterine Bleeding 1. Non-pregnancy related genital lesions (benign or malignant pelvic lesions) M" . Fraser IS. 6th ed. Mechanisms of abnormal uterine bleeding. Livingston M. Word RA. The absence of any. Hum Reprod Update 2002. volume. Pregnancy related complication • Pregnancy is the first consideration in women of reproductive age who present with AUB. Kamm KE. PATHOPHYSIOLOGY A. Cape Town International Convention Center. Potential causes of pregnancy-related bleeding include: o spontaneous pregnancy loss o ectopic pregnancy o placenta previa o abruptio placentae o hydatidiform mole o choriocarcinoma ii. 21-38. and 3) stabilization of the hemostatic platelet plug. 5. that is abnormal in duration. 3. 8: 60-7. Contractile effects of prostaglandins. oxytocin. Kase NG. Normal Menstruation: • Factors that come into play for hemostasis: 1) a higher thromboxane level (PGF2) in relation to prostacyclin (PGE2 ) 2) fibrin clot formation.2. II. Clinical gynecologic endocrinology and infertility. Statement 7 Chronic AUB is bleeding from the uterine corpus. Fraser IS et al. 6 October 2009. FIGO 2009 Congress Interactive Session on AUB. and endothelin-1 in human myometrium in vitro: refractoriness of myometrial tissue of pregnant women to prostaglandins E2 and F2 alpha. B. despite their rare occurrence. • Endometrial polyps are found in all age groups. usually implies an anatomic lesion rather than an endocrine disorder. fragile vessels on their surfaces. contribute to the problem of AUB and should therefore be included in the differential diagnosis of women with acute. Bleeding from these large-caliber vessels during menstruation cannot be stopped promptly by myometrial contractions because of their intracavitary position. • The abnormal bleeding associated with submucous myomas typically begins as prolonged menses. . or postmenopausal bleeding and may be associated with dysmenorrhea. intermenstrual. but the precise mechanisms by which they increase bleeding are poorly understood. several hypotheses have been introduced and these include: o an increased endometrial surface o altered PGE/PGF ! balance o hampered myometrial contractility o abnormal myometrial angionesis associated with fragile blood vessels. • Myomas and polyps are widely recognized structural abnormalities causing abnormal uterine bleeding. heavy menstrual bleeding. with large. which indicates ovulation. • Arteriovenous malformations. which may be sufficiently severe to cause anemia. but mostly in older women. polyps or hyperplasia o Chronic cervicitis o Cervical polyps & carcinomas o Vaginal carcinoma o Functional ovarian cysts or neoplasms • Bleeding from a secretory endometrium. It has been suggested that myoma-related AUB may result from: o an increased surface area of the endometrium due to mechanical distortion o ulceration and hemorrhage of endometrium overlying the submucous fibroids o interference by the myomas with normal uterine hemostasis o mechanical compression of the venous drainage by the myomas at any site. although ovulatory bleeding may occasionally produce minimal midcyclic bleeding in the absence of an organic lesion. and may also present as heavy menstrual. • The association of adenomyosis with AUB is controversial and remains unclear. and o dilatation of the venous plexuses draining the endometrium • Submucous myomas are highly vascularized. However.W!" • Non-pregnancy related genital causes include: o Myomas o Endometrial carcinoma. and abnormal factor VIII activity. premature ovarian failure. A meta-analysis of high-quality epidemiological prevalence studies indicated a 13% prevalence rate of the biochemical markers of von Willebrand disease among women with heavy menstruation. Hyperthyroidism. and other anatomic causes must be ruled out): o Blood dyscrasias o Thrombocytopenia o Deficient clotting factors o Thyroid dysfunction o Hepatic dysfunction o Renal dysfunction • AUB. • Renal or liver diseases may also result in abnormal uterine bleeding. and androgen excess. metabolic. digitalis. dilantin and/or IUD may manifest with AUB. Systemic Disease • Non-pregnancy-related systemic disorders (i. hypothalamic dysfunction. However. and may result from an inconsistent use. particularly Chlamydia trachomatis infection should likewise be considered among women who presents with irregular bleeding and post-coital spotting. Coagulopathies also may occur with liver disease. neoplasms. Dysfunctional (or Endocrinologic) Causes (anovulatory or ovulatory dysfunctional uterine bleeding) WW" . • Diabetes mellitus can be associated with anovulation. c. as a “breakthrough” bleeding especially during the first few months of hormonal contraceptive use. insulin resistance. Women with liver disease may have higher circulating levels of estrogen due to hepatic dysfunction and an inability to metabolize estrogen. anticoagulants. may be suggestive of an inherited systemic disorder of hemostasis. not all bleeding that occurs in this group of women can be attributed to hormonal contraceptive use. particularly in premenarcheal girls. platelet dysfunction. tranquilizers. • Women on chronic use of steroids. and increases the likelihood of abnormal uterine bleeding. or.• Genital tract infections. b. associated with amenorrhea and rarely result in heavy bleeding. 2. Iatrogenic • AUB among women on contraceptive hormones are usually manifested as irregular bleeding. while renal failure is associated with irregularities of the HPO axis due to gonadal resistance to hormones.e. hyperprolactinemia. obesity. most often than not. and primary pituitary disease are. more commonly. • AUB is likewise associated with hypothyroidism. organic. Obstetrics and Gynecology the clinical core. PA: Lea & Febiger. The bleeding is caused by estrogenic overstimulation followed by withdrawal or diminution of estrogen. Abnormal Uterine Bleeding. Wynn RM. unopposed by progesterone. • High sustained levels of estrogen result in episodes of amenorrhea followed by acute heavy bleeding. • Prolonged DUB may result from a persistent graafian follicle.1 . No. Albers JR. It is most common after the menarche or just before the menopause. • Abnormal uterine bleeding may reflect a disordered regulation of endometrial gene expression. 3. III. 4. 2: 6-8. 69:1915-26. Hickey M. Garefalakis M. 5th ed. Gynaecology Forum 2007 Vol. Present understanding of abnormal uterine bleeding mechanisms. 12. Gynaecology Forum 2007 Vol. 12. No. explanations on many of the cellular and molecular alterations in endometrial pathologies remain to be elusive and have yet to be fully elucidated. 6. 1931-2. No. • Despite a wealth of studies on this very common clinical entity. • In perimenopause. Berek JS. 12. Philadelphia. Am Fam Physician 2004. 2: 11-14. Wesley MA. Acute uterine bleeding unrelated to pregnancy.• Dysfunctional uterine bleeding (DUB) is usually anovulatory and is associated with a non-secretory endometrium. Gynaecology Forum 2007 Vol. the decline of inhibin and rise in follicle-stimulating hormone (FSH) levels reflect the loss of follicular activity and competence. References: 1. the HPO axis has not yet developed the necessary hormonal feedback to sustain the endometrium. withdrawal of estrogen leads to a delayed endometrial shedding and irregular bleeding. The role of disorders of hemostasis and abnormal uterine bleeding. Huli SK. In such cases. Healing within the endometrium is irregular and dyssynchronous. 2007. Munro MG. Berek & Novak’s Gynecology. Lukes AS. EPIDEMIOLOGY • WL" Abnormalities in menstruation are a common cause of general practice consultations with considerable health-service resources devoted to their management. 14th ed. 2: 14-19. • In puberty. 5. 1992. but it may occur at other times as well. PA: Lippincott Williams & Wilkins. 2. Philadelphia. A family history of menorrhagia was documented in 38% of girls and more than 50% of them suffered from heavy periods themselves.3 • Women with heavier periods are 72% as likely to be working as women who have normal flow. Menstrual abnormalities.6).8 • Anovulation (46%) was the predominant cause of admission for adolescent menorrhagia. followed by hematological disease (33%) and unfortunately.4% of participants (95% CI 31.4–2. and work loss secondary to heavy periods has been estimated to cost $1692 per woman annually. have significant economic implications.6.92 times higher in women with menorrhagia (95% CI 1.4%) with the incidence of dysmenorrhea being 1.7 years found that nearly 37% of girls experienced menorrhagia and onefifth of them were being treated with drugs for this condition. especially heavy periods.9 • A Nepal survey of 96 school girls with an age range of 11–17 years.13 • Menstrual irregularities are more common in female athletes and in those who begin training prior to menarche (43%).2% of girls.W]" • Women who report one or more menstrual symptoms have significantly lower health status and quality of life compared with women reporting no menstrual symptoms.4 • The 12-month cumulative incidence of AUB are as follows5: o Menorrhagia 25% (95% CI 22–29%) o Metrorrhagia 29% (95% CI 26–32%) o Oligomenorrhea 15% (95% CI 13–18%) o Intermenstrual bleeding 17% (95% CI 14–19%) o Postcoital bleeding 6% (95% CI 5–8%) • The modern-day definition of menorrhagia is a blood loss of > 80 ml but it is of limited clinical usefulness since the diagnosis and treatment of patients appears to be unrelated to the volume of blood loss. Nearly 10% of girls gave a history of hypomenorrhea and 6.7 • Menstrual problems are common during adolescence due to a relatively immature hypothalamo-pituitary-ovarian (HPO) axis leading to anovulation.10 • A population-based survey of 1019 Swedish girls with a mean age of 16.11 • A postal survey of 4610 women (aged 25–44 years) in Scotland found that 30–35% of women reported menorrhagia. nearly 63% of adolescents required blood transfusion in view of severe anemia. Subjective judgment of the volume lost in combination with clinical features can predict a loss of > 80 ml. moderate-to-severe dysmenorrhea was reported in 33.12 • In a cross-sectional survey of 2262 women of reproductive age (18–45 years).9% had oligomenorrhiec cycles. menorrhagia was identified in 6.4–35. AUB in athletes has . Jacobs P & Cumming D. 10. 11: 13–15. Abnormal uterine bleeding in adolescents. Critchley HO. 48:186–191.14 References 1. Physical Examination 3. 8. Smith YR. Menorrhagia in adolescents requiring hospitalization. Lumsden MA et al. Orno AK. 100: 683–687. 5. Patel V. 4. DIAGNOSIS Diagnosis of Heavy Menstrual Bleeding 1. 12: 911–919. 3. 190: 1224–1229. Lindgren A et al. Skinner KM et al. J Midwifery Womens Health 2003. 85: 200–206. and outcome in women with heavy periods: a survey with follow-up data. Menstrual pattern and abnormalities in the high school girls of Dharan: a cross sectional study in two boarding schools. Jordan K & Croft PR. Warner PE. Bleeding disorders among young women: a population-based prevalence study. Lumsden MA et al. Coulter A. Br J Gen Pract 2004. 6. J Womens Health (Larchmt) 2003. Blood Tests 4. 93: 979–985. Imaging Procedures Statement 1 Wa" . Toriola AL & Mathur DN. Health status among women with menstrual symptoms. McPherson K & Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988. clinical features. 2. Cote I. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol 2004. Warner PE. Am J Obstet Gynecol 2004. Obstet Gynecol 2002. 7. 13. Ball-game players (35%) and distance runners (51%) most commonly experience oligomenorrhea or amenorrhea. Menstrual dysfunction in Nigerian athletes. 11. The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa. Frayne SM. Acta Obstet Gynecol Scand 2006. Sharma M & Gupta S. India. 12.significant associations with low body fat and weight and the stress of sports activity. Quint EH & Smith YR. Tanksale V. Shapley M. History 2. 113: 453–463. An epidemiological survey of symptoms of menstrual loss in the community. Warner P & Wyke S. Menorrhagia I: measured blood loss. Friberg B. 9. Quint EH & Hertzberg RB. Barnard K. J Clin Epidemiol 2005. 5: 34–36. Br J Obstet Gynaecol 1986. Santer M. whereas swimmers (37%) and sprinters (41%) experience dysmenorrhea and menorrhagia. Nepal Med Coll J 2003. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. Critchley HO. 190: 1216–1223. Work loss associated with increased menstrual loss in the United States. Sahasrabhojanee M et al. 27: 987–994. 58: 1206–1210. 54: 359–363. J Pediatr Adolesc Gynecol 1998. Br J Obstet Gynaecol 2006. IV. 8 References Wg" . amount. C) Supporting Statements: General survey should include assessment for anemia. pelvic tenderness and adnexal masses. 2000.7 but should not be part of routine investigation. family history. Pregnancy must always be excluded. Penny GC. Chapter 16. The investigation of menorrhagia. In: Disorders of the Menstrual Cycle. C) Supporting Statements: The clinical history should focus on the probable causes of abnormal menstrual bleeding by determining the interval. Mohan S. Abdominal palpation may detect an enlarged uterus.1 Risk factors for endometrial carcinoma should be sought. References 1. thyroid disease and coagulopathies. (III.A detailed history should be obtained. London: RCOG Press. Heavy menstrual bleeding. C) Supporting Statements: A full blood count should be obtained to identify women with anemia.2 References 1. Family history should investigate risks for cancer. and other medical conditions that can cause abnormal uterine bleeding. Five epidemiological studies showed that anemia is an associated problem for women with HMB. 12(2): 8-10. as well as presence of co-morbid factors. coagulopathies. frequency. Iron supplements should be prescribed as needed. Clinical guideline. Higham JM. Page LM. Bimanual examination will allow assessment of the uterine size. with iron deficiency becoming a clinical problem at a menstrual blood loss of 60–80 ml. pelvic pain and/or pressure symptoms. How do we assess abnormal uterine bleeding? Gynaecology Forum 2007. 24 January 2007. and duration of bleeding. contraceptive history. 2007. 2. Statement 3 A complete blood count should be obtained from all women with abnormal uterine bleeding. vagina and cervix is essential to exclude any gross pathology. National Institute for Health and Clinical Excellence. (III. which should include inquiry into the character and nature of bleeding. (III. related symptoms that may implicate a structural or histologic abnormality.6 Serum ferritin level may be useful if there is any doubt on iron deficiency.1-5 These studies show that MBL and iron-deficiency anemia are linked. National Collaborating Centre for Women’s and Children’s Health. London: RCOG press.1 Pelvic examination to inspect the vulva. Statement 2 Physical examination should be performed to identify any structural pathology or systemic disease as the etiology for abnormal uterine bleeding. suggest structural or histologic abnormality. Symptoms such as intermenstrual or postcoital bleeding. 8. Kouides PA. Souza JP. Fertil Steril 2005. Variation at different ages and attempts to define normality. 1999.1-2 One case–control study (n = 428) found no link between thyroid disorders and menstrual disturbances.277(12):973–6. Menstrual blood loss--a population study. Br J Obstet Gynaecol 2004. et al. A review of 11 studies (988 women) on the prevalence of Von Willebrand disease in women with HMB showed that the prevalence in individual studies ranged from 5% to 24%. Reconsidering menorrhagia in gynecological practice. 2007. Gao J. 7. 24 January 2007. Gynecology. Heintz AP.5%) had irregular cycles. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. 196 (91. Clinical guideline. Menstrual blood loss and body iron stores in Brazilian women. matched for age and weight. Royal College of Obstetricians and Gynaecologists. C Supporting Statements: Epidemiological studies have found no link between hormone levels and heavy menstrual bleeding. Shaw ST Jr. 3. (III. and have personal or family history suggestive of a coagulopathy.2 References 1. C) Supporting Statements: Universal screening for coagulation disorders in women with HMB is not costeffective. et al. Statement 4 Coagulation tests may be considered only in women with HMB at an early age (since menarche). Fraser IS. Of the 214 women with thyroid disorders. et al. 168 (78.0-15. 2. Dallman PR. Von Willebrand disease in women with menorrhagia: a systematic review. Scholten PC. Looker AC. Hogdahl AM. LH. Menstrual blood loss and hematologic indices in healthy Chinese women.6%) had normal menstruation and 18 (8.5%) had regular menstrual cycles and 46 (21. postpartum hemorrhage. 4. Janssen CA. 43(3):241–9. 101(supplement 11): 3–7. JAMA: the journal of the American Medical Association 1997.45(3):320–51. Shankar M. and/or bleeding associated with dental work. Peyvandi F. 84: 1345-51. Lee CA. Any one of the following aspects in the history taking should prompt the clinician to work-up the woman for a coagulation disorder: HMB since menarche. London: RCOG.6). with an overall prevalence rate of 13% (95% CI 11.3 Wd" . Sabin CA. et al. London: RCOG Press. National Collaborating Centre for Women’s and Children’s Health. The Management of Menorrhagia in Secondary Care. Journal of Reproductive Medicine 1987. National Evidence Based Clinical Guideline No 5. et al. Zeng S. and Reproductive Biology 1998. Carroll MD.32(11):822–6. surgery-related bleeding. Contraception 1991.4%) had irregular cycles.1. Prevalence of iron deficiency in the United States. 6.1 A personal and family history of bleeding symptoms is a valid reason for investigation. Br J Obstet Gynaecol 1994. National Institute for Health and Clinical Excellence. Out of 214 normal controls. 3 III. Andrade AT. Menorrhagia – a pragmatic approach to the understanding of causes and the need for investigations. Thyroid screening should only be obtained in the presence of signs and/or symptoms of thyroid disease. Statement 5 Female hormone testing (estradiol. Sun BL.78(1):69–72. Heavy menstrual bleeding. et al. 111: 734-40. Nilsson L. progesterone. FSH) should not be routinely done on women with HMB. 2. Is a 30-year-old definition still valid? European Journal of Obstetrics. Hallberg L. Acta Obstetricia et Gynecologica Scandinavica 1966. 5. Conard J. References 1. Transvaginal ultrasound allows rapid assessment of size. Clinical Endocrinology 1994. Normally. and TVUS should be scheduled between days 4 to 6 of the menstrual cycle. (III. placenta previa. A) for identifying structural Supporting Statements: Transvaginal ultrasound (TVUS) may reveal myomas.References 1. when the endometrium is the thinnest. and presence of uterine fibroids. ectopic pregnancy. It is highly sensitive for detecting endometrial carcinoma (96%) and endometrial abnormality (92%). Obstetrics and Gynecology 1994. 2. Krassas GE.84(5): 775–8. When the endometrium is We" . the endometrial echo measures less than 5 mm. Adnexal pathology and pelvic tenderness can be assessed.27:219-34.40(5):641–4.1 TVUS is most sensitive in detecting disease in women with postmenopausal bleeding. endometrial hyperplasia. Abnorma uterine bleeding. In a meta-analysis of > 6. Evidence suggests that measurement of endometrial thickness via TVUS can accurately discriminate between women at high and low risk of endometrial cancer.000 women with postmenopausal bleeding. Wesley RM. Patterns of menstrual blood loss in menorrhagia. the use of a 5 mm cut-off to define abnormal endometrium identified 96% of women with endometrial cancer and 92% of women with any endometrial pathology with a false-positive rate of 39% and 10%. Pontikides N. Shwayder JM. Haynes PJ. Statement 6 Pregnancy test should be done in women of reproductive-age group. beta-hCG test and pelvic ultrasound are useful in ruling out pregnancy-related causes. Measurement of the endometrial echo in postmenopausal women is helpful in determining whether endometrial biopsy or further imaging studies are necessary.2 A bimanual pelvic exam (to assess uterine size). Pituitary and ovarian hormone levels in unexplained menorrhagia. Anderson ABM. since a cutoff of 5 mm or less reliably excludes endometrial cancer. Menstrual disturbances in thyrotoxicosis. Obstet Gynecol Clin North Am 2000. (I. Kaltsas T. Albers JR. or focal masses. endometrial thickening. 2.1 Possible causes of pregnancy-related bleeding include abortion. endometrial polyps. Statement 7 Ultrasound is the first-line diagnostic tool abnormalities. fibroids.2 In premenopausal women. respectively. Eldred JM. Pathophysiology of abnormal uterine bleeding. The texture of the endometrium can be evaluated for homogeneity or heterogeneity. Increased endometrial thickness is associated with intrauterine synechiae. Hull SK. endometrial thickness varies between the proliferative phase (4 to 8 mm) and the secretory phase (8 to 14 mm). and trophoblastic disease.1(2): 73–8. C) Supporting Statements: Pregnancy is the primary consideration of abnormal uterine bleeding in women of childbearing age. et al. Research and Clinical Forums 1979. 3. abruptio placenta. Turnbull AC. and endometrial cancer. Thomas EJ. position. Am Acad Fam Physician 2004. Bradley LD. Wald NJ. 1997. For hysteroscopy (3 studies) the range of sensitivity was 90–97% and for specificity it was 62–93%.4 A second review also showed a range of results for the various investigations. A) Supporting Statements: Saline infusion sonography infuses saline into the endometrial cavity during TVUS to enhance the image. 110:(10)938–47. Dieben SW. Belinson JL. Feldstein VA.5% of cases. et al: Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. sonohysteroscopy and hysteroscopy in an AUB population. Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery.3 A systematic review studied the use of ultrasound.4 References 1.174:1327–1334. 3. Outpatient hysteroscopy and ultrasonography in the management of endometrial disease. Acta Obstetricia et Gynecologica Scandinavica 2003.3 However. Statement 8 Saline-infusion sonography should not be used as first-line diagnostic tool.82(6):493–504. Wf" . et al. Endometrial thickness as a test for endometrial cancer in women with post menopausal vaginal bleeding.20:1510–1517. Obstetrical and Gynecological Survey 2002. Watt HC. 16: 305–311. The review concluded that saline infusion sonography was an accurate method for investigation of uterine pathology. JAMA 1998. et al. cannot be visualized completely. an enhanced view is required with saline infusion sonography (SIS) or hysteroscopy. Tabor A. An endometrial echo of less than 5 mm is associated with malignancy in less than 0. A systematic review of transvaginal ultrasonography. but may be useful in providing a more accurate evaluation of the uterus with intracavitary lesions. Am J Obstet Gynecol. For identification of any intrauterine pathology. Smith-Bindman R. transvaginal ultrasound (TVS) (10 studies) had a sensitivity range of 48–100% and specificity of 12–100%. Widrich T. (I.5 References 1. 3. Furness S. Mitchinson AR. et al: Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities.57(6):389–403.99:663-70. Farquhar C. Olesen F. Am J Obstet Gynecol 1996. 5. Bradley L. Confirmation of an intracavitary mass (submucous fibroid or polyp) is improved substantially with SIS. Dueholm M. Justin Clark T. Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis. 2. The review showed a wide range in variation of results. sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. it should not be used as first-line in the investigation of AUB. 2. Obstet Gynecol 2002. de Bock GH. For sonohysteroscopy (11 studies) the range of sensitivity was 85–100% and for specificity it was 50–100%. Ekeroma A. 4.177:924–929. De Kroon CD.greater than 5 mm. Weber A.1-2 A meta-analysis involving 16 studies on saline contrast hysterosonography for AUB showed pooled sensitivity of 95% and specificity of 88%. Lundorf E. BJOG: an International Journal of Obstetrics and Gynaecology 2003. is indistinct or indeterminate. Kerlikowske K. et al: Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Curr Opin Obstet Gynecol 2004. The review concluded that all three methods were at least moderately accurate at identifying uterine pathology. Statement 10 Endometrial biopsy may be performed in symptomatic women who are at high risk for the disease. Fraser IS. 101(supplement 11): 3–7. Clinical guideline.8%). Br J Obstet Gynaecol 1994. A review of 65 papers on the use of hysteroscopy in endometrial disease found that hysteroscopy is accurate at identifying endometrial cancer (sensitivity = 86.4. but less so at identifying endometrial disease (sensitivity = 78%. General Guidelines for the General Obstetrician and Gynecologist: SGOP. 2007. Clark TJ. JAMA: the Journal of the American Medical Association 2002. Medical Management of Acute Heavy Menstrual Bleeding 1. 24 January 2007. National Collaborating Centre for Women’s and Children’s Health. London: RCOG Press. Gupta JK. 2. Women who are still “menstruating” after 52 years of age Reference 1. Menorrhagia – a pragmatic approach to the understanding of causes and the need for investigations. Progestins 4. et al. Heavy menstrual bleeding.4%.1 It is better at identifying polyps than ultrasound. 2003. and 4. 3. Breast cancer patients on Tamoxifen who complain of abnormal vaginal bleeding. 24 January 2007. High dose combined oral contraceptives 3. 3.g. A) Supporting Statements: Modern hysteroscopes combine miniaturization with excellent image resolution and visualization. National Institute for Health and Clinical Excellence. Tranexamic acid WM" . Postmenopausal women with endometrial cells seen on pap smear or premenopausal women with atypical glandular cells on pap smear. importantly.2 Hysteroscopy allows direct visualization of the endometrial cavity and. Voit D. Heavy menstrual bleeding. Clinical guideline. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. London: RCOG Press. National Institute for Health and Clinical Excellence. targeted endometrial sampling of any suspicious areas. Society of Gynecologic Oncologists of the Philippines. 2. MANAGEMENT A. Endometrial sampling is recommended for: 1 1. to determine the exact location of a fibroid or the exact nature of an abnormality. V. 2007. Any postmenopausal woman with bleeding or premenopausal woman with heavy and/ or irregular vaginal bleeding.3 References 1. Statement 9 Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive. specificity = 95. e. specificity = 99.288(13):1610–21. (I.2%). High dose estrogen 2. National Collaborating Centre for Women’s and Children’s Health. then once daily for 3 weeks. Abnormal uterine bleeding: a management algorithm. C) Reference 1. J Am Board Fam Med 2006.59:285-91. DeVore GR.3 mg 1 active pill 4 times a day for 4 days. Abnormal uterine bleeding: a management algorithm. Obstet Gynecol 1982.19:590-602.e. In another review. et al. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized trial. References 1. a tapering schedule of COCs was recommended. References 1. Kase N. Statement 4 There is limited evidence that oral progestogens are effective in treating acute. In a modest-sized randomized controlled trial. Munro MG. et al. unless bleeding is suspected to be due to intrauterine lesions (i. to achieve hemodynamic stability.19:590-602. Such regimen is continued for 24 hours. COC containing 35 ug ethinylestradiol and 1 mg norethisterone was equivalent to a progesterone-only regimen. J Am Board Fam Med 2006. A) Supporting Statements: One randomized trial showed that intravenous conjugated equine estrogen (CEE) was effective in treating non-pregnant acute uterine bleeding. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding. submucous myoma).2 Promethazine was given as needed for nausea. Ely JW. Munro MG.12 (2):1114.5 mg every 6 hours was recommended as outpatient management of severe acute bleeding in the non-pregnant woman. 2. Gynaecol Forum 2007. (I. oral CEE 2. Obstet Gynecol 2006. Acute uterine bleeding unrelated to pregnancy.1 In this study. Statement 2 High dose conjugated equine estrogen is effective in treating acute severe abnormal uterine bleeding.2 The regimen is 30 ug ethinylestradiol/norgestrel 0. L!" . Basu R. Mainor N. followed by 3 times daily for 3 days.1 (III. Statement 3 Combined oral contraceptive pills may be used to treat acute AUB. 2. (I. 25 mg intravenous CEE every 4 hours stopped the bleeding within 5 hours in 72% of the treatment group versus 38% of the placebo group.Statement 1 Medical management of non-gestational acute AUB should be considered before any surgical procedure. Owens O. then 2 times a day for 2 days.108:924-9. bleeding stopped within 3 days when the COC was given 3 times a day for a week and then tapered to once a day for 3 weeks. et al. Ely JW.a double-blind randomized control study. B) Supporting Statements: Combined oral contraceptives (COCs) are frequently used in treating acute AUB despite the relative lack of evidence.1 In the algorithm for treating acute AUB. (II. Reference 1. Basu R. A) Supporting Statements: In one study. Munro MG. 148 ml during treatment) and tranexamic acid reduced blood loss by 54% (mean blood loss 164 ml before treatment.313:579-582. Combined oral contraceptives 5.1 This resulted to a reduction in blood loss in all patients (25% stopped bleeding within 24 hours.12 (2):1114. mefenamic acid and tranexamic acid. stopped bleeding on average on day 3 of the regimen. and 26 patients to take tranexamic acid 1 g six hourly. followed by 20 mg/day. Acute uterine bleeding unrelated to pregnancy. Tranexamic acid given during menstruation is a safe and highly effective treatment for excessive bleeding. B.37:22831. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Mainor N. Aksu F.108:924-9. Gynaecol Forum 2007. Statement 5 Tranexamic acid may be used to treat of acute AUB. et al. Budak E. 3.heavy menstrual bleeding. 60 mg /day for a week. BMJ 1996. Nonsteroidal anti-inflammatory drugs (NSAIDs) 4. Twenty-seven (27) patients were randomised to take ethamsylate 500 mg six hourly. 75 ml during treatment). Medical Management of Chronic Heavy Menstrual Bleeding 1. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate.2 Norethisterone acetate (5-15 mg/day) daily until cessation of bleeding for at least 2 days. Obstet Gynecol 2006. the rest by the fourth day). followed by 5-10 mg/day for 3-6 weeks. 23 patients to take mefenamic acid 500 mg eight hourly. 2. Aust NZ J Obstet Gynaecol 1997. (I. Cyclic progestogen 6. Levonorgestrel-releasing intrauterine system (LNG-IUS) 2. B) Supporting Statements: In one study (24 adolescents hospitalized for excessive bleeding and anemia). Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized trial. Madazli R.3 References 1. In an RCT. et al. oral medroxyprogesterone acetate (MPA) was given at a dose of 60-100 mg for the first day and 20 mg/day for the next 10 days. Bonnar J & Sheppard BL. Ethamsylate did not reduce mean menstrual blood loss whereas mefenamic acid reduced blood loss by 20% (mean blood loss 186 ml before treatment. Danazol LW" . Antifibrinolytic agents (AFA) 3. Sanitary towel usage was significantly reduced in patients treated with mefenamic acid and tranexamic acid. Munro MG. is another alterntive. menorrhagia treatment for five days from day 1 of menses during three consecutive menstrual periods was done on 76 patients. A) Supporting Statements: Antifibrinolytic agents inhibit plasminogen activation and subsequently fibrinolysis. Lethaby A. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Statement 2 Antifibrinolytic therapy causes a greater reduction in heavy menstrual bleeding when compared with placebo or other medical treatments (NSAIDs. luteal norethisterone and ethamsylate. ethamsylate). Issue 4. Busfield RA. Farquhar CM.5). Rees MC. Br J Obstet Gynaecol 2006. where the LNG IUS was compared with a control group taking their existing medical therapy. A meta-analysis of 9 RCTs comparing progesterone releasing IUS with cyclic oral norethisterone (days 5-26 of cycle) showed that the IUS was significantly more effective in reducing blood loss. 95% CI -151. (I. Cochrane Database of Systematic Reviews 2005. References: 1. with the additional benefit of relieving dysmenorrhea.4 to -36. a higher proportion of the women in the intrauterine device group cancelled their planned surgery after six months of treatment. 2006). Recent evidence shows that LNG-IUS normalizes blood flow in women with heavy menstrual bleeding. leading to a marked reduction in blood loss. In all studies comparing antifibrinolytics with mefenamic acid. Sowter MC. Women with an LNG IUS are more satisfied and willing to continue with treatment but experience more side effects. the LNG IUS results in a lesser reduction in menstrual blood loss but there is no evidence of a difference in the rate of satisfaction with treatment. with 35% being amenorrheic at 2 years (Busfield et al. A randomized trial comparing the levonorgestel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. Cooke I. When compared with endometrial ablation.0. This treatment is not associated with an increase in side effects compared to placebo or other medical therapies (NSAIDs. A) Supporting Statements: The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective. Results showed a significant reduction in mean blood loss with antifibrinolytic therapy compared to placebo (WMD -94.Statement 1 The Levonorgestrel-releasing intrauterine system (LNG IUS) is a highly effective treatment for heavy menstrual bleeding. The LNG-IUS reduces endometrial thickness and vascularity. 113:257-63. oral luteal progestogens. results showed a significant reduction in mean blood LL" . oral luteal progestogens and ethamsylate). In one trial of women awaiting hysterectomy. An increase in the levels of plasminogen activators has been found in the endometrium of women with heavy menstrual bleeding compared with those with normal menstrual loss. reversible contraceptive with the additional benefits of reducing blood loss and dysmenorrhea. oral luteal progestogen and ethamsylate). (I. et al. 2. A meta-analysis of four randomized controlled trials compared antifibrinolytic agents versus placebo or other medical therapies (NSAIDs. such as intermenstrual bleeding and breast tenderness. using an NSAID may reduce prostaglandin production by inhibiting the enzyme cyclo-oxygenase. In a limited number of studies with small sample sizes. Moreover. and oral contraceptive. (I. there was no difference in efficacy between different NSAIDs (naproxen and mefenamic acid) in reducing heavy menstrual bleeding. Results showed that NSAIDs were more effective than placebo.4 to -22. A) Supporting Statements: A rationale for the use of nonsteroidal anti-inflammatory drugs is due to an accumulation of data suggesting a role for prostaglandins in the pathogenesis of HMB (Hagenfeldt 1987). LNG-IUS. seventeen randomized controlled trials comparing individual NSAIDs with each other. 95% CI -123. Lethaby A. 95% CI -143. danazol. placebo or other medical treatments in women with heavy menstrual bleeding were analyzed. B) Supporting Statements: A Cochrane database systematic review found only one small (45 patients) randomized. 95% CI -178. Farquhar C. Reference: 1. Cooke I. cross-over trial investigating the combined oral contraceptive in the L]" .9 to -56. but less effective than tranexamic acid.5 to -43. Statement 4 Combined oral contraceptives may be an alternative in the medical management of heavy menstrual bleeding. Statement 3 Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce heavy menstrual bleeding when compared with placebo.1. and NSAIDs. There was no significant difference in menstrual blood loss (MBL) between treatments with OCP. Lastly. Contraception 1987.0. there was no associated increase in side effects compared to placebo and other medical therapies. Farquhar C. The role of prostaglandins and allied substances in uterine haemostasis. danazol. respectively) and a strong. Limited evidence shows no significant difference in efficacy between NSAIDs and oral luteal progestogen. Antifibrinolytics for heavy menstrual bleeding.5. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. WMD -111. ethamsylate.0.36(1):23–35. Duckitt K. Lethaby A. Seven crossover trials were also described. ethamsylate. or levonorgestrel-releasing intrauterine system (LNG-IUS). Augood C. In the latest Cochrane review of nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. References: 1. and WMD -100. in reducing heavy menstrual bleeding.loss (WMD -73. 2. Cochrane Database of Systematic Reviews 2000. The endometrium of women with excessive menstrual bleeding has been found to have higher levels of prostaglandin E2 and prostaglandin F2a when compared with women with normal menses. or oral contraceptive pill. Issue 4. (I. Hagenfeldt K.6. there were no statistically significant differences between NSAIDs and other medical treatments like oral luteal progestogen. but are less effective than tranexamic acid. although nonsignificant trend in favor of tranexamic acid in the participants’ perception of an improvement in menstrual blood loss. Cochrane Database of Systematic Reviews 2007. Issue 4. danazol. its acceptability to women and the need for continuing treatment. Danazol for heavy menstrual bleeding. Results are based on a small number of trials. This is based on nine randomized controlled trials (353 women). and with wide confidence intervals. A) Supporting Statements: Danazol appears to be more effective than placebo. progestogens. Randomized trial of 2 hormonal and 2 prostaglandin inhibiting agents in women with a complaint of menorrhagia. non-steroidal antiinflammatory drugs (NSAIDs) and the IUS.treatment of heavy menstrual bleeding (Frasier 1991). Aust NZ J Obstet Gynaecol 1991. tranexamic acid. Issue 3. Treatments given were mefenamic acid. References: 1. However. This regimen of progestogen may have a role in the short-term treatment of menorrhagia. Further studies are unlikely in the future and this review will not be updated unless further studies are identified. Reference: 1. Reference: 1. Cameron IT.6 to10. although women found the treatment less acceptable than intrauterine levonorgestrel. Lethaby A.05. Issue 2. There was no significant difference in menstrual blood loss reduction between those patients treated with the OCP and danazol. danazol use may be limited by its side effect profile. although it has no advantage over other medical therapies (NSAIDs. danazol. and IUS). and the small sample sizes of the included trials limit the recommendations for clinical care. Statement 6 Danazol appears to be an effective treatment for heavy menstrual bleeding compared to other medical treatments. Cochrane Database of Systematic Reviews 2007. 95% CI 1. Cochrane Database of Systematic Reviews 2008. The small number of trials. Duckitt K. all of which are underpowered.2). Irvine GA. Cyclical progestogens for heavy menstrual bleeding. Statement 5 Cyclic progestogen given for twenty one (21) days for ovulatory bleeding results in a significant reduction in blood loss. NSAIDs and the OCP at reducing MBL. A) Supporting Statements: A meta-analysis of seven randomized controlled trials compared cyclic progestogen with other medical therapies such as danazol. low dose danazol and a combined oral monophasic contraceptive pill. Issue 1. Progestogens administered from day 15 or 19 to day 26 of the cycle offer no advantage over other medical therapies in the treatment of menorrhagia in women with ovulatory cycles.0. naproxen. Frasier IS. (I. Augood C.2) and progestogens (OR 4. McCarron G. 31: 66-70. Beaumont HH. 2. Treatment with Danazol caused more adverse events than NSAIDs (OR 7. Lethaby A. Oral contraceptive pills for heavy menstrual bleeding.7 to 28. La" . but majority of which are unsuitable for meta-analysis. 95% CI 1. Iyer V. Jepson RG. Cochrane Database of Systematic Reviews 1997. tranexamic acid. mefenamic acid or naproxen. Farquhar C. Progestogen therapy for 21 days of the cycle results in a significant reduction in menstrual blood loss. (I. C) Supporting Statements: The observational study (n = 22) showed that MBL was reduced for 1 month after dilatation and curettage but then returned to previous levels.! C. et al. C) Reference: 1. (III. both TBEA and Lg" . Haynes PJ. although one RCT found that MEA is superior to TCRE in terms of satisfaction at 5 years follow-up. Endometrial ablation and resection techniques are marginally less effective than hysterectomy at improving MBL and quality of life. When compared with hysterectomy. Reference: 1. [I. Hodgson H. (III.1 There were no systematic reviews or RCTs. It should be considered in women who have a normal uterus and also those with small uterine fibroids (less than 3 cm in diameter). Dilatation and curettage 2. Endometrial ablation 3. Inclusion criteria of RCTs showed that uterine fibroids < 3 cm in size were allowable. endometrial ablation should be considered preferable to hysterectomy. Journal of American Board of Family Medicine. Anderson AB. Transcervical resection of the endometrium (TCRE). In women with heavy menstrual bleeding alone. thermal balloon endometrial ablation (TBEA) and rollerball endometrial ablation (REA) techniques appear to be largely equivalent to one another in terms of clinical outcome. Hysterectomy Statement 1 Dilatation and curettage should not be used as a therapeutic treatment. Statement 3 Endometrial ablation may be offered as an initial treatment for heavy menstrual bleeding. with uterus no bigger than a 10-week pregnancy. British Journal of Obstetrics and Gynaecology 1977. Measurement of menstrual blood loss in patients complaining of menorrhagia. Statement 2 Dilatation and curettage may be performed for acute heavy mesntrual bleeding unresponsive to initial medical management. Ely JW. Surgical Management of Heavy Menstrual Bleeding 1. Second-generation ablation techniques should be used where no structural or histological abnormality is present. 84(10):763–8.. microwave endometrial ablation (MEA). 2007. A] Supporting Statements: Three reviews and one RCT show that endometrial ablation and resection methods produce clinically relevant reductions in MBL and are associated with improvements in quality of life. There was no difference between laser ablation and TRCE for amenorrhea rates.59]).31 [95% CI 0. n = 519) OR 0. There were no differences between methods for amenorrhea rates. n = 706) WMD = "23. Of the 13 types of adverse event reported.80 to "22. however.12 [95% CI 0. complications or satisfaction. More patients favored hysterectomy (at 12 months (three studies. Ablation/resection is less effective at reducing MBL and improving satisfaction.32] in favor of ablation/resection).06 [95% CI "23.46 [95% CI 0. Hydrothermablation versus REA Ld" . more women in the endometrial ablation groups required further surgery within 12 months ((five studies. n = 354) OR 0.87]) and fewer adverse events. Amenorrhea rates at 12 months reported by seven trials ranged from 36% to 40% for MEA and from 10% to 40% for TBEA. n = 706) WMD = "4.MEA are less costly.3 Laser ablation versus TCRE There were two RCTs (n = 388) were identified.25]). MEA performed in an outpatient setting under local anaesthetic compares favourably in terms of cost with standard MEA in a day-case setting after drug preparation of the endometrium.18 to 12. Hysterectomy provided greater reductions in MBL. There were high levels of satisfaction (> 75%) for both MEA and TBEA. Thermal laser ablation versus TCRE One RCT (n = 111) was identified.06 to 0. satisfaction or HRQoL. Endometrial ablation techniques required less time to undertake ((five studies.2 A second systematic review (19 RCTs) compared the various ablation techniques with one another for treatment of DUB. HRQoL or complications. Only limited differences were found when comparing one ablation method with another. re-surgery. and five were no different. REA versus TCRE There was no difference between techniques in terms of future hysterectomy or resurgery at 2 and 5 years follow-up. However. shorter hospital stays ((five studies. Endometrial ablation versus other treatments Hysterectomy was compared with endometrial ablation in a systematic review.95 to "4. leads to shorter surgery. The review concluded that both MEA and TBEA were equivalent to first-generation ablation techniques.(at 12 months (three studies. satisfaction. Ablation/resection.33 [95% CI 4.86]). results favored ablation/resection over hysterectomy for eight of these.88] and at 24 months (three studies.24 to 0. Vaporizing electrode ablation versus TCRE One RCT (n = 91) was identified. It was concluded that ablation/resection is an alternative to hysterectomy.91 [95% CI "4. Quality of life measures SF36) showed no difference between groups. There were no differences between groups for menorrhagia.1 Endometrial ablation/resection There is one systematic review which examined the effectiveness and safety of MEA and TBEA for DUB. The review also reported significant reductions in levels of MBL or reclassification of bleeding patterns for both MEA and TBEA. n = 440) OR 0. shorter hospital stay and fewer complications. n = 706) OR 7.16 to 0. but result in slightly fewer QALYs. 8 to 15. TBEA was quicker (WMD 13 minutes [95% CI 10.02 to 0. Women in the cryoablation group were less likely to have amenorrhea at 1 year (OR 0.02 to 0.7 [95% CI 1. Amenorrhea was less likely with TBEA at 12 and 36 months (OR 0.9 [95% CI 1.8].1 to 6. At 5 years.3 [95% CI 1. complications rates.3 to 10.8 ml [95% CI "70.7 [1.9 [95% CI = 1.3] and OR 3.3]) and satisfaction was greater at 24 months (OR 7. There were no differences in other outcomes or in the same outcomes at different time periods. TBEA versus REA One RCT (n = 239) was identified.2). The hysterectomy rate was significantly lower (18% versus 28%) following MEA.8 to 20.3 to "93.9 [95% CI 10. respectively).33 to 0.1] and less likely to have cervical tears or lacerations (OR 0.2 to 0.7]). Cryoablation versus REA Two RCTs (n = 279) were identified.3 [95% CI 0. The operation time with TCRE was longer (WMD 18. menorrhagia rates or hysterectomy rates.One RCT (n = 269) was identified. 24 and 36 months.5 to 9.1 to 15. equipment failure rates (OR 4.80]).14 [95% CI 0.1 to 25. TBEA versus TCRE One RCT (n = 82) was identified.97].94]). Hydrothermablation patients were more likely to have local than general anesthesia (OR 2. There were no differences in satisfaction rates.90]).2 to 4. Electrode ablation (balloon or mesh) versus TCRE Two RCTs (n = 520) were identified. In addition.2 [95% CI 1. However. odds of satisfaction with treatment were lower in the balloon group (OR 0. vomiting (OR 4. Women having TBEA treatment had a significantly greater pain score than women in the laser group (WMD 32. and complications were more likely with TBEA than with REA.18 [95% CI 0. microwave was more satisfactory and acceptable than TCRE (OR 1.13 [95% CI 0. Duration of surgery was lower in the balloon group (WMD 20.1]) and nausea (OR 3.7 minutes [95% CI 16.7]).6]) but more likely to have local than general anesthesia (OR 13. satisfaction rates or need for hysterectomy. Le" .96] and OR 0. TBEA versus laser ablation One RCT (n = 70) was identified.01 to 0.0]).3] and OR 2.8]) were greater in the MEA group.1 to 2.1].8 to 30.4 to 35.25 to 0.7 to 41.93]) but were more likely to have abdominal pain (OR 1.8 minutes [95% CI 19.9 [95% CI 1.1 to 3. 12 month PBAC.2 to 22.03 to 0. Other outcomes showed no differences at 12. The electrode group was more likely to have local than general anesthesia (OR 15. At 5 years follow-up the difference was maintained (OR 2. There were no differences between groups in amenorrhea rates.07 [95% CI 1. mean intra-operative blood loss was lower (WMD "81.7 [95% CI 1.0 [95% CI 1.9]) when compared with TCRE. respectively).4 to 11.7] and uterine cramping (OR 1.0]).7 [95% CI 1.5]).60 [95% CI 0.2 [95% CI 5. MEA versus TCRE plus REA One RCT (n = 322) was identified. odds of hemorrhage were lower in the microwave group (OR 0. success rates (PBAC < 75).6 to 5.7 [95% CI 23.1]) and were less likely to experience hematometra (OR 0. At 2 years follow-up. respectively) but there were no differences at 24 months and 5 years.11 [95% CI "0.1 to 3.0]).50 [95% CI 0. 8(3):iii.However.11 (95% CI 0. 2004. Issue Oxford.53 to 10.3 to 7. physical function.0]). (Cochrane Review). Shepperd S. The effectiveness and cost-effectiveness of microwave and thermal balloon endometrial ablation for heavy menstrual bleeding: a systematic review and economic modelling.70) in favor of surgery.11 to 10.38]).97) in favor of surgery.7 [95% CI 1. women in the pharmaceutical group were more likely to undergo additional surgery: by 2 years follow-up (n = 236) OR 0. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. vitality and physical role limitation. Lethaby A. Lf" . The figures showed that objective measurement of MBL at 12 months was in favor of surgery (one RCT.50] in favor of surgery. In: Cochrane Database of Systematic Reviews. women in the TBEA group had higher scores on the Euroquol 5D VAS than women in the laser group (WMD 5. The figures for patient satisfaction were: at 4 months (n = 183) OR 8.6 (95% CI 5.1 Six other RCTs compared LNG-IUS with surgery (hysterectomy. used in determining health status of patients) scale for general health. There were statistically significant differences for emotional role (n = 269. n = 223.84 to 4. However. Issue 2. Lethaby A.6]). Oxford: Update Software.69 (95% CI 0. results from health related quality of life (HRQoL) measures were more mixed. Cooke I. by 2 years (n = 173) OR 2. et al.12 (95% CI 0.1–155.73] There was no statistical difference between the groups.29 to 15.70) with no statistical difference between the groups.46 to 5. 3. There was no statistical difference between the groups by the 5th year of follow-up. Also.22) in favor of surgery. Amenorrhea was more likely in the bipolar radiofrequency group (OR 7. References: 1. n = 189. 2005. eight RCTs compared pharmaceutical with surgical treatments for HMB. Stein K.06 to 0.5 to 440. (cure or improvement): at 4 months (n = 186) OR 10.3 to 21. OR 25. the subjective measurement of MBL at 12 months was in favor of surgery (three RCTs. C) Supporting evidence: In one systematic review (n = 821) in 2006.8 to 14.0 [95% CI 1. Oxford: Update Software. The difference between pharmaceutical treatments and surgery diminished over time. and by 5 years (n = 140) OR 1.99 [95% CI 0. OR 3.4]) and women in the bipolar radiofrequency group were more likely to be satisfied with treatment outcome at 12 months (OR 3. Hickey M. There was no difference between groups on the SF-36 (a short form with 36 questions. 2.99 [95% CI 1.28 (95% CI 4. These studies concluded that the treatments were equivalent.83 [95% CI 1. by 2 years (n = 173) OR 2. Garside R. Health Technology Assessment 2004.22) in favour of surgery and by 5 years follow-up (n = 140) OR 0. ablation) in secondary care settings. In: Cochrane Database of Systematic Reviews.(Cochrane Review). mental health.At 12 months follow up.77 to 3.0]).4 [95% CI 3.06 to 0. Wyatt K. Endometrial destruction techniques for heavy menstrual bleeding. and by 5 years (n = 140) OR 1. Regarding control of bleeding. Bipolar radiofrequency endometrial ablation versus TBEA One RCT (n = 126) was identified.3 [95% CI 0.3) in favor of surgery. Statement 4 Hysterectomy should not be used as first-line treatment for heavy menstrual bleeding. Farquhar C. (I.39 (95% CI 1. Two RCTs in the systematic review examined use of pharmaceutical or surgical interventions on women with HMB in a secondary care setting.21 to 4. WMD 3. Dwyer N. et al. Faisst K.1(2):96–105. Magos A. Herman CJ.9(Suppl 2): S27–38. Women’s stories: Ethnic variations in women’s attitudes and experiences of menopause. Browning J.11 to 0.24 [95% CI 0.65 to 17. Swiss consensus guidelines for hysterectomy. (Cochrane Review). Bongers MY. Fuchs T.3 In addition. social function (n = 274. 2006. Swiss Society of Gynecology and Obstetrics. von Schoultz B. WMD 6.68 to 12. Wyss P.69(6):1063–6. Journal of Womens Health and Gender-Based Medicine 2000. et al. a levonorgestrel-releasing intrauterine device.49]). Health Expectations 1998. Rubinger T. Surgery versus medical therapy for heavy menstrual bleeding. Journal of Obstetrics and Gynaecology Canada: JOGC 2002. Consumer’s attitude to hysterectomy: The experience of 678 women. Allaire C.4-8 References 1. 5. failed pharmaceutical treatment and full information provision to the woman.71(3):230–4. et al. 3. Nagele F. Mingo C.1 While surgery has an advantage over pharmaceutical treatment in terms of outcome.64 [95% CI "1. Bourdrez P. Switzerland. 6. SOGC clinical guidelines. Sculpher MJ. Acta Obstetricia et Gynecologica Scandinavica 1992. hysterectomy.14 to 8. 4. Schilling J.11 [95% CI 0. Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation. Lefebvre G.43]) and bodily pain (n = 274. 82(1):160–6. The systematic review states that investigations for causes of HMB. 8.67 [95% CI 1. Jasperse M. In: Cochrane Database of Systematic Reviews. and hormone replacement therapy. 2. Why do women choose endometrial ablation rather than hysterectomy? Fertility and Sterility 1998.29]) in favor of surgery. LM" . this does not take into account the reversible nature of pharmaceutical treatment compared with surgery.04 to 0. Use of LNG-IUS was more likely to result in additional surgery at 12 months (n = 423. Hysterectomy [French]. Issue 2. Lethaby A.64(3):297–305.98[95% CI 1. but also often want to avoid hysterectomy in order to achieve these outcomes. or hysterectomy. hysterectomy is only indicated where HMB is causing anemia and/or serious HRQoL impact.24(1):37–61. Nathorst-Boos J. OR 0.2 A consensus statement highlights that hysterectomy for HMB should only be undertaken after investigations to establish cause of HMB.30]) and were less likely to have reported adverse effects (OR 0. Farquhar C.69]). attempts at pharmaceutical treatment and provision of full information to the woman are required prior to hysterectomy. 7. Oxford: Update Software. A survey of women’s preferences regarding alternative surgical treatments for menorrhagia. Jeffrey J. International Journal of Gynaecology and Obstetrics 1999. Fertility and Sterility 2004. Patient preference studies show that women want certain outcomes for treatment of HMB.WMD 9. Mol BW. Marjoribanks J. based on clinical experience. There is good evidence to support the recommendation that the practice be excluded in abnormal uterine bleeding.APPENDIX A LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION LEVEL I II-1 II-2 II-3 III GRADE A B C D E GPP ]!" DEFINITION Evidence obtained from at least one properly randomized controlled trial Evidence obtained from well-designed controlled trials without randomization Evidence obtained from well-designed cohort or case-control analytic studies. descriptive studies and case reports or reports of expert committees. A good practice point (GPP) is a recommendation for best practice based on the experience of the Technical Working Group. There is insufficient evidence to recommend for or against the inclusion of the practice in abnormal uterine bleeding. There is fair evidence to support the recommendation of the practice in abnormal uterine bleeding. DEFINITION There is good evidence to support the recommendation of the practice in abnormal uterine bleeding. There is fair evidence to support the recommendation that the practice be excluded in abnormal uterine bleeding. preferably from more than one center or research group Evidence obtained from multiple time series with or without the intervention. . Opinions of respected authorities. Naproxen 550 mg LD. Norethisterone acetate 5 mg PO TID on cycle days 16-25 for anovulatory cycles 9. Medroxyprogesterone 10 mg PO OD on cycle days 16-25 for anovulatory cycles 7. Danazol 200-400 mg PO daily for progestin-resistant cases """""""""""""""""""""""""""""""""""""""""""""""""""""""" ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ]W" . Levonorgestrel-releasing intrauterine system once every 5 years 2. then 275 mg PO BID during heavy bleeding x 3 days 6. Mefenamic acid 500 mg PO TID during heavy bleeding x 3 days 5.APPENDIX B DRUG DOSAGES 1. Norethisterone acetate 5 mg PO TID on cycle days 5-26 for ovulatory cycles 10. Medroxyprogesterone 10 mg PO TID on cycle days 5-26 for ovulatory cycles 8. Tranexamic acid 1 gram QID PO during heavy bleeding x 3 days 3. Ibuprofen 200 mg PO TID during heavy bleeding x 3 days 4.