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JOGC

No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women

      Abstract

      Background

      Abnormal uterine bleeding is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. This guideline replaces previous clinical guidelines on the topic and is aimed to enable health care providers with the tools to provide the latest evidence-based care in the diagnosis and the medical and surgical management of this common problem.

      Objective

      To provide current evidence-based guidelines for the diagnosis and management of abnormal uterine bleeding (AUB) among women of reproductive age.

      Outcomes

      Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB.

      Methods

      Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada, type of practice, subspecialty expertise, and general gynaecology background. The committee reviewed relevant evidence in the English medical literature including published guidelines. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

      Results

      This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of AUB. The resulting recommendations may be adapted by individual health care workers when serving women with this condition.

      Conclusions

      Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age. Standardization of related terminology, a systematic approach to diagnosis and investigation, and a step-wise approach to intervention is necessary. Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions.

      Evidence

      Published literature was retrieved through searches of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary (e. g., uterine hemorrhage, menorrhagia) and key words (e. g., menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1999 to March 2011. Searches were updated on a regular basis and incorporated in the guideline to February 2013.
      Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology- related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Values

      The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

      Benefits, harms, and costs

      Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding, their families, and society. The economic cost of implementing these guidelines in the Canadian health care system was not considered.

      Summary Statements

      • 1
        Abnormal uterine bleeding is a common condition affecting women of reproductive age that has significant social and economic impact (II-2).
      • 2
        Contemporary terminology used to describe abnormal uterine bleeding in reproductive-aged women aims to simplify definitions and to provide standard descriptions related to patient presentation (III).
      • 3
        The consequences of abnormal uterine bleeding on an individual's overall health determine the degree to which intervention may be required (II-2).
      • 4
        A thorough history and physical exam will often indicate the cause of abnormal uterine bleeding and direct the need for further investigation and treatment (III).
      • 5
        Imaging and hysteroscopy offer the clinician additional information to assist in patient assessment and treatment in indicated circumstances (I).
      • 6
        Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option for abnormal uterine bleeding (I).
      • 7
        Medical treatment tailored to the individual woman's therapeutic goals, desire for contraception, underlying medical conditions, and tolerance of side effects will encourage compliance and maximize the likelihood of treatment success (III).
      • 8
        Non-hysteroscopic ablation techniques offer similar patient satisfaction results with fewer risks of complications and less anaesthetic requirement than traditional hysteroscopic ablation (I-A).
      • 9
        Hysterectomy provides definitive treatment for abnormal uterine bleeding.
      • 10
        Abnormal uterine bleeding secondary to submucosal fibroids may be managed by hysteroscopic myomectomy.
      • 11
        Inherited bleeding disorders may be an underlying cause of abnormal uterine bleeding, with von Willebrand's disease present in the majority of cases (II-2).
      • 12
        Acute heavy menstrual bleeding may result in significant anemia and emergent care (III).
      • 13
        Abnormal uterine bleeding in the adolescent most commonly represents ovulatory dysfunction related to immaturity of the hypothalamic-pituitary-ovarian axis (II-2).

      Recommendations

      • 1
        Adoption of standardized international terminology for abnormal uterine bleeding should be considered (III-C).
      • 2
        A complete blood count is recommended for women with heavy or prolonged bleeding (II-2A).
      • 3
        If there is any possibility of pregnancy, a sensitive urine or serum pregnancy test should be performed (III-C).
      • 4
        Testing for coagulation disorders should be considered only in women who have a history of heavy menstrual bleeding beginning at menarche or who have a personal or family history of abnormal bleeding (II-2B).
      • 5
        Thyroid function tests are not indicated unless there are clinical findings suggestive of and index of possible suspicions of thyroid disease (II-2D).
      • 6
        If imaging is indicated, transvaginal ultrasound should be the first line imaging modality for abnormal uterine bleeding (I-A).
      • 7
        Saline infusion sonohysterography and diagnostic hysteroscopy should be used in the diagnosis and characterization of discrete intrauterine abnormalities such as submucosal fibroids (I-A).
      • 8
        Endometrial biopsy should be considered in bleeding women over age 40 or in those with bleeding not responsive to medical therapy, as well as in younger women with risk factors from endometrial cancer (II-2A).
      • 9
        Office endometrial biopsy should replace dilation and uterine curettage as the initial assessment of the endometrium for these women (II-2A).
      • 10
        Focal lesions of the endometrium that require biopsy should be managed through hysteroscopy-guided evaluation (II-2A).
      • 11
        Non-hormonal options such as non-steroidal anti-inflammatory drugs and antifibrinolytics can be used effectively to treat heavy menstrual bleeding that is mainly cyclic or predictable in timing (I-A).
      • 12
        Combined oral contraceptive pills, depot medroxyprogesterone acetate, and levonorgestrel-releasing intrauterine systems significantly reduce menstrual bleeding and should be used to treat women with abnormal uterine bleeding who desire effective contraception (I-A).
      • 13
        Cyclic luteal-phase progestins do not effectively reduce blood loss and therefore should not be used as a specific treatment for heavy menstrual bleeding (I-E).
      • 14
        Danazol and gonadotropin-releasing hormone agonists will effectively reduce menstrual bleeding, and may be used for scenarios in which other medical or surgical treatments have failed or are contraindicated (I-C).
      • 15
        Patients receiving a gonadotropin-releasing hormone agonist for longer than 6 months should be prescribed add-back hormone therapy, if not already initiated with gonadotropin-releasing hormone agonist commencement (I-A).
      • 16
        The progestin intrauterine system has outcomes similar to endometrial ablation for women with heavy menstrual bleeding and thus may be considered prior to surgical intervention (I-A).
      • 17
        In appropriate candidates, non-hysteroscopic ablation techniques should be the ablation methods of choice in view of their higher efficacy and safety than hysteroscopic techniques (I-A).
      • 18
        With the exception of non-steroidal anti-inflammatory drugs, the same medical agents used to treat heavy menstrual bleeding among women with normal coagulation can effectively be used in the setting of inherited bleeding disorders (II-1B).
      • 19
        Women with inherited bleeding disorders who have significant heavy menstrual bleeding or those who fail conventional medical therapy are best managed with a multidisciplinary approach (III-C).
      • 20
        Hysterectomy planning or blood product therapy should be performed in consultation with a hematologist in patients with inherited bleeding disorders (III-C).
      • 21
        Acute heavy menstrual bleeding should be managed promptly and systematically to minimize patient morbidity and the need for blood transfusion (III-C).
      • 22
        High-dose estrogen and tranexamic acid may help decrease or arrest acute heavy menstrual bleeding (III-C).
      • 23
        For the adolescent presenting with heavy menstrual bleeding at or in close approximation to menarche, history and investigations should include an assessment for an underlying bleeding disorder (II-2A).

      Key Words

      Abbreviations:

      AUB (abnormal uterine bleeding), β-hCG (beta-human chorionic gonadotropin), CBC (complete blood count), CHC (combined hormonal contraceptives), cOCP (combined oral contraceptive pill), DMPA (depot medroxyprogesterone acetate), FIGO (International Federation of Gynecology and Obstetrics), GnRH (gonadotropin releasing hormone), IUS (intrauterine system), IV (intravenous), LNG (levonorgestrel), LNG-IUS (levonorgestrel-releasing intrauterine system HPNCC hereditary non-polyposis colorectal cancer), MPA (medroxyprogesterone acetate), NET (norethindrone (or norethisterone)), NSAIDs (non-steroidal anti-inflammatory drugs), OCP (oral contraceptive pill), PCOS (polycystic ovary syndrome), SIS (saline infusion sonohysterography), VTE (venous thromboembolism), vWF (von Willbrand's factor)
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      Linked Article

      • No 292-Saignements utérins anormaux chez les femmes préménopausées
        Journal of Obstetrics and Gynaecology Canada Vol. 40Issue 5
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