The grades of evidence (I-1 – IV) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Guideline Candidates (both must be present)
- Reproductive aged women who are not pregnant
- Abnormal uterine bleeding that is one or a combination of the following
- Irregular (unpredictable timing; e.g., every(q) 21 to 60 days)
- Bleeding between predictable periods ("metrorrhagia")
- Heavy, predictable onset, normal cycle length (q 22 to 35 days)
- Excessive volume (Heavy menstrual bleeding; menorrhagia)
- Excessive duration (Heavy menstrual bleeding; menorrhagia)
- Heavy, predictable onset, abnormal normal cycle length
- Too frequent (cycle length < 22 days)("polymenorrhea")
- Too infrequent (cycle length >35 days)("oligomenorrhea")
General Investigation of Reproductive Aged Women with Chronic Abnormal Uterine Bleeding (AUB)
- All patients with chronic AUB should be considered for a complete blood count (CBC). (Level C)
- All patients presenting with chronic AUB should be evaluated for pregnancy, if necessary with a blood or urine pregnancy test. (Level C)
- Women with heavy uterine bleeding should have a structured history to screen for inherited systemic disorders of hemostasis. (Level A) (see Table 1 below)
- Each patient with chronic AUB should be assessed for ovulatory function which can be reliably confirmed with a history of predictable, cyclic mense with a cycle length of every 22 to 35 days. (Level C)
- Measurement of thyroid function with TSH is appropriate in women with suspected or known anovulatory dysfunctional uterine bleeding (DUB). Further investigation of endocrinopathy should be performed in conjunction with a gynecologist. (Level C)
Table 1: Screening for an underlying disorder of hemostasis in the patient with excessive menstrual bleeding*
| Initial screening for an underlying disorder of hemostasis in patients with excessive menstrual bleeding should be by a structured history: |
- Heavy menstrual bleeding since menarche
|
- One of the following:
- Post-partum hemorrhage
- Surgical related bleeding
- Bleeding associated with dental work
|
- Two or more of the following symptoms:
- Bruising 1-2 times/month
- Epistaxis 1-2 times/month
- Frequent gum bleeding
- Family history of bleeding symptoms
|
A positive screen comprises any of the following (1) heavy bleeding since menarche, one from list (2) or two or more from list (3). Patients with a positive screen should be considered for further evaluation including consultation with a hematologist and/or testing of von Willebrand factor and Ristocetin cofactor.
*From Kadir RA, Economides DL, Sabin CA, Owens D, Lee CA. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet 1998; 351:485-9.
Uterine Cavity Assessment
- The goals for evaluation of the endometrial cavity in women with chronic abnormal uterine bleeding (AUB) include (1) Detection of endometrial hyperplasia or cancer in selected patients, and (2) Identification of focal lesions such as polyps and leiomyomas which might explain the patient's bleeding. (Level C)
- Evaluation of the Endometrium
- When endometrial sampling is indicated in premenopausal women with AUB, outpatient endometrial biopsy with catheter techniques should be considered the first line approach. (Level A)
- When there is an increased risk of endometrial hyperplasia or neoplasia, endometrial sampling should be performed. (Level A) Such circumstances include the following:
- Over the age of 40. (Level B)
- Women less than forty with risk factors judged sufficient to warrant biopsy. These include features suggestive of chronic anovulation (irregular menses, infertility); and weight greater than 90 Kg. (Level B)
- Patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome [see Appendix IV in the original guideline document]) (Level B)
- If the endometrial biopsy is indicated and cannot be obtained or is inadequate, repeat sampling should be attempted, if necessary with Dilation and Curettage (D&C). Patients taken to the operating room should have hysteroscopic evaluation prior to endometrial sampling and it is preferable that the surgeon be prepared to remove identified lesions under hysteroscopic guidance. (Level C)
- If chronic AUB continues despite normal and satisfactory endometrial sampling, the patient should be considered for further evaluation with ultrasound, saline infusion sonography (SIS), and or hysteroscopy. (Level A)
- Transvaginal Sonography (TVS)
- In general, patients should not be sent to radiology for pelvic ultrasounds prior to evaluation by gynecology. Office ultrasound should be done by a gynecologist (or other practitioner) with training in office ultrasound techniques. (Level C)
- Routine ultrasonography is generally unnecessary for initial visits but should be considered in any individual with persisting symptoms and especially those who fail initial medical therapy. (Level C)
- An ultrasound scan is deemed adequate if it demonstrates the entire endometrial echo in the longitudinal and transverse planes through the widest part of the endometrial cavity. (Level C)
- There is no consensus on the upper limit of endometrial thickness in premenopausal women, in part because the thickness varies with the normal systemic variation in ovarian gonadal steroids. (Level B)
- Evaluation of Endometrial Cavity Structure
- Evaluation for structural causes of (abnormal uterine bleeding) AUB is most reliably determined by hysteroscopy and/or diagnostic imaging techniques (e.g., transvaginal ultrasonography or saline infusion sonography). (Level A)
- Transvaginal ultrasound is a good screening test but may miss some focal lesions such as polyps. (Level B)
- Irregular thickening of the endometrium (as seen by ultrasound) suggests the presence of one or more focal lesions. When such irregularity exists, when the endometrial cavity cannot be identified in its entirety or, if for any other reason polyps or fibroids involving the endometrial cavity are suspected, further evaluation should include either saline infusion sonography (SIS) or hysteroscopy. (Level A)
Treatment of Reproductive Aged Women with Chronic AUB
Definitions:
Support for Recommendations
Based on the American College of Obstetricians and Gynecologists Strength of Recommendation Classification:
Level A. Recommendations are based on good and consistent scientific evidence
Level B. Recommendations are based on limited or inconsistent scientific evidence
Level C. Recommendations are based primarily on consensus and expert opinion
Classification of Evidence
Modified US Preventive Services Task Force Hierarchy of Research Design
I-1: Evidence obtained from at least one meta-analysis or systematic review of randomized clinical trials.
I-2: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III: Descriptive studies and case reports.
IV: Opinions of respected authorities, consensus committees, clinical experience
