• Amann M, Anguino H, Bauman RA, Cheung ML, Harris S, Kennedy J, Kivnick S, Lim A, Moore D, Munro M, Musoke L, Solh S. Chronic abnormal uterine bleeding in nongravid women. Pasadena (CA): Kaiser Permanente Southern California; 2006 Dec. 91 p. [344 references]

This is the current release of the guideline.

The process was designed to be a continuous one, allowing for ongoing modifications and revisions as new higher quality or otherwise clarifying evidence becomes available.

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*

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

• All women with excessive bleeding secondary to chronic AUB should be offered oral iron therapy. (Level C)
• Ovulatory DUB (cyclical heavy bleeding unrelated to structural abnormalities): Medical therapy options. (Note: women with DUB may have asymptomatic lesions such as intramural or subserosal fibroids)
  • Nonsteroidal anti-inflammatory agents. (Level A)
  • Combination oral contraceptives (Level C)
  • Oral progestins either continuously or nearly continuously. (Level C)
  • Local progestins as administered via a progestin secreting intrauterine contraceptive device. (Level A)
  • Antifibrinolytics (Level A) (currently not readily available in the US)
  • Depot GnRH agonists (for limited duration). (Level C)
  • Danazol, oral or transvaginal. (Level A)
• Anovulatory DUB (irregular and unpredictable bleeding unrelated to structural abnormalities): Medical therapy options: (Note: women with DUB may have asymptomatic lesions such as intramural or subserosal fibroids)
  • Lifestyle issues including stress reduction and weight loss may be important in the management of AUB associated with an anovulatory state. (Level C)
  • Progestins administered cyclically. (Level B)
  • Progestin administered continuously or nearly continuously. (Level B)
  • Combination oral contraceptives. (Level B)
  • The role of metformin and other hypoglycemic agents for the routine treatment of chronic anovulatory AUB has not been established. (Level B)
  • Ovulation induction is not indicated as therapy for anovulatory DUB. (Level C)
  • GnRH agonists may have a role in the management of selected women with chronic anovulatory AUB. (Level B) Such management should only be offered following consultation with a gynecologist.
• Persistent AUB: If AUB persists after a negative endometrial biopsy and appropriate medical therapy, the endometrial cavity should be assessed if not previously evaluated.
• Surgical therapy for women with chronic DUB is currently reserved for women not interested in future fertility. (Level C)
  • Patients taken for surgery for chronic AUB should have preoperative complete blood count (CBC) adequate screening for coagulopathy (See Table 1 above) and appropriate assessment of the endometrium and endometrial cavity. (Level C)
  • Endometrial ablation is frequently effective for chronic DUB and can be performed by outpatient resectoscopic or non-resectoscopic techniques which have equal efficacy when used by well trained and experienced surgeons. (Level A).
  • Hysterectomy is a surgical option for women with chronic DUB.
• Surgical Options for Women with Chronic AUB Associated with Leiomyomas and Polyps
  • Symptomatic endometrial polyps should be completely removed under hysteroscopic direction. (Level B)
  • The surgical management of AUB secondary to leiomyomas is determined by the size, location and number of the myomas as well as the patient's desires regarding future fertility. (Level C)
  • Endometrial Ablation: Selected patients with leiomyoma-related AUB who do not wish to retain fertility may be considered for endometrial ablation with a resectoscope or non-resectoscopic device demonstrated effective in the presence of submucous leiomyomas. (Level A)
  • Resectoscopic myomectomy
    • Resectoscopic myomectomy should be offered to patients with type 0, I, and selected type II myomas (see Appendix V in the original guideline document) particularly those who wish to retain fertility. (Level C)
    • Resectoscopic myomectomy should be performed with an accurate system and protocol for measuring and managing systemic absorption of distention media. (Level A)
    • In some instances, and particularly with multiple submucous leiomyomas, staged resectoscopic removal may be appropriate. (Level B)
    • Women with submucosal leiomyomas greater than 5 cm in diameter should be considered for alternate methods of removal. (Level C)
  • Abdominal myomectomy is the preferred procedure for women with AUB related to myomas unsuitable for resectoscopic removal and who wish to retain their uterus. (Level C)
  • Uterine Artery Embolization/Occlusion
    • Radiologic uterine artery occlusion may be offered to women with chronic AUB associated with uterine leiomyomata. (Level A)
    • Although successful pregnancies have occurred following uterine artery embolization (UAE), the role for this procedure in women who wish to preserve fertility has not been established. (Level B)
  • Myolysis is an investigational procedure for the in situ treatment of uterine leiomyomas with radiofrequency electrosurgery, cryotherapy, or focused ultrasound. It does not appear to be appropriate for women who desire future fertility. (Level B)
• Hysterectomy for Women with Chronic AUB

  If hysterectomy (total or subtotal) is to be performed for AUB it should be done by the least invasive technique within the capabilities of the surgeon. (Level A)

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

Clinical algorithms are provided in the original guideline document, titled:

• Chronic Abnormal Uterine Bleeding (AUB) Investigation
• Chronic Dysfunctional Uterine Bleeding (DUB) Therapy
• Chronic Abnormal Uterine Bleeding (AUB) Therapy - Secondary to Benign Target Lesions (Wishes to retain uterus not fertility)

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations").

• Amann M, Anguino H, Bauman RA, Cheung ML, Harris S, Kennedy J, Kivnick S, Lim A, Moore D, Munro M, Musoke L, Solh S. Chronic abnormal uterine bleeding in nongravid women. Pasadena (CA): Kaiser Permanente Southern California; 2006 Dec. 91 p. [344 references]

Not applicable: The guideline was not adapted from another source.

2006 Dec

Kaiser Permanente-Southern California - Managed Care Organization

Kaiser Permanente Southern California

Southern California Permanente Medical Group, Abnormal Uterine Bleeding Working Group

Clinical Lead: Malcolm Munro, MD (Chair)

Kaiser Permanente Southern California Abnormal Uterine Bleeding Working Group Members: Michael Amann, MD; Hector Anguino, MD; Roselie A. Bauman, MD; Mon-Lai Cheung, MD; Selena Harris, MD; John Kennedy, MD; Seth Kivnick, MD; Aaron Lim, MD; Damien Moore, MD; Lois Musoke, MD; Saad Solh, MD

Not stated

This is the current release of the guideline.

The process was designed to be a continuous one, allowing for ongoing modifications and revisions as new higher quality or otherwise clarifying evidence becomes available.

None available

None available

This NGC summary was completed by ECRI Institute on August 15, 2007.

This NGC summary is based on the original guideline, which is subject to Kaiser Permanente Southern California's copyright restrictions.