Hierarchy (classes) of evidence (1– 6) and support for recommendation (A –D and I) definitions are given at the end of the "Major Recommendations" field.
Summary of Recommendations
Recommendations are evidence based (E) unless sufficient evidence is not available where consensus-based recommendations are provided (C).
| |
Method* |
Strength** |
Recommendation |
| 1 |
C |
N/A |
It is important to exclude pregnancy in all patients with acute abnormal uterine bleeding (AUB) in the reproductive years. |
| 2 |
E |
A |
Perimenarcheal patients with acute AUB may be at increased risk for an inherited coagulopathy and should be screened accordingly with a structured history. (See Appendix III in the original guideline document). |
| 3 |
C |
N/A |
Hemodynamically stable patients may be offered either oral multidose progestins, or oral multidose, monophasic, combination oral contraceptives. (See Appendix IV in the original guideline document). |
| 4 |
E |
C |
There is fair evidence supporting the efficacy of intravenous conjugated equine estrogens for hemodynamically-stable patients. |
| 5 |
C |
N/A |
Dilation and curettage (D&C) should be reserved for patients who, in the opinion of the clinician, are inappropriate for, unresponsive to, or contraindicated from the use of medical therapy. |
| 6 |
E |
A |
When performed, D&C should be accompanied by hysteroscopy. |
| 7 |
C |
N/A |
Parenteral antifibrinolytic agents such as epsilon aminocaproic acid may have a role in the management of patients with recalcitrant acute AUB who otherwise would be candidates for more invasive surgical procedures including those that remove fertility, such as hysterectomy. |
| 8 |
C |
N/A |
Patients with acute uterine bleeding may be offered surgical alternatives to D&C that may preserve fertility including intrauterine Foley balloon and uterine artery occlusion/embolization. |
| 9 |
C |
N/A |
In some instances it will be necessary to offer patients options that will remove future fertility by removing or destroying the endometrium. These include endometrial ablation and hysterectomy. |
| 10 |
E |
A |
Many patients with acute uterine bleeding have an underlying chronic disorder that requires systematic evaluation and, in many instances, chronic therapy, following the arrest of the acute phase of the process. |
*E = Evidence-based; C = Consensus-based
**See Definitions below; Strength of evidence is not applicable (N/A) to consensus-based recommendations.
Definitions:
Hierarchy of Evidence*
- Randomized controlled trials
- Non-randomized, but internally controlled trials. Controls are considered to be "internal" if they are included in the original design of the study. Post hoc or historical comparisons are not considered internal controls. Comparisons of otherwise uncontrolled clinical series are not considered internal controls
- Case control studies
- Cohort studies
- Clinical series, without internal comparison
- Expert opinion, without available clinical studies**
Support for Recommendations*
Recommendation: A
Language: The Guideline Development Team (GDT) strongly recommends that clinicians routinely provide the intervention to eligible patients.
Evidence: The intervention improves important health outcomes, based on good evidence, and the GDT concludes that benefits substantially outweigh harms and costs.
Recommendation: B
Language: The GDT recommends that clinicians routinely provide the intervention to eligible patients.
Evidence: The intervention improves important health outcomes, based on 1) good evidence that benefits outweigh harms and costs; or 2) fair evidence that benefits substantially outweigh harms and costs.
Recommendation: C
Language: The GDT makes no recommendation for or against routine provision of the intervention. At the discretion of the GDT, the recommendation may use the language "option," but must list all the equivalent options.
Evidence: Evidence is sufficient to determine the benefits, harms, and costs of an intervention, and there is at least fair evidence that the intervention improves important health outcomes. But the GDT concludes that the balance of the benefits, harms, and costs is too close to justify a general recommendation.
Recommendation: D
Language: The GDT recommends against routinely providing the intervention to eligible patients.
Evidence: The GDT found at least fair evidence that the intervention is ineffective, or that harms or costs outweigh benefits.
Recommendation: I
Language: The GDT concludes that the evidence is insufficient to recommend for or against routinely providing the intervention. At the discretion of the GDT, the recommendation may use the language "option," but must list all the equivalent options.
Evidence: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits, harms, and costs cannot be determined.
*Kaiser Permanente National Guideline Directors Group, Edition 3, September 1, 2004
**Level of evidence added by the Abnormal Uterine Bleeding Work Group (AUBWG).
