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Philippine Obstetrical and Gynecological
Society (Foundation), Inc. (POGS)

CLINICAL

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PRACTICE
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on!

GUIDELINES

ABNORMAL
UTERINE
BLEEDING
Second Edition,
November
2009
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November 2009
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Technical Working Group for the Clinical Practice Guidelines
On Abnormal Uterine Bleeding

T!

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Philippine Obstetrical and Gynecological
Society (Foundation), Inc (POGS)

!

CLINICAL PRACTICE GUIDELINES
on
ABNORMAL UTERINE BLEEDING

November 2009!

Technical Working Group for the Clinical Practice Guidelines
On Abnormal Uterine Bleeding

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5-8. Normal limits for menstrual parameters in the mid-reproductive years (III. frequency.0 4. based primarily on the independent WHO analysis2. Based on these limits. Statement 2 The normal limits for the four main clinical dimensions of menstruation and the menstrual cycle (regularity. These have been developed following the consensus meeting of clinicians and scientists in Washington1. intermenstrual bleeding.) 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. C) Reference: 1. and also on other published population data3-6. (III. heavy or light menstrual periods. C) (Modified from the Consensus Meeting of Clinicians and Scientists (2007) by Frasier IS. 3-5. duration and flow) are set on the basis of medians and 95% confidence intervals. 1-9. Hum Reprod. Fraser IS (2007) What do we mean by abnormal uterine bleeding and dysfunctional uterine bleeding? Gynecol Forum 12:2. duration and volume or amount) are outlined below. 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. References: d" . Critchley HOD. irregular menstrual cycles. regularity. frequency.I. heaviness (volume or amount) and duration of menstrual bleeding. DEFINITION OF TERMS Statement 1 Abnormal uterine bleeding (AUB) encompasses any significant deviation from normal frequency. Broder M. with or without any recognizable pathology. Munro MG.0 < 4. premenarcheal or postmenopausal bleeding. It is used to describe all abnormal menstrual signs and symptoms arising from the uterine corpus.5 > 80 5-80 <5 Supporting Statements: Suggested normal limits for the four main clinical dimensions of menstruation and the menstrual cycle (regularity. AUB may include short or long (but regular) menstrual cycles.

Frasier IS. Statement 3 It is recommended that the term menorrhagia be discarded and replaced by the term “heavy menstrual bleeding”. 141-52. In Europe. 77-126. anovulatory DUB is characterized by irregular. Fraser IS and Inceboz US (2000) Defining disturbances of the menstrual cycle. Critchley HOD.339. On the other hand. Behn BG and Brown BW (1967) Variation of the human menstrual cycle through reproductive life. along with other terms such as hypermenorrhea. Frasier IS. London. 4. The current popular term for heavy menstruation is heavy menstrual bleeding3. Contraception 55. National Institute for Health and Clinical Excellence (NICE). 2. In: O’Brien PMS. Broder M (2007) Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. but some clinicians use it as a diagnosis. 1-9. Critchley HOD. metrorrhagia and menometrorrhagia. Munro MG. Fraser IS and Inceboz US (2000) Defining disturbances of the menstrual cycle. Disorders of the menstrual cycle. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation (1997) Menstrual bleeding patterns in untreated women. prolonged and/or heavy bleeding. Munro MG. It is usually used to describe a symptom. DUB is further differentiated into ovulatory and anovulatory DUB. References: 1. 57-65. Acta Obstet Gynecol Scand 45. 3. Nilsson L and Rybo G (1966) Menstrual blood loss: a population study. be abandoned1-2. It has been used as a diagnosis of exclusion. Cameron IT and Maclean AB (eds). Treloar AE. p. 3. DUB usually connotes anovulatory cycles. Snowden R and Christian B (eds) (1983) Patterns and Perceptions of Menstruation (A World Health Organization international study). Broder M (2007) Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. The term menorrhagia is used to describe such heavy bleeding. Heavy menstrual bleeding (2007). 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. London: RCOG Press. while in USA. 320-351. It is a term used when the disorder involves primarily the endometrial molecular mechanisms (ovulatory DUB) or the hypothalamic-pituitary-ovarian axis (anovulatory DUB). Hallberg L. In: O’Brien PMS. Croom Helm. 141-52. Boynton RE. Disorders of the menstrual cycle. C) Supporting Statements: The most common clinically significant disturbance in uterine bleeding is abnormally heavy bleeding. 5. but its exact use is variable. Hogdahl AM. Cameron IT and Maclean AB (eds). Ovulatory DUB is described as having regular cycles with heavy bleeding. London: RCOG Press. Int J Fertil 12.3 e" . Belsey EM and Pinol AP. Thus. (III.1. 1-9. (GPP) Supporting Statements: DUB is commonly used to describe abnormally heavy or irregular bleeding without recognizable organic pathology1-2. 2. 6. it is recommended that this term.

6 October 2009. signs.4 Acute uterine bleeding requires urgent or emergent medical intervention that more often leads to frequent use of urgent care. Acute uterine bleeding unrelated to pregnancy. f" .3.The recent FIGO 2009 Congress recommended that the term DUB should be discarded. Textbook of clinical reproductive endocrinology. Statement 6 Acute AUB is characterized by significant blood loss that results in hypovolemia (hypotension or tachycardia) or shock. Clark EC and Bowdler NC (2006) Abnormal uterine bleeding: a management algorithm. 3. Kennedy CM. Fraser IS (1985) The dysfunctional uterus. Hum Reprod 5: 637-8. References: 1.dysmenorrhea and dysfunctional uterine bleeding.5 It occurs more frequently in anovulatory women. (GPP) Supporting Statements: Acute uterine bleeding ranges from modestly heavy menstrual bleeding to excessively heavy bleeding associated with hypovolemic shock. 2. ovulatory disorders and endometrial dysfunction (infection. (III. 19: 590-602. C) Supporting Statements: When AUB is due to systemic causes or disorders of the reproductive tract. 12(2): 1114. Edinburgh: Churchill Livingstone. FIGO 2009 Congress Interactive Session on AUB. In: Shearman RP.2. disturbances of local hemostasis. Fraser IS (2007) What do we mean by abnormal uterine bleeding and dysfunctional uterine bleeding? Gynecol Forum 12:2. 578-98. J Am Board Fam Med. 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. Gynaecol Forum 2007. SA Fam Pract 49(8): 32-33. Lindeque BG (2007) Clinical approach to a patient with abnormal uterine bleeding. emergency and operating room resources. Munro MG. Statement 5 AUB includes both DUB and bleeding from organic causes. South Africa. vasoactive regulators) The Technical Working Group for the POGS 2009 Clinical Practice Guidelines on Abnormal Uterine Bleeding concurs with the FIGO recommendation. diagnoses) • “old DUB” includes the following – coagulopathies (congenital and acquired). 3-5. 4. Crosignani PG and Rubin B (1990) Dysfunctional uterine bleeding. Cape Town International Convention Center. The absence of organic pathology makes the cause of bleeding as dysfunctional1-2. References: 1. 2. ed. the etiology is described as organic. inflammation.1. Ely JW. Fraser IS et al. References: 1.

Non-pregnancy related genital lesions (benign or malignant pelvic lesions) M" . Reproductive Tract Disease i. Kase NG. regularity. 4. Pregnancy related complication • Pregnancy is the first consideration in women of reproductive age who present with AUB. 75: 127-32. and endothelin-1 in human myometrium in vitro: refractoriness of myometrial tissue of pregnant women to prostaglandins E2 and F2 alpha. oxytocin. 21-38.499. FIGO 2009 Congress Interactive Session on AUB. B. The absence of any. FIGO 2009 Congress Interactive Session on AUB. that is abnormal in duration. volume. South Africa. 3. Fraser IS et al. J Clin Endocrinol Metab 1992. Cape Town International Convention Center. Baltimore: Lippincott Williams & Wilkins 1999. II. Casey ML.575-9. Speroff L. Organic Causes a. Fraser IS. Abnormal Uterine Bleeding (AUB) Etiology of Abnormal Uterine Bleeding 1. Kamm KE. 6th ed. Statement 7 Chronic AUB is bleeding from the uterine corpus. and/or frequency and has been present for the majority of the last six (6) months. Livingston M. (GPP) References: 1. Normal Menstruation: • Factors that come into play for hemostasis: 1) a higher thromboxane level (PGF2) in relation to prostacyclin (PGE2 ) 2) fibrin clot formation. and 3) stabilization of the hemostatic platelet plug. 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. Clinical gynecologic endocrinology and infertility. Fraser IS et al. Glass RH. Hum Reprod Update 2002. PATHOPHYSIOLOGY A. 6 October 2009. South Africa. Cape Town International Convention Center. Mechanisms of abnormal uterine bleeding. 5. 8: 60-7. 6 October 2009. Word RA.2. Contractile effects of prostaglandins. or all of these factors may result in heavier menstruation.

with large. intermenstrual. although ovulatory bleeding may occasionally produce minimal midcyclic bleeding in the absence of an organic lesion. polyps or hyperplasia o Chronic cervicitis o Cervical polyps & carcinomas o Vaginal carcinoma o Functional ovarian cysts or neoplasms • Bleeding from a secretory endometrium. which indicates ovulation. heavy menstrual bleeding. • Arteriovenous malformations. • Myomas and polyps are widely recognized structural abnormalities causing abnormal uterine bleeding. • 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. contribute to the problem of AUB and should therefore be included in the differential diagnosis of women with acute. fragile vessels on their surfaces. • Endometrial polyps are found in all age groups. 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. However. or postmenopausal bleeding and may be associated with dysmenorrhea. despite their rare occurrence. 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. usually implies an anatomic lesion rather than an endocrine disorder. but mostly in older women. 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. which may be sufficiently severe to cause anemia. but the precise mechanisms by which they increase bleeding are poorly understood.W!" • Non-pregnancy related genital causes include: o Myomas o Endometrial carcinoma. and may also present as heavy menstrual.

insulin resistance. 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. and androgen excess. hyperprolactinemia. • Women on chronic use of steroids. anticoagulants. may be suggestive of an inherited systemic disorder of hemostasis. and increases the likelihood of abnormal uterine bleeding. c. obesity. • Diabetes mellitus can be associated with anovulation. more commonly. Hyperthyroidism. Iatrogenic • AUB among women on contraceptive hormones are usually manifested as irregular bleeding. Coagulopathies also may occur with liver disease. particularly in premenarcheal girls. as a “breakthrough” bleeding especially during the first few months of hormonal contraceptive use. and abnormal factor VIII activity. neoplasms. particularly Chlamydia trachomatis infection should likewise be considered among women who presents with irregular bleeding and post-coital spotting. Systemic Disease • Non-pregnancy-related systemic disorders (i. digitalis. metabolic. not all bleeding that occurs in this group of women can be attributed to hormonal contraceptive use. hypothalamic dysfunction. 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. 2. organic. or.e. b. Women with liver disease may have higher circulating levels of estrogen due to hepatic dysfunction and an inability to metabolize estrogen.• Genital tract infections. dilantin and/or IUD may manifest with AUB. Dysfunctional (or Endocrinologic) Causes (anovulatory or ovulatory dysfunctional uterine bleeding) WW" . most often than not. platelet dysfunction. • Renal or liver diseases may also result in abnormal uterine bleeding. associated with amenorrhea and rarely result in heavy bleeding. and primary pituitary disease are. tranquilizers. and may result from an inconsistent use. However. while renal failure is associated with irregularities of the HPO axis due to gonadal resistance to hormones. premature ovarian failure. • AUB is likewise associated with hypothyroidism.

Munro MG. Abnormal Uterine Bleeding. Berek JS. 1931-2. 1992. 2007. Garefalakis M. In such cases. • In perimenopause. Hickey M. No. explanations on many of the cellular and molecular alterations in endometrial pathologies remain to be elusive and have yet to be fully elucidated. but it may occur at other times as well. 69:1915-26. Acute uterine bleeding unrelated to pregnancy. 12. • In puberty. Am Fam Physician 2004. Gynaecology Forum 2007 Vol. 3. Present understanding of abnormal uterine bleeding mechanisms. Gynaecology Forum 2007 Vol. EPIDEMIOLOGY • WL" Abnormalities in menstruation are a common cause of general practice consultations with considerable health-service resources devoted to their management. 5. 2: 14-19. No. withdrawal of estrogen leads to a delayed endometrial shedding and irregular bleeding. PA: Lea & Febiger.1 . the decline of inhibin and rise in follicle-stimulating hormone (FSH) levels reflect the loss of follicular activity and competence. Gynaecology Forum 2007 Vol. References: 1. 12. No. • Prolonged DUB may result from a persistent graafian follicle. • Despite a wealth of studies on this very common clinical entity. 5th ed. • High sustained levels of estrogen result in episodes of amenorrhea followed by acute heavy bleeding. Healing within the endometrium is irregular and dyssynchronous. • Abnormal uterine bleeding may reflect a disordered regulation of endometrial gene expression. It is most common after the menarche or just before the menopause. 2. the HPO axis has not yet developed the necessary hormonal feedback to sustain the endometrium. III. Wynn RM. 12. Philadelphia. 6. 4.• Dysfunctional uterine bleeding (DUB) is usually anovulatory and is associated with a non-secretory endometrium. Philadelphia. Huli SK. Obstetrics and Gynecology the clinical core. Albers JR. 2: 11-14. 14th ed. 2: 6-8. The role of disorders of hemostasis and abnormal uterine bleeding. Wesley MA. unopposed by progesterone. Berek & Novak’s Gynecology. Lukes AS. PA: Lippincott Williams & Wilkins. The bleeding is caused by estrogenic overstimulation followed by withdrawal or diminution of estrogen.

Nearly 10% of girls gave a history of hypomenorrhea and 6.92 times higher in women with menorrhagia (95% CI 1. especially heavy periods. AUB in athletes has .6.3 • Women with heavier periods are 72% as likely to be working as women who have normal flow.6). followed by hematological disease (33%) and unfortunately.4–2.7 • Menstrual problems are common during adolescence due to a relatively immature hypothalamo-pituitary-ovarian (HPO) axis leading to anovulation. A family history of menorrhagia was documented in 38% of girls and more than 50% of them suffered from heavy periods themselves. Menstrual abnormalities.10 • A population-based survey of 1019 Swedish girls with a mean age of 16.4%) with the incidence of dysmenorrhea being 1. and work loss secondary to heavy periods has been estimated to cost $1692 per woman annually.9 • A Nepal survey of 96 school girls with an age range of 11–17 years. have significant economic implications. Subjective judgment of the volume lost in combination with clinical features can predict a loss of > 80 ml. menorrhagia was identified in 6.11 • A postal survey of 4610 women (aged 25–44 years) in Scotland found that 30–35% of women reported menorrhagia.8 • Anovulation (46%) was the predominant cause of admission for adolescent menorrhagia.7 years found that nearly 37% of girls experienced menorrhagia and onefifth of them were being treated with drugs for this condition.2% of girls.4% of participants (95% CI 31. nearly 63% of adolescents required blood transfusion in view of severe anemia.4–35.12 • In a cross-sectional survey of 2262 women of reproductive age (18–45 years).13 • Menstrual irregularities are more common in female athletes and in those who begin training prior to menarche (43%).9% had oligomenorrhiec cycles. moderate-to-severe dysmenorrhea was reported in 33.4 • 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.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.

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. 13. Work loss associated with increased menstrual loss in the United States. Warner P & Wyke S. 11. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988. Sharma M & Gupta S. Friberg B. Sahasrabhojanee M et al. Quint EH & Smith YR. Frayne SM. IV. 6. Cote I. Health status among women with menstrual symptoms.significant associations with low body fat and weight and the stress of sports activity. Warner PE. 58: 1206–1210. Br J Gen Pract 2004. 27: 987–994. 4. Santer M. Jordan K & Croft PR. The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa. Bleeding disorders among young women: a population-based prevalence study. Am J Obstet Gynecol 2004. Acta Obstet Gynecol Scand 2006. Skinner KM et al. History 2. Critchley HO. clinical features. Patel V. Lindgren A et al. Abnormal uterine bleeding in adolescents. J Pediatr Adolesc Gynecol 1998. Critchley HO. Menorrhagia in adolescents requiring hospitalization. 10. 190: 1216–1223. 7. 9. Tanksale V. Physical Examination 3. Br J Obstet Gynaecol 2006. Warner PE. Lumsden MA et al. 2. Jacobs P & Cumming D. Toriola AL & Mathur DN.14 References 1. 48:186–191. Obstet Gynecol 2002. An epidemiological survey of symptoms of menstrual loss in the community. Menstrual pattern and abnormalities in the high school girls of Dharan: a cross sectional study in two boarding schools. DIAGNOSIS Diagnosis of Heavy Menstrual Bleeding 1. 85: 200–206. 3. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol 2004. 190: 1224–1229. Ball-game players (35%) and distance runners (51%) most commonly experience oligomenorrhea or amenorrhea. Shapley M. Smith YR. 5. 93: 979–985. and outcome in women with heavy periods: a survey with follow-up data. whereas swimmers (37%) and sprinters (41%) experience dysmenorrhea and menorrhagia. Imaging Procedures Statement 1 Wa" . Menorrhagia I: measured blood loss. 54: 359–363. Lumsden MA et al. India. J Womens Health (Larchmt) 2003. Blood Tests 4. 113: 453–463. Orno AK. J Clin Epidemiol 2005. McPherson K & Vessey M. Br J Obstet Gynaecol 1986. 100: 683–687. 12. Menstrual dysfunction in Nigerian athletes. 11: 13–15. Coulter A. J Midwifery Womens Health 2003. Quint EH & Hertzberg RB. 12: 911–919. 8. 5: 34–36. Barnard K.

which should include inquiry into the character and nature of bleeding.A detailed history should be obtained. Symptoms such as intermenstrual or postcoital bleeding. National Institute for Health and Clinical Excellence. pelvic pain and/or pressure symptoms. Page LM.6 Serum ferritin level may be useful if there is any doubt on iron deficiency.1 Risk factors for endometrial carcinoma should be sought. Heavy menstrual bleeding. (III. 2. vagina and cervix is essential to exclude any gross pathology. Bimanual examination will allow assessment of the uterine size. Clinical guideline. 2000. Mohan S. Pregnancy must always be excluded. amount. pelvic tenderness and adnexal masses. Abdominal palpation may detect an enlarged uterus. In: Disorders of the Menstrual Cycle. as well as presence of co-morbid factors. contraceptive history. London: RCOG press. National Collaborating Centre for Women’s and Children’s Health. Statement 3 A complete blood count should be obtained from all women with abnormal uterine bleeding. Five epidemiological studies showed that anemia is an associated problem for women with HMB. thyroid disease and coagulopathies. C) Supporting Statements: A full blood count should be obtained to identify women with anemia. C) Supporting Statements: General survey should include assessment for anemia. and other medical conditions that can cause abnormal uterine bleeding.8 References Wg" . (III. London: RCOG Press. family history. (III. Statement 2 Physical examination should be performed to identify any structural pathology or systemic disease as the etiology for abnormal uterine bleeding. coagulopathies. 2007. Iron supplements should be prescribed as needed. related symptoms that may implicate a structural or histologic abnormality. Chapter 16. suggest structural or histologic abnormality. C) Supporting Statements: The clinical history should focus on the probable causes of abnormal menstrual bleeding by determining the interval.1 Pelvic examination to inspect the vulva. How do we assess abnormal uterine bleeding? Gynaecology Forum 2007. with iron deficiency becoming a clinical problem at a menstrual blood loss of 60–80 ml.7 but should not be part of routine investigation. and duration of bleeding. 24 January 2007. References 1. Penny GC. 12(2): 8-10.1-5 These studies show that MBL and iron-deficiency anemia are linked. Family history should investigate risks for cancer.2 References 1. frequency. The investigation of menorrhagia. Higham JM.

Heintz AP. Sun BL. JAMA: the journal of the American Medical Association 1997. Br J Obstet Gynaecol 1994. Nilsson L. Hallberg L. Br J Obstet Gynaecol 2004. 196 (91. Dallman PR. surgery-related bleeding. 4. 6. Carroll MD. Reconsidering menorrhagia in gynecological practice. Janssen CA. 3. London: RCOG Press. 84: 1345-51. Gao J. et al. Royal College of Obstetricians and Gynaecologists. FSH) should not be routinely done on women with HMB. et al. 43(3):241–9. Menorrhagia – a pragmatic approach to the understanding of causes and the need for investigations. and have personal or family history suggestive of a coagulopathy. C Supporting Statements: Epidemiological studies have found no link between hormone levels and heavy menstrual bleeding.32(11):822–6.277(12):973–6. Thyroid screening should only be obtained in the presence of signs and/or symptoms of thyroid disease. postpartum hemorrhage. Peyvandi F. Conard J. Souza JP. 2007. matched for age and weight. Of the 214 women with thyroid disorders.78(1):69–72. Zeng S.5%) had irregular cycles. National Collaborating Centre for Women’s and Children’s Health. 2. et al. Statement 4 Coagulation tests may be considered only in women with HMB at an early age (since menarche). 3 III. Menstrual blood loss and hematologic indices in healthy Chinese women. Scholten PC. LH.4%) had irregular cycles. and/or bleeding associated with dental work. Hogdahl AM. Menstrual blood loss--a population study. Out of 214 normal controls.45(3):320–51.5%) had regular menstrual cycles and 46 (21. Variation at different ages and attempts to define normality.1-2 One case–control study (n = 428) found no link between thyroid disorders and menstrual disturbances. 1999.3 Wd" .6). The Management of Menorrhagia in Secondary Care. 111: 734-40. 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%. Statement 5 Female hormone testing (estradiol. (III. 7. Von Willebrand disease in women with menorrhagia: a systematic review. Journal of Reproductive Medicine 1987. C) Supporting Statements: Universal screening for coagulation disorders in women with HMB is not costeffective. 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. Looker AC. 2.0-15. Clinical guideline.1. 168 (78. Heavy menstrual bleeding. 8. Menstrual blood loss and body iron stores in Brazilian women. Lee CA. Gynecology. Fraser IS. National Evidence Based Clinical Guideline No 5. National Institute for Health and Clinical Excellence. Contraception 1991. 5. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. et al. Is a 30-year-old definition still valid? European Journal of Obstetrics. Shaw ST Jr. Shankar M. progesterone. Acta Obstetricia et Gynecologica Scandinavica 1966. London: RCOG. 101(supplement 11): 3–7. 24 January 2007.6%) had normal menstruation and 18 (8.1 A personal and family history of bleeding symptoms is a valid reason for investigation. with an overall prevalence rate of 13% (95% CI 11. Andrade AT.2 References 1. Kouides PA. Sabin CA. et al. et al. Fertil Steril 2005. Prevalence of iron deficiency in the United States. and Reproductive Biology 1998.

and trophoblastic disease. Adnexal pathology and pelvic tenderness can be assessed. fibroids. References 1. the endometrial echo measures less than 5 mm. Statement 6 Pregnancy test should be done in women of reproductive-age group. Pontikides N. It is highly sensitive for detecting endometrial carcinoma (96%) and endometrial abnormality (92%). Anderson ABM. Kaltsas T. endometrial thickening. Thomas EJ. and endometrial cancer.84(5): 775–8.27:219-34. endometrial polyps. Transvaginal ultrasound allows rapid assessment of size.References 1. Pituitary and ovarian hormone levels in unexplained menorrhagia. abruptio placenta. et al. Pathophysiology of abnormal uterine bleeding.2 In premenopausal women. Shwayder JM. 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%.1 Possible causes of pregnancy-related bleeding include abortion.2 A bimanual pelvic exam (to assess uterine size). Wesley RM. Eldred JM. In a meta-analysis of > 6. Krassas GE. Evidence suggests that measurement of endometrial thickness via TVUS can accurately discriminate between women at high and low risk of endometrial cancer.40(5):641–4. Haynes PJ. endometrial thickness varies between the proliferative phase (4 to 8 mm) and the secretory phase (8 to 14 mm). (I. or focal masses. since a cutoff of 5 mm or less reliably excludes endometrial cancer. Hull SK.000 women with postmenopausal bleeding. A) for identifying structural Supporting Statements: Transvaginal ultrasound (TVUS) may reveal myomas. Menstrual disturbances in thyrotoxicosis. The texture of the endometrium can be evaluated for homogeneity or heterogeneity. Clinical Endocrinology 1994. respectively. Statement 7 Ultrasound is the first-line diagnostic tool abnormalities. C) Supporting Statements: Pregnancy is the primary consideration of abnormal uterine bleeding in women of childbearing age. 2. Measurement of the endometrial echo in postmenopausal women is helpful in determining whether endometrial biopsy or further imaging studies are necessary. Abnorma uterine bleeding. when the endometrium is the thinnest. 3. Patterns of menstrual blood loss in menorrhagia. and TVUS should be scheduled between days 4 to 6 of the menstrual cycle. Turnbull AC. Obstetrics and Gynecology 1994. and presence of uterine fibroids. (III. When the endometrium is We" . Obstet Gynecol Clin North Am 2000. position. Normally. placenta previa.1 TVUS is most sensitive in detecting disease in women with postmenopausal bleeding. ectopic pregnancy. beta-hCG test and pelvic ultrasound are useful in ruling out pregnancy-related causes. Am Acad Fam Physician 2004. 2. Albers JR. Research and Clinical Forums 1979. endometrial hyperplasia. Increased endometrial thickness is associated with intrauterine synechiae.1(2): 73–8.

Belinson JL.82(6):493–504.1-2 A meta-analysis involving 16 studies on saline contrast hysterosonography for AUB showed pooled sensitivity of 95% and specificity of 88%. Lundorf E. 2. (I. Widrich T. Olesen F. Wf" .20:1510–1517. Mitchinson AR. Obstetrical and Gynecological Survey 2002. cannot be visualized completely. Furness S. et al. Obstet Gynecol 2002. Feldstein VA. Bradley LD. Statement 8 Saline-infusion sonography should not be used as first-line diagnostic tool. 16: 305–311.57(6):389–403. Confirmation of an intracavitary mass (submucous fibroid or polyp) is improved substantially with SIS. For identification of any intrauterine pathology. et al: Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding. Watt HC. For hysteroscopy (3 studies) the range of sensitivity was 90–97% and for specificity it was 62–93%.greater than 5 mm. Tabor A. Wald NJ. is indistinct or indeterminate.3 A systematic review studied the use of ultrasound. De Kroon CD. The review concluded that all three methods were at least moderately accurate at identifying uterine pathology. The review showed a wide range in variation of results. Weber A. Ekeroma A. Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis. Justin Clark T. JAMA 1998. 5.5% of cases. The review concluded that saline infusion sonography was an accurate method for investigation of uterine pathology. Am J Obstet Gynecol 1996. Kerlikowske K.174:1327–1334.177:924–929. et al: Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. Dueholm M. de Bock GH. BJOG: an International Journal of Obstetrics and Gynaecology 2003. A systematic review of transvaginal ultrasonography. Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery. it should not be used as first-line in the investigation of AUB. Endometrial thickness as a test for endometrial cancer in women with post menopausal vaginal bleeding. et al: Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. For sonohysteroscopy (11 studies) the range of sensitivity was 85–100% and for specificity it was 50–100%. 2. transvaginal ultrasound (TVS) (10 studies) had a sensitivity range of 48–100% and specificity of 12–100%. A) Supporting Statements: Saline infusion sonography infuses saline into the endometrial cavity during TVUS to enhance the image. Farquhar C. Am J Obstet Gynecol. 110:(10)938–47. An endometrial echo of less than 5 mm is associated with malignancy in less than 0.4 A second review also showed a range of results for the various investigations. sonohysteroscopy and hysteroscopy in an AUB population. sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. but may be useful in providing a more accurate evaluation of the uterus with intracavitary lesions. Dieben SW.99:663-70. Smith-Bindman R. et al. Bradley L. 4. 1997. Outpatient hysteroscopy and ultrasonography in the management of endometrial disease. Curr Opin Obstet Gynecol 2004.5 References 1.4 References 1. 3. an enhanced view is required with saline infusion sonography (SIS) or hysteroscopy.3 However. 3. Acta Obstetricia et Gynecologica Scandinavica 2003.

1 It is better at identifying polyps than ultrasound. 3. Br J Obstet Gynaecol 1994. Society of Gynecologic Oncologists of the Philippines. Clinical guideline. Breast cancer patients on Tamoxifen who complain of abnormal vaginal bleeding. High dose estrogen 2. 2007. National Collaborating Centre for Women’s and Children’s Health. importantly. Clark TJ. Gupta JK. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review.g. Progestins 4. 2. Statement 9 Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive.2%). targeted endometrial sampling of any suspicious areas. V. National Institute for Health and Clinical Excellence. specificity = 99. National Collaborating Centre for Women’s and Children’s Health. JAMA: the Journal of the American Medical Association 2002. to determine the exact location of a fibroid or the exact nature of an abnormality.4%. 2007. Clinical guideline.4.2 Hysteroscopy allows direct visualization of the endometrial cavity and. London: RCOG Press. Medical Management of Acute Heavy Menstrual Bleeding 1. 101(supplement 11): 3–7.288(13):1610–21. Menorrhagia – a pragmatic approach to the understanding of causes and the need for investigations.3 References 1. A review of 65 papers on the use of hysteroscopy in endometrial disease found that hysteroscopy is accurate at identifying endometrial cancer (sensitivity = 86. Heavy menstrual bleeding. High dose combined oral contraceptives 3. et al. Tranexamic acid WM" . 24 January 2007. Any postmenopausal woman with bleeding or premenopausal woman with heavy and/ or irregular vaginal bleeding. London: RCOG Press. Heavy menstrual bleeding. Voit D. Endometrial sampling is recommended for: 1 1. General Guidelines for the General Obstetrician and Gynecologist: SGOP. A) Supporting Statements: Modern hysteroscopes combine miniaturization with excellent image resolution and visualization. MANAGEMENT A. e. 24 January 2007. Fraser IS. but less so at identifying endometrial disease (sensitivity = 78%. and 4. Postmenopausal women with endometrial cells seen on pap smear or premenopausal women with atypical glandular cells on pap smear. specificity = 95. (I. Statement 10 Endometrial biopsy may be performed in symptomatic women who are at high risk for the disease. 2. 2003.8%). Women who are still “menstruating” after 52 years of age Reference 1. National Institute for Health and Clinical Excellence. 3.

Obstet Gynecol 2006.19:590-602. 2.1 (III.2 Promethazine was given as needed for nausea. then 2 times a day for 2 days. Munro MG. Ely JW. Gynaecol Forum 2007. References 1. et al. submucous myoma). Acute uterine bleeding unrelated to pregnancy. oral CEE 2. Obstet Gynecol 1982.a double-blind randomized control study. 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 4 There is limited evidence that oral progestogens are effective in treating acute. Owens O.Statement 1 Medical management of non-gestational acute AUB should be considered before any surgical procedure. C) Reference 1.12 (2):1114. followed by 3 times daily for 3 days. et al. Ely JW. Statement 2 High dose conjugated equine estrogen is effective in treating acute severe abnormal uterine bleeding.59:285-91. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding. Munro MG. J Am Board Fam Med 2006.19:590-602. 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.2 The regimen is 30 ug ethinylestradiol/norgestrel 0.1 In the algorithm for treating acute AUB. Abnormal uterine bleeding: a management algorithm. DeVore GR. A) Supporting Statements: One randomized trial showed that intravenous conjugated equine estrogen (CEE) was effective in treating non-pregnant acute uterine bleeding. Abnormal uterine bleeding: a management algorithm. Mainor N. References 1.3 mg 1 active pill 4 times a day for 4 days. then once daily for 3 weeks. Such regimen is continued for 24 hours. (I. J Am Board Fam Med 2006. In another review. to achieve hemodynamic stability. COC containing 35 ug ethinylestradiol and 1 mg norethisterone was equivalent to a progesterone-only regimen.1 In this study.5 mg every 6 hours was recommended as outpatient management of severe acute bleeding in the non-pregnant woman.e. unless bleeding is suspected to be due to intrauterine lesions (i. Basu R. L!" . In a modest-sized randomized controlled trial. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized trial. Statement 3 Combined oral contraceptive pills may be used to treat acute AUB. 2. et al. Kase N.108:924-9. a tapering schedule of COCs was recommended. (I. B) Supporting Statements: Combined oral contraceptives (COCs) are frequently used in treating acute AUB despite the relative lack of evidence.

2 Norethisterone acetate (5-15 mg/day) daily until cessation of bleeding for at least 2 days. Ethamsylate did not reduce mean menstrual blood loss whereas mefenamic acid reduced blood loss by 20% (mean blood loss 186 ml before treatment.3 References 1. (II. followed by 5-10 mg/day for 3-6 weeks. Medical Management of Chronic Heavy Menstrual Bleeding 1. B. B) Supporting Statements: In one study (24 adolescents hospitalized for excessive bleeding and anemia). is another alterntive. 60 mg /day for a week. Statement 5 Tranexamic acid may be used to treat of acute AUB.37:22831. Budak E. Antifibrinolytic agents (AFA) 3.108:924-9. Munro MG. 75 ml during treatment). 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. Aust NZ J Obstet Gynaecol 1997. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate. Mainor N. stopped bleeding on average on day 3 of the regimen. Twenty-seven (27) patients were randomised to take ethamsylate 500 mg six hourly. Levonorgestrel-releasing intrauterine system (LNG-IUS) 2. menorrhagia treatment for five days from day 1 of menses during three consecutive menstrual periods was done on 76 patients. and 26 patients to take tranexamic acid 1 g six hourly. Madazli R. Munro MG.313:579-582. et al. In an RCT. Danazol LW" .heavy menstrual bleeding. A) Supporting Statements: In one study. 23 patients to take mefenamic acid 500 mg eight hourly. Aksu F. Reference 1. et al. Basu R. Sanitary towel usage was significantly reduced in patients treated with mefenamic acid and tranexamic acid. 148 ml during treatment) and tranexamic acid reduced blood loss by 54% (mean blood loss 164 ml before treatment. followed by 20 mg/day. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. BMJ 1996. 3. Acute uterine bleeding unrelated to pregnancy. Obstet Gynecol 2006. Gynaecol Forum 2007. mefenamic acid and tranexamic acid. Bonnar J & Sheppard BL. 2. the rest by the fourth day).12 (2):1114. Combined oral contraceptives 5.1 This resulted to a reduction in blood loss in all patients (25% stopped bleeding within 24 hours. Tranexamic acid given during menstruation is a safe and highly effective treatment for excessive bleeding. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized trial. Cyclic progestogen 6. (I. Nonsteroidal anti-inflammatory drugs (NSAIDs) 4.

A) Supporting Statements: The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective. Br J Obstet Gynaecol 2006. When compared with endometrial ablation.Statement 1 The Levonorgestrel-releasing intrauterine system (LNG IUS) is a highly effective treatment for heavy menstrual bleeding. Rees MC. A) Supporting Statements: Antifibrinolytic agents inhibit plasminogen activation and subsequently fibrinolysis. 2. (I. 2006). where the LNG IUS was compared with a control group taking their existing medical therapy. Cooke I. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. 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. A randomized trial comparing the levonorgestel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. The LNG-IUS reduces endometrial thickness and vascularity. with the additional benefit of relieving dysmenorrhea. Cochrane Database of Systematic Reviews 2005. such as intermenstrual bleeding and breast tenderness. 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. Women with an LNG IUS are more satisfied and willing to continue with treatment but experience more side effects. Results showed a significant reduction in mean blood loss with antifibrinolytic therapy compared to placebo (WMD -94. Lethaby A. a higher proportion of the women in the intrauterine device group cancelled their planned surgery after six months of treatment. Issue 4. A meta-analysis of four randomized controlled trials compared antifibrinolytic agents versus placebo or other medical therapies (NSAIDs.0. 113:257-63. with 35% being amenorrheic at 2 years (Busfield et al. oral luteal progestogens. In one trial of women awaiting hysterectomy. (I. References: 1. Recent evidence shows that LNG-IUS normalizes blood flow in women with heavy menstrual bleeding. ethamsylate). oral luteal progestogen and ethamsylate). 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.5). luteal norethisterone and ethamsylate. Farquhar CM. leading to a marked reduction in blood loss. Statement 2 Antifibrinolytic therapy causes a greater reduction in heavy menstrual bleeding when compared with placebo or other medical treatments (NSAIDs.4 to -36. reversible contraceptive with the additional benefits of reducing blood loss and dysmenorrhea. oral luteal progestogens and ethamsylate). In all studies comparing antifibrinolytics with mefenamic acid. Sowter MC. Busfield RA. results showed a significant reduction in mean blood LL" . et al. This treatment is not associated with an increase in side effects compared to placebo or other medical therapies (NSAIDs. 95% CI -151.

4 to -22. and oral contraceptive. Cooke I. and WMD -100. using an NSAID may reduce prostaglandin production by inhibiting the enzyme cyclo-oxygenase. Augood C.6. Duckitt K. there were no statistically significant differences between NSAIDs and other medical treatments like oral luteal progestogen. In the latest Cochrane review of nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Lethaby A. (I. there was no difference in efficacy between different NSAIDs (naproxen and mefenamic acid) in reducing heavy menstrual bleeding. Farquhar C. References: 1. Issue 4.loss (WMD -73. ethamsylate. in reducing heavy menstrual bleeding.9 to -56. placebo or other medical treatments in women with heavy menstrual bleeding were analyzed. 2. (I. LNG-IUS. Results showed that NSAIDs were more effective than placebo. respectively) and a strong. Farquhar C. 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. Moreover. and NSAIDs. or levonorgestrel-releasing intrauterine system (LNG-IUS). danazol. Cochrane Database of Systematic Reviews 2000. danazol. 95% CI -143.0. Seven crossover trials were also described. Cochrane Database of Systematic Reviews 2007. seventeen randomized controlled trials comparing individual NSAIDs with each other. 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). cross-over trial investigating the combined oral contraceptive in the L]" . WMD -111. ethamsylate.5. 95% CI -123. Lastly. there was no associated increase in side effects compared to placebo and other medical therapies. but are less effective than tranexamic acid.1.5 to -43. Antifibrinolytics for heavy menstrual bleeding. There was no significant difference in menstrual blood loss (MBL) between treatments with OCP.0. Reference: 1. Limited evidence shows no significant difference in efficacy between NSAIDs and oral luteal progestogen.36(1):23–35. In a limited number of studies with small sample sizes. B) Supporting Statements: A Cochrane database systematic review found only one small (45 patients) randomized. danazol. Statement 3 Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce heavy menstrual bleeding when compared with placebo. although nonsignificant trend in favor of tranexamic acid in the participants’ perception of an improvement in menstrual blood loss. Issue 4. Lethaby A. but less effective than tranexamic acid. The role of prostaglandins and allied substances in uterine haemostasis. Contraception 1987. 95% CI -178. or oral contraceptive pill. Statement 4 Combined oral contraceptives may be an alternative in the medical management of heavy menstrual bleeding. Hagenfeldt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding.

95% CI 1. Progestogen therapy for 21 days of the cycle results in a significant reduction in menstrual blood loss. However. (I. Further studies are unlikely in the future and this review will not be updated unless further studies are identified. This is based on nine randomized controlled trials (353 women). This regimen of progestogen may have a role in the short-term treatment of menorrhagia. Treatments given were mefenamic acid.2) and progestogens (OR 4. Irvine GA. 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. low dose danazol and a combined oral monophasic contraceptive pill.treatment of heavy menstrual bleeding (Frasier 1991). Statement 6 Danazol appears to be an effective treatment for heavy menstrual bleeding compared to other medical treatments. and the small sample sizes of the included trials limit the recommendations for clinical care. Duckitt K. Cameron IT. 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. Reference: 1. A) Supporting Statements: A meta-analysis of seven randomized controlled trials compared cyclic progestogen with other medical therapies such as danazol. Cochrane Database of Systematic Reviews 2008. although it has no advantage over other medical therapies (NSAIDs. Cochrane Database of Systematic Reviews 1997. (I. Danazol for heavy menstrual bleeding.7 to 28. Jepson RG. Cochrane Database of Systematic Reviews 2007. 31: 66-70. danazol. although women found the treatment less acceptable than intrauterine levonorgestrel. non-steroidal antiinflammatory drugs (NSAIDs) and the IUS. Lethaby A. Farquhar C. tranexamic acid. Treatment with Danazol caused more adverse events than NSAIDs (OR 7.6 to10. but majority of which are unsuitable for meta-analysis. Beaumont HH. Issue 2. La" . McCarron G. tranexamic acid. Randomized trial of 2 hormonal and 2 prostaglandin inhibiting agents in women with a complaint of menorrhagia. Issue 3. naproxen. Oral contraceptive pills for heavy menstrual bleeding. progestogens. 2. Results are based on a small number of trials. all of which are underpowered. Aust NZ J Obstet Gynaecol 1991. 95% CI 1. A) Supporting Statements: Danazol appears to be more effective than placebo. Augood C. Reference: 1. 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. Lethaby A. Issue 1. and with wide confidence intervals.0. and IUS). its acceptability to women and the need for continuing treatment.2). References: 1.05. Frasier IS. Cyclical progestogens for heavy menstrual bleeding. Iyer V. mefenamic acid or naproxen. The small number of trials.

Statement 3 Endometrial ablation may be offered as an initial treatment for heavy menstrual bleeding. microwave endometrial ablation (MEA). Second-generation ablation techniques should be used where no structural or histological abnormality is present. et al. [I. (III. Endometrial ablation and resection techniques are marginally less effective than hysterectomy at improving MBL and quality of life. Measurement of menstrual blood loss in patients complaining of menorrhagia. 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. 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. British Journal of Obstetrics and Gynaecology 1977. Statement 2 Dilatation and curettage may be performed for acute heavy mesntrual bleeding unresponsive to initial medical management. It should be considered in women who have a normal uterus and also those with small uterine fibroids (less than 3 cm in diameter).1 There were no systematic reviews or RCTs. Hodgson H. Reference: 1. 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. both TBEA and Lg" . When compared with hysterectomy. although one RCT found that MEA is superior to TCRE in terms of satisfaction at 5 years follow-up. In women with heavy menstrual bleeding alone. endometrial ablation should be considered preferable to hysterectomy. Journal of American Board of Family Medicine. Transcervical resection of the endometrium (TCRE). Haynes PJ. 2007. Inclusion criteria of RCTs showed that uterine fibroids < 3 cm in size were allowable. Surgical Management of Heavy Menstrual Bleeding 1. with uterus no bigger than a 10-week pregnancy. (III.! C. C) Reference: 1. 84(10):763–8. Ely JW. Dilatation and curettage 2. Anderson AB. Endometrial ablation 3.

shorter hospital stays ((five studies.3 Laser ablation versus TCRE There were two RCTs (n = 388) were identified.87]) and fewer adverse events. results favored ablation/resection over hysterectomy for eight of these.80 to "22.25]). Endometrial ablation techniques required less time to undertake ((five studies.59]). Ablation/resection.1 Endometrial ablation/resection There is one systematic review which examined the effectiveness and safety of MEA and TBEA for DUB.(at 12 months (three studies. Hydrothermablation versus REA Ld" .06 to 0. but result in slightly fewer QALYs.95 to "4.88] and at 24 months (three studies. Amenorrhea rates at 12 months reported by seven trials ranged from 36% to 40% for MEA and from 10% to 40% for TBEA.2 A second systematic review (19 RCTs) compared the various ablation techniques with one another for treatment of DUB. leads to shorter surgery. n = 519) OR 0.06 [95% CI "23. n = 706) WMD = "4. n = 706) OR 7. n = 706) WMD = "23.18 to 12.24 to 0. Vaporizing electrode ablation versus TCRE One RCT (n = 91) was identified. 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. The review also reported significant reductions in levels of MBL or reclassification of bleeding patterns for both MEA and TBEA. More patients favored hysterectomy (at 12 months (three studies.46 [95% CI 0.32] in favor of ablation/resection). Hysterectomy provided greater reductions in MBL.86]).16 to 0. Thermal laser ablation versus TCRE One RCT (n = 111) was identified. Only limited differences were found when comparing one ablation method with another. There were high levels of satisfaction (> 75%) for both MEA and TBEA.33 [95% CI 4. satisfaction. It was concluded that ablation/resection is an alternative to hysterectomy.MEA are less costly. satisfaction or HRQoL.91 [95% CI "4.31 [95% CI 0. re-surgery. Quality of life measures SF36) showed no difference between groups. n = 354) OR 0. more women in the endometrial ablation groups required further surgery within 12 months ((five studies. However. There was no difference between laser ablation and TRCE for amenorrhea rates. Endometrial ablation versus other treatments Hysterectomy was compared with endometrial ablation in a systematic review. Of the 13 types of adverse event reported. There were no differences between methods for amenorrhea rates. shorter hospital stay and fewer complications.12 [95% CI 0. There were no differences between groups for menorrhagia. and five were no different. complications or satisfaction. n = 440) OR 0. HRQoL or complications. Ablation/resection is less effective at reducing MBL and improving satisfaction. The review concluded that both MEA and TBEA were equivalent to first-generation ablation techniques. however. REA versus TCRE There was no difference between techniques in terms of future hysterectomy or resurgery at 2 and 5 years follow-up.

Other outcomes showed no differences at 12. menorrhagia rates or hysterectomy rates.0]).97].1 to 25.9 [95% CI 1.8 minutes [95% CI 19.3 to 10.3]) and satisfaction was greater at 24 months (OR 7.3 to "93.7] and uterine cramping (OR 1.2 to 0.80]). Electrode ablation (balloon or mesh) versus TCRE Two RCTs (n = 520) were identified.2 [95% CI 5.2). Amenorrhea was less likely with TBEA at 12 and 36 months (OR 0. MEA versus TCRE plus REA One RCT (n = 322) was identified.33 to 0. 24 and 36 months.93]) but were more likely to have abdominal pain (OR 1.02 to 0.3] and OR 3.9 [95% CI 1. 12 month PBAC.1] and less likely to have cervical tears or lacerations (OR 0.3 [95% CI 1. success rates (PBAC < 75). and complications were more likely with TBEA than with REA. TBEA versus REA One RCT (n = 239) was identified. microwave was more satisfactory and acceptable than TCRE (OR 1.03 to 0.8 to 30.94]).2 [95% CI 1.7 [95% CI 1.11 [95% CI "0.60 [95% CI 0.2 to 22.9 [95% CI 10.7]). At 2 years follow-up. In addition.02 to 0. There were no differences in satisfaction rates.One RCT (n = 269) was identified.7 to 41.0]).6]) but more likely to have local than general anesthesia (OR 13. Women having TBEA treatment had a significantly greater pain score than women in the laser group (WMD 32.5]).7 [95% CI 1.8 ml [95% CI "70. There were no differences between groups in amenorrhea rates.8 to 20. At 5 years. At 5 years follow-up the difference was maintained (OR 2. vomiting (OR 4.1 to 3.0 [95% CI 1.9]) when compared with TCRE.1 to 2. TBEA versus laser ablation One RCT (n = 70) was identified. equipment failure rates (OR 4.1 to 15. The electrode group was more likely to have local than general anesthesia (OR 15.96] and OR 0. There were no differences in other outcomes or in the same outcomes at different time periods.9 [95% CI = 1.13 [95% CI 0.8 to 15.07 [95% CI 1. respectively) but there were no differences at 24 months and 5 years. satisfaction rates or need for hysterectomy.25 to 0. odds of hemorrhage were lower in the microwave group (OR 0. TBEA was quicker (WMD 13 minutes [95% CI 10. complications rates.5 to 9.2 to 4.90]).1]) and nausea (OR 3. Duration of surgery was lower in the balloon group (WMD 20.7 minutes [95% CI 16. respectively).3 [95% CI 0. odds of satisfaction with treatment were lower in the balloon group (OR 0.0]).4 to 11.1 to 6.1]. TBEA versus TCRE One RCT (n = 82) was identified. respectively).3] and OR 2. Hydrothermablation patients were more likely to have local than general anesthesia (OR 2.6 to 5.8]) were greater in the MEA group.7]). mean intra-operative blood loss was lower (WMD "81.1 to 3.7 [1.1]) and were less likely to experience hematometra (OR 0. Women in the cryoablation group were less likely to have amenorrhea at 1 year (OR 0.7 [95% CI 23. Le" .18 [95% CI 0.7 [95% CI 1.14 [95% CI 0.4 to 35.8]. The operation time with TCRE was longer (WMD 18. However. The hysterectomy rate was significantly lower (18% versus 28%) following MEA.50 [95% CI 0. Cryoablation versus REA Two RCTs (n = 279) were identified.01 to 0.

22) in favor of surgery. results from health related quality of life (HRQoL) measures were more mixed. (I. Amenorrhea was more likely in the bipolar radiofrequency group (OR 7. Wyatt K.46 to 5.69 (95% CI 0.11 (95% CI 0.70) in favor of surgery. and by 5 years (n = 140) OR 1. There was no difference between groups on the SF-36 (a short form with 36 questions. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.4 [95% CI 3.4]) and women in the bipolar radiofrequency group were more likely to be satisfied with treatment outcome at 12 months (OR 3. (Cochrane Review).83 [95% CI 1. and by 5 years (n = 140) OR 1.77 to 3. n = 223.21 to 4.84 to 4.8(3):iii. These studies concluded that the treatments were equivalent. Oxford: Update Software. by 2 years (n = 173) OR 2.06 to 0.3) in favor of surgery.29 to 15. The difference between pharmaceutical treatments and surgery diminished over time. Cooke I. Farquhar C. vitality and physical role limitation. Endometrial destruction techniques for heavy menstrual bleeding. mental health.53 to 10.(Cochrane Review). women in the TBEA group had higher scores on the Euroquol 5D VAS than women in the laser group (WMD 5.However.06 to 0. References: 1. Lethaby A.3 [95% CI 0. Also. women in the pharmaceutical group were more likely to undergo additional surgery: by 2 years follow-up (n = 236) OR 0. Two RCTs in the systematic review examined use of pharmaceutical or surgical interventions on women with HMB in a secondary care setting.12 (95% CI 0. Health Technology Assessment 2004. However. used in determining health status of patients) scale for general health. Hickey M. Stein K. 3. Bipolar radiofrequency endometrial ablation versus TBEA One RCT (n = 126) was identified.99 [95% CI 1.3 to 7.6]).8 to 14. et al.50] in favor of surgery. n = 189. The effectiveness and cost-effectiveness of microwave and thermal balloon endometrial ablation for heavy menstrual bleeding: a systematic review and economic modelling.73] There was no statistical difference between the groups.0]).0]). Issue Oxford. Oxford: Update Software. There was no statistical difference between the groups by the 5th year of follow-up. Lf" . the subjective measurement of MBL at 12 months was in favor of surgery (three RCTs.7 [95% CI 1. Statement 4 Hysterectomy should not be used as first-line treatment for heavy menstrual bleeding. OR 25.99 [95% CI 0.70) with no statistical difference between the groups. ablation) in secondary care settings. In: Cochrane Database of Systematic Reviews. In: Cochrane Database of Systematic Reviews.1 Six other RCTs compared LNG-IUS with surgery (hysterectomy. Garside R. The figures showed that objective measurement of MBL at 12 months was in favor of surgery (one RCT.6 (95% CI 5.38]). physical function. C) Supporting evidence: In one systematic review (n = 821) in 2006.At 12 months follow up.0 [95% CI 1. Regarding control of bleeding.28 (95% CI 4.3 to 21.97) in favor of surgery. OR 3. 2.1–155. The figures for patient satisfaction were: at 4 months (n = 183) OR 8. Lethaby A.5 to 440. (cure or improvement): at 4 months (n = 186) OR 10. by 2 years (n = 173) OR 2.39 (95% CI 1. Shepperd S. There were statistically significant differences for emotional role (n = 269. Issue 2.22) in favour of surgery and by 5 years follow-up (n = 140) OR 0.11 to 10. 2004. eight RCTs compared pharmaceutical with surgical treatments for HMB. 2005.

but also often want to avoid hysterectomy in order to achieve these outcomes.67 [95% CI 1. or hysterectomy. 4. Switzerland. SOGC clinical guidelines. 2. Rubinger T.1 While surgery has an advantage over pharmaceutical treatment in terms of outcome. A survey of women’s preferences regarding alternative surgical treatments for menorrhagia. this does not take into account the reversible nature of pharmaceutical treatment compared with surgery. Mingo C. The systematic review states that investigations for causes of HMB.69]).49]). Nagele F.4-8 References 1.1(2):96–105. Dwyer N. attempts at pharmaceutical treatment and provision of full information to the woman are required prior to hysterectomy. failed pharmaceutical treatment and full information provision to the woman. Oxford: Update Software. Journal of Obstetrics and Gynaecology Canada: JOGC 2002. Issue 2. WMD 3. Women’s stories: Ethnic variations in women’s attitudes and experiences of menopause.11 [95% CI 0. Swiss Society of Gynecology and Obstetrics. Browning J.24 [95% CI 0. International Journal of Gynaecology and Obstetrics 1999. 82(1):160–6. Swiss consensus guidelines for hysterectomy. Nathorst-Boos J. Magos A. Faisst K. Lethaby A.29]) in favor of surgery. Why do women choose endometrial ablation rather than hysterectomy? Fertility and Sterility 1998.71(3):230–4.11 to 0. Farquhar C. Bourdrez P.64(3):297–305.04 to 0. et al. Fertility and Sterility 2004. (Cochrane Review).68 to 12. LM" .64 [95% CI "1. hysterectomy is only indicated where HMB is causing anemia and/or serious HRQoL impact. Journal of Womens Health and Gender-Based Medicine 2000. Surgery versus medical therapy for heavy menstrual bleeding. 7.WMD 9.9(Suppl 2): S27–38. Allaire C. 3. Jasperse M. In: Cochrane Database of Systematic Reviews. 5. Patient preference studies show that women want certain outcomes for treatment of HMB.43]) and bodily pain (n = 274.98[95% CI 1. a levonorgestrel-releasing intrauterine device. hysterectomy.65 to 17. WMD 6. von Schoultz B.2 A consensus statement highlights that hysterectomy for HMB should only be undertaken after investigations to establish cause of HMB. 8. 6. et al.24(1):37–61. Hysterectomy [French].3 In addition. Acta Obstetricia et Gynecologica Scandinavica 1992. Mol BW. Consumer’s attitude to hysterectomy: The experience of 678 women. et al. Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation.14 to 8. Bongers MY. Health Expectations 1998. Jeffrey J. Sculpher MJ. social function (n = 274. 2006. and hormone replacement therapy.30]) and were less likely to have reported adverse effects (OR 0. OR 0. Herman CJ. Wyss P. Marjoribanks J.69(6):1063–6. Lefebvre G. Schilling J. Use of LNG-IUS was more likely to result in additional surgery at 12 months (n = 423. Fuchs T.

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. based on clinical experience. There is fair 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. There is good 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. descriptive studies and case reports or reports of expert committees. DEFINITION There is good evidence to support the recommendation of the practice in abnormal uterine bleeding. Opinions of respected authorities. . A good practice point (GPP) is a recommendation for best practice based on the experience of the Technical Working Group.

Norethisterone acetate 5 mg PO TID on cycle days 5-26 for ovulatory cycles 10. Tranexamic acid 1 gram QID PO during heavy bleeding x 3 days 3. Danazol 200-400 mg PO daily for progestin-resistant cases """""""""""""""""""""""""""""""""""""""""""""""""""""""" ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ]W" . Levonorgestrel-releasing intrauterine system once every 5 years 2.APPENDIX B DRUG DOSAGES 1. Mefenamic acid 500 mg PO TID during heavy bleeding x 3 days 5. Medroxyprogesterone 10 mg PO OD on cycle days 16-25 for anovulatory cycles 7. Ibuprofen 200 mg PO TID during heavy bleeding x 3 days 4. Naproxen 550 mg LD. Medroxyprogesterone 10 mg PO TID on cycle days 5-26 for ovulatory cycles 8. Norethisterone acetate 5 mg PO TID on cycle days 16-25 for anovulatory cycles 9. then 275 mg PO BID during heavy bleeding x 3 days 6.