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Guideline Summary
Guideline Title
Menstrual disorders in HIV-infected women.
Bibliographic Source(s)
New York State Department of Health. Menstrual disorders in HIV-infected women. New York (NY): New York State Department of Health; 2010 Sep. 5 p. [9 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Human immunodeficiency virus (HIV) infection
  • Menstrual disorders
Guideline Category
Diagnosis
Evaluation
Management
Clinical Specialty
Allergy and Immunology
Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

To provide guidelines for diagnosis and management of menstrual disorders in human immunodeficiency virus (HIV)-infected women

Target Population

Human immunodeficiency virus (HIV)-infected women with menstrual disorders

Interventions and Practices Considered

Evaluation

  1. Complete menstrual history
  2. Assessment of disease status including the presence of opportunistic infections
  3. Pregnancy test in all human immunodeficiency virus (HIV)-infected women of childbearing potential
  4. Papanicolaou (Pap) test
  5. Instructing patients to keep a 3-month calendar outlining their bleeding patterns

Management

  1. Referral of pregnant women to an obstetrical HIV-experienced clinician
  2. Referral of women with apparent menstrual irregularities without acute symptoms to a gynecologic care provider
  3. Referral of women with amenorrhea or irregular bleeding with acute symptoms (e.g., pain, positive pregnancy test and pain, or vital signs consistent with acute blood loss) for immediate emergency evaluation
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence for Recommendation

  1. One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
  2. One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
  3. Expert opinion
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with human immunodeficiency virus (HIV) infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

  • Medical Care Criteria Committee
  • Committee for the Care of Children and Adolescents with HIV Infection
  • Dental Standards of Care Committee
  • Mental Health Guidelines Committee
  • Committee for the Care of Women with HIV Infection
  • Committee for the Care of Substance Users with HIV Infection
  • Physicians' Prevention Advisory Committee
  • Pharmacy Advisory Committee
Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

  1. Strong recommendation for the statement
  2. Moderate recommendation for the statement
  3. Optional recommendation
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

Recommendations

Major Recommendations

Definitions for the quality of the evidence (I, II, III) and strength of recommendation (A-C) are provided at the end of the "Major Recommendations" field.

Causes of Abnormal Menses in Human Immunodeficiency Virus (HIV)-Infected Women

Key Point
  • HIV-specific causes of abnormal uterine bleeding (AUB) are unusual.
  • Many studies have demonstrated that comorbidities are more likely to be the cause of menstrual abnormalities in HIV-infected women than HIV itself.

Refer to Table 1 in the original guideline document for information on causes of menstrual irregularities in HIV-infected women.

Assessing Menstrual Irregularities in HIV-Infected Women

Clinicians should obtain a complete menstrual history in all HIV-infected female patients that includes the following: (AIII)

  • Age of onset of menses
  • Amount, duration, and frequency of menses or vaginal bleeding
  • Recent changes in the menstrual cycle (during the past 6 to 12 months)
  • Whether the onset of menstrual irregularity was associated with pain, intercourse, weight change, contraception, or new medications

When evaluating amenorrhea and other menstrual irregularities in HIV-infected women, clinicians should review the patient's disease status, including the presence of opportunistic infections, and inquire about substance use and use of medications, such as psychotropics, that contribute to abnormal menses. (AIII)

Clinicians should obtain a pregnancy test for all HIV-infected women of childbearing potential who give a current history of amenorrhea or irregular vaginal bleeding, regardless of history of sexual activity or contraception use. Patients who are pregnant should be referred to an obstetrical HIV-experienced clinician for evaluation and management as soon as possible. (AIII)

Clinicians should obtain annual Papanicolaou (Pap) tests for all HIV-infected women. Pap tests should be repeated in patients with abnormal vaginal bleeding. Follow-up would be determined by the results of the Pap test. (AIII)

Clinicians should instruct patients with abnormal uterine bleeding and no acute signs or symptoms to keep a 3-month calendar outlining their bleeding patterns. (AIII)

Key Point: The most common reason for amenorrhea in premenopausal women is pregnancy. The onset of irregular bleeding, which may or may not be accompanied by pain, may indicate complications such as ectopic pregnancy, miscarriage, or incomplete abortion. Therefore, the first step in the evaluation and management of any change in menstrual pattern in women of childbearing potential should be a pregnancy test, even if the history suggests that pregnancy is unlikely.

Managing Menstrual Irregularities in HIV-Infected Women

Clinicians with gynecologic expertise should evaluate and manage menstrual irregularities in HIV-infected women in the same manner as non-HIV-infected women. The causes of menstrual abnormalities are unlikely to be HIV-related. (AIII)

Clinicians without gynecologic expertise should refer HIV-infected women with apparent menstrual irregularities without acute symptoms to a gynecologic care provider for evaluation and management. (AIII)

Clinicians should refer women with amenorrhea or irregular bleeding for immediate emergency evaluation when: (AII)

  • They present with pain
  • They have a positive pregnancy test and pain
  • Their vital signs are consistent with acute blood loss
Key Point: Ectopic pregnancy, spontaneous abortion (miscarriage), and other causes of uterine bleeding can result in either obvious or hidden blood loss. Symptoms of hypovolemia, such as pallor, hypotension, tachycardia, change in mental status, and paradoxical hypertension, may indicate a life-threatening condition and require immediate evaluation for blood loss that may not be evident.

Definitions:

Quality of Evidence for Recommendation

  1. One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
  2. One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes
  3. Expert opinion

Strength of Recommendation

  1. Strong recommendation for the statement
  2. Moderate recommendation for the statement
  3. Optional recommendation
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of menstrual disorders in human immunodeficiency virus (HIV)-infected women

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

When formulating guidelines for a disease as complex and fluid as human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), it is impossible to anticipate every scenario. It is expected that in specific situations, there will be valid exceptions to the approaches offered in these guidelines and sound reason to deviate from the recommendations provided within.

Implementation of the Guideline

Description of Implementation Strategy

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with human immunodeficiency virus (HIV) infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers, and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative (CEI), the AIDS Educational Training Centers (AETC), and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the CEI and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
New York State Department of Health. Menstrual disorders in HIV-infected women. New York (NY): New York State Department of Health; 2010 Sep. 5 p. [9 references]
Adaptation

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

Date Released
2010 Sep
Guideline Developer(s)
New York State Department of Health - State/Local Government Agency [U.S.]
Source(s) of Funding

New York State Department of Health

Guideline Committee

Women's Health Committee

Composition of Group That Authored the Guideline

Chair: Mary Jo Fink, MD, Columbia Center for Family Medicine, New York, New York

Vice-chair: Barbara C Zeller, MD, Project Samaritan AIDS Services, Inc., Bronx, New York

Members: Machelle Allen, MD, Bellevue Hospital Center, New York, New York; Kathryn Anastos, MD, Montefiore Medical Center, Bronx, New York; Jeffrey M Birnbaum, MD, MPH, SUNY Downstate Medical Center, Brooklyn, New York; Susan E Cohn, MD, MPH, University of Rochester Medical Center, Rochester, New York; Vanessa E Cullins, MD, MPH, MBA, Planned Parenthood Federation of America, New York, New York; Katherine D LaGuardia, MD, MPH, FACOG, Ortho-McNeil Pharmaceutical, Inc, Raritan, New Jersey; Howard Minkoff, MD, Maimonides Medical Center, Brooklyn, New York; Renee Samelson, MD, MPH, Albany Medical Center, Albany, New York; Diane J Tufaro, NP, AIDS Care Center, Valhalla, New York; Janice R Verley, MD, SUNY at Stony Brook, East Meadow, New York; Mary Vogler, MD, Weill College of Medicine, New York, New York; Barbara L Warren, BSN, MPH, PNP, New York State Department of Health AIDS Institute, Albany, New York

AIDS Institute Staff Liaison: Gina M Brown, MD, National Institutes of Health, Office of AIDS Research, Bethesda, Maryland

Principal Contributors: Gina M Brown, MD, National Institutes of Health, Office of AIDS Research, Bethesda, Maryland; David C Foster, MD, MPH, University of Rochester School of Medicine and Dentistry, Rochester

Peer Reviewer: John F J Clark, MD, Columbia University Medical Center, New York

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 19, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site External Web Site Policy for terms of use.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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