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Guideline Summary
Guideline Title
Diagnosis of abnormal uterine bleeding in reproductive-aged women.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Diagnosis of abnormal uterine bleeding in reproductive-aged women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2012 Jul. 10 p. (ACOG practice bulletin; no. 128).  [71 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Abnormal uterine bleeding (AUB)

Guideline Category
Diagnosis
Evaluation
Management
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Oncology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide evidence-based management guidelines for the evaluation of the reproductive-aged patient with abnormal uterine bleeding (AUB)
  • To introduce a new classification system for AUB

Note: This document does not address pregnancy-related bleeding or postmenopausal bleeding.

Target Population

Reproductive-aged women with abnormal uterine bleeding (AUB)

Interventions and Practices Considered
  1. Medical history and physical examination
  2. Sonohysterography
  3. Transvaginal ultrasonography
  4. Laboratory testing (complete blood count [CBC] with platelets, prothrombin time, and partial thromboplastin time, fibrinogen or thrombin time)
  5. Chlamydia trachomatis testing
  6. Screening for thyroid disease (thyroid-stimulating hormone [TSH] level measurement)
  7. Endometrial tissue sampling
  8. Adoption of the polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified (PALM–COEIN) nomenclature system
  9. Magnetic resonance imaging (MRI)
  10. Further testing to rule out nonfocal endometrial pathology or a structural pathology
Major Outcomes Considered

Sensitivity and specificity of diagnostic tests

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

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between: January 1990 - February 2012. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician–gynecologists were used.

Number of Source Documents

Not stated

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

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force.

I 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 also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic 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

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Level C recommendations.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

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.

Cost Analysis

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

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

  • Substantial evidence exists to indicate that sonohysterography is superior to transvaginal ultrasonography in the detection of intracavitary lesions, such as polyps and submucosal leiomyomas.
  • In all adolescents with heavy menstrual bleeding and adult patients with a positive screening history for a bleeding disorder, laboratory testing is indicated. Initial tests should include a complete blood count (CBC) with platelets, prothrombin time, and partial thromboplastin time (fibrinogen or thrombin time are optional); bleeding time is neither sensitive nor specific and is not indicated.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):

  • Testing for Chlamydia trachomatis should be considered, especially in patients at high risk of infection.
  • Hypothyroidism and hyperthyroidism are associated with abnormal uterine bleeding (AUB). Screening for thyroid disease with thyroid-stimulating hormone (TSH) level measurement in women with AUB is reasonable and inexpensive.

The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):

  • Endometrial tissue sampling should be performed in patients with AUB who are older than 45 years as a first-line test (see Figure 2 in the original guideline document).
  • The American College of Obstetricians and Gynecologists supports the adoption of the polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified (PALM–COEIN) nomenclature system developed by Federation of Gynecology and Obstetrics (FIGO) to standardize the terminology used to describe AUB.
  • Some experts recommend transvaginal ultrasonography as the initial screening test for AUB and magnetic resonance imaging (MRI) as a second-line test to be used when the diagnosis is inconclusive, when further delineation would affect patient management, or when coexisting uterine myomas are suspected.
  • MRI may be useful to guide the treatment of myomas, particularly when the uterus is enlarged, contains multiple myomas, or precise myoma mapping is of clinical importance. However, the benefits and costs to the patient must be weighed when considering its use.
  • Persistent bleeding with a previous benign pathology, such as proliferative endometrium, requires further testing to rule out nonfocal endometrial pathology or a structural pathology, such as a polyp or leiomyoma.

Definitions:

Grades of Evidence

I 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 also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Levels of Recommendations

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.

Clinical Algorithm(s)

A clinical algorithm for uterine evaluation is provided in the original guideline document.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate evaluation and diagnosis of women with abnormal uterine bleeding

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Diagnosis of abnormal uterine bleeding in reproductive-aged women. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2012 Jul. 10 p. (ACOG practice bulletin; no. 128).  [71 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2012 Jul
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins — Gynecology

Composition of Group That Authored the Guideline

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 4500, Kearneysville, WV 25430-4500; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

Proposed performance measures are included in the original guideline document.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on January 23, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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

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