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SOGC CLINICAL PRACTICE GUIDELINE Abnormal Uterine

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SOGC CLINICAL PRACTICE GUIDELINE Abnormal Uterine Journal of Obstetrics and Gynaecology Canada The official voice of reproductive health care in Canada Le porte-parole officiel des soins génésiques au Canada Journal d’obstétrique et gynécologie du Canada Volume 35, Number 5 • volume 35, numéro 5 May • mai 2013 Supplement 1 • supplément 1 Abstract. .S1 Introduction . .S4 Chapter 1: Definitions. .S5 Chapter 2: Evaluation. .S7 Chapter 3: Medical Treatment. .S12 Chapter 4: Surgical Management. .S18 Chapter 5: Special Scenarios. .S21 Abnormal Uterine Appendix . .S25 Bleeding in Pre-Menopausal Women Publications mailing agreement #40026233. Return undeliverable Canadian copies and change of address notifications to SOGC Subscriptions Services, 780 Echo Dr. Ottawa, Ontario K1S 5R7. Editor-in-Chief / Rédacteur en chef Timothy Rowe CPL Editor / Rédactrice PPP Vyta Senikas Translator / Traducteur Martin Pothier Assistant Editor / Rédactrice adjointe Jane Fairbanks Editorial Assistant / Adjointe à la rédaction Daphne Sams Editorial Office / Bureau de la rédaction Journal of Obstetrics and Gynaecology Canada Room D 405A Women's Health Centre Building 4500 Oak Street Vancouver BC V6H 3N1 [email protected] Tel: (604) 875-2424 ext. 5668 Fax: (604) 875-2590 http://www.jogc.com The Journal of Obstetrics and Gynaecology Canada (JOGC) is owned by the Society of Obstetricians and Gynaecologists of Canada (SOGC), published by the Canadian Psychiatric Association (CPA), and printed by Dollco Printing, Ottawa, ON. Le Journal d’obstétrique et gynécologie du Canada (JOGC), qui relève de la Société des obstétriciens et gynécologues du Canada (SOGC), est publié par l’Association des psychiatres du Canada (APC), et imprimé par Dollco Printing, Ottawa (Ontario). Publications Mail Agreement no. 40026233. Return undeliverable Canadian copies and change of address notices to SOGC, JOGC Subscription Service, 780 Echo Dr., Ottawa ON K1S 5R7. USPS #021-912. USPS periodical postage paid at Champlain, NY, and additional locations. Return other undeliverable copies to International Media Services, 100 Walnut St., #3, PO Box 1518, Champlain NY 12919-1518. Numéro de convention poste-publications 40026233. Retourner toutes les copies canadiennes non livrées et les avis de changement d’adresse à la SOGC, Service de l’abonnement au JOGC, 780, promenade Echo, Ottawa (Ontario), K1S 5R7. Numéro USPS 021-912. Frais postaux USPS au tarif des périodiques payés à Champlain (NY) et autres bureaux de poste. Retourner les autres copies non livrées à International Media Services, 100 Walnut St., #3, PO Box 1518, Champlain (NY) 12919-1518. ISSN 1701-2163 The cover image was created from JupiterImages.com and Istockphoto.com SOGC CLINICAL PRACTICE GUIDELINE No. 292, May 2013 (Replaces No. 106, Aug 2001) Abnormal Uterine Bleeding in Pre-Menopausal Women Abstract This clinical practice guideline has been prepared by the Clinical Practice – Gynaecology Committee, reviewed by Background:.Abnormal.uterine.bleeding.is.the.direct.cause.of.a. the Canadian Paediatric and Adolescent Gynaecology/ significant.health.care.burden.for.women,.their.families,.and. Obstetrics Committee, and approved by the Executive and society.as.a.whole ..Up.to.30%.of.women.will.seek.medical. Council of the Society of Obstetricians and Gynaecologists assistance.for.this.problem.during.their.reproductive.years ..This. of Canada. guideline.replaces.previous.clinical.guidelines.on.the.topic.and. PRINCIPAL AUTHORS is.aimed.to.enable.health.care.providers.with.the.tools.to.provide. the.latest.evidence-based.care.in.the.diagnosis.and.the.medical. Sukhbir.Singh,.MD,.Ottawa.ON and.surgical.management.of.this.common.problem . Carolyn.Best,.MD,.Toronto.ON Objective:.To.provide.current.evidence-based.guidelines.for.the. Sheila.Dunn,.MD,.Toronto.ON diagnosis.and.management.of.abnormal.uterine.bleeding.(AUB). among.women.of.reproductive.age . Nicholas.Leyland,.MD,.Toronto.ON Outcomes:.Outcomes.evaluated.include.the.impact.of.AUB.on. Wendy.Lynn.Wolfman,.MD,.Toronto.ON quality.of.life.and.the.results.of.interventions.including.medical. and.surgical.management.of.AUB . CLINICAL PRACTICE – GYNAECOLOGY COMMITTEE Methods:.Members.of.the.guideline.committee.were.selected.on. Nicholas.Leyland,.MD,.(Co-chair),.North.York.ON the.basis.of.individual.expertise.to.represent.a.range.of.practical. Wendy.Wolfman,.MD,.(Co-chair),.Toronto.ON and.academic.experience.in.terms.of.location.in.Canada,.type. of.practice,.subspecialty.expertise,.and.general.gynaecology. Catherine.Allaire,.MD,.Vancouver.BC background ..The.committee.reviewed.relevant.evidence.in. Alaa.Awadalla,.MD,.Winnipeg.MB the.English.medical.literature.including.published.guidelines .. Recommendations.were.established.as.consensus.statements .. Carolyn.Best,.MD,.Toronto.ON The.final.document.was.reviewed.and.approved.by.the.Executive. Sheila.Dunn,.MD,.Toronto.ON and.Council.of.the.SOGC . Mark.Heywood,.MD,.Vancouver.BC Results:.This.document.provides.a.summary.of.up-to-date.evidence. regarding.diagnosis,.investigations,.and.medical.and.surgical. Madeleine.Lemyre,.MD,.Quebec.QC management.of.AUB ..The.resulting.recommendations.may.be. Violaine.Marcoux,.MD,.Ville.Mont-Royal.QC adapted.by.individual.health.care.workers.when.serving.women. with.this.condition . Chantal.Menard,.RN,.Ottawa.ON Conclusions:.Abnormal.uterine.bleeding.is.a.common.and. Frank.Potestio,.MD,.Thunder.Bay.ON sometimes.debilitating.condition.in.women.of.reproductive.age .. David.Rittenberg,.MD,.Halifax.NS Standardization.of.related.terminology,.a.systematic.approach. to.diagnosis.and.investigation,.and.a.step-wise.approach.to. Sukhbir.Singh,.MD,.Ottawa.ON intervention.is.necessary ..Treatment.commencing.with.medical. Disclosure.statements.have.been.received.from.all.members.of. therapeutic.modalities.followed.by.the.least.invasive.surgical. the.committee . modalities.achieving.results.satisfactory.to.the.patient.is.the. ultimate.goal.of.all.therapeutic.interventions . Key Words:.Menorrhagia,.heavy.menstrual.bleeding,.abnormal. uterine.bleeding,.hysterectomy,.endometrial.ablation J.Obstet.Gynaecol.Can.2013;35(5.eSuppl):S1–S28 This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. MAY.JOGC.MAI 2013..l..S1 Abnormal Uterine Bleeding in Pre-Menopausal Women Evidence:.Published.literature.was.retrieved.through.searches. Recommendations of.MEDLINE.and.the.Cochrane.Library.in.March.2011.using. 01 ... Adoption.of.standardized.international.terminology.for.abnormal. appropriate.controlled.vocabulary.(e .g ..uterine.hemorrhage,. uterine.bleeding.should.be.considered.(III-C). menorrhagia).and.key.words.(e .g ..menorrhagia,.heavy.menstrual. bleeding,.abnormal.uterine.bleeding) ..Results.were.restricted.to. 02 ... A.complete.blood.count.is.recommended.for.women.with.heavy. systematic.reviews,.randomized.control.trials/controlled.clinical. or.prolonged.bleeding ..(II-2A) trials,.and.observational.studies.written.in.English.and.published. 03 ... If.there.is.any.possibility.of.pregnancy,.a.sensitive.urine.or.serum. from.January.1999.to.March.2011 ..Searches.were.updated.on.a. pregnancy.test.should.be.performed ..(III-C) regular.basis.and.incorporated.in.the.guideline.to.February.2013 . 04 ... Testing.for.coagulation.disorders.should.be.considered.only. Grey.(unpublished).literature.was.identified.through.searching.the. in.women.who.have.a.history.of.heavy.menstrual.bleeding. websites.of.health.technology.assessment.and.health.technology- beginning.at.menarche.or.who.have.a.personal.or.family.history. related.agencies,.clinical.practice.guideline.collections,.clinical.trial. of.abnormal.bleeding ..(II-2B). registries,.and.national.and.international.medical.specialty.societies . 05 ... Thyroid.function.tests.are.not.indicated.unless.there.are.clinical. Values:.The.quality.of.evidence.in.this.document.was.rated.using.the. findings.suggestive.of.and.index.of.possible.suspicions.of.thyroid. criteria.described.in.the.Report.of.the.Canadian.Task.Force.on. disease ..(II-2D) Preventive.Health.Care.(Table.1) . 06 ... If.imaging.is.indicated,.transvaginal.ultrasound.should.be.the.first. Benefits, harms, and costs:.Implementation.of.the.guideline. line.imaging.modality.for.abnormal.uterine.bleeding ..(I-A) recommendations.will.improve.the.health.and.well-being.of.women. with.abnormal.uterine.bleeding,.their.families,.and.society ..The. 07 ... Saline.infusion.sonohysterography.and.diagnostic.hysteroscopy. economic.cost.of.implementing.these.guidelines.in.the.Canadian. should.be.used.in.the.diagnosis.and.characterization.of.discrete. health.care.system.was.not.considered . intrauterine.abnormalities.such.as.submucosal.fibroids ..(I-A) 08 ... Endometrial.biopsy.should.be.considered.in.bleeding.women. Summary Statements over.age.40.or.in.those.with.bleeding.not.responsive.to.medical. 01 ... Abnormal.uterine.bleeding.is.a.common.condition.affecting. therapy,.as.well.as.in.younger.women.with.risk.factors.from. women.of.reproductive.age.that.has.significant.social.and. endometrial.cancer ..(II-2A). economic.impact ..(II-2) 09 ... Office.endometrial.biopsy.should.replace.dilation.and.uterine. 02 ... Contemporary.terminology.used.to.describe.abnormal.uterine. curettage.as.the.initial.assessment.of.the.endometrium.for.these.
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