Abnormal uterine bleeding -...
Transcript of Abnormal uterine bleeding -...
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Abnormal uterine bleeding
Updated 2014 Feb 17 032000 PM ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with
ovulatory dysfunction (National Guideline Clearinghouse 2014 Feb 17) view update Show more updates
Related Summaries
Heavy menstrual bleeding
Endometrial ablation
Polycystic ovary syndrome
Hysterectomy
Uterine leiomyoma
Overview
terminology describing abnormaluterinebleeding varies widely
initial evaluation of women presenting with abnormaluterinebleeding
history should include
specific details of bleeding pattern
assessment for possible inherited systemic disorders of hemostasis (Kaiser Level A)
testing to consider for all women with abnormaluterinebleeding
pregnancy test (Kaiser Level C)
complete blood count (CBC) (Kaiser Level C)
additional testing guided by patient history and response to treatment
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
thyroid-stimulating hormone (TSH) if suspected anovulatory bleeding (Kaiser Level C)
endocrine studies if suspected hyperprolactinemia or hyperandrogenic state
factor VIII platelets and bleeding time if suspected bleeding disorder
further evaluation with ultrasound saline infusion sonography andor hysteroscopy for persistent bleeding (Kaiser Level A)
treatment for acute severe bleeding
IV conjugated equine estrogen 25 mg (repeated at 3-4 hours if needed) may terminate endometrial bleeding in patients with
dysfunctional uterinebleeding (level 2 [mid-level] evidence)
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in terminating acute
uterinebleeding (level 2 [mid-level] evidence)
treatment for women with irregular uterinebleeding
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (level 2 [mid-level] evidence)
consider stress reduction and weight loss (Kaiser Level C)
surgical therapy for women not interested in preserving fertility (Kaiser Level C)
endometrial ablation is almost as effective as hysterectomy for dysfunctional uterinebleeding (level 1 [likely reliable]
evidence)
for patients with abnormaluterinebleeding due to leiomyomas surgical management determined by size location and
number of myomas (Kaiser Level C)
treatment for heavy menstrual bleeding
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
levonorgestrel-releasing intrauterine system (LNG-IUS)
appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
improves quality of life as effectively as surgery (level 1 [likely reliable] evidence)
treatment of choice if hormonal treatments are acceptable and at least 12 months use anticipated (NICE A
recommendation)
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
other medical options include nonsteroidal anti-inflammatory drugs (NSAID) tranexamic acid (Lysteda) oral or injected
progestins and danazol
endometrial ablation preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week
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pregnancy size (NICE A recommendation)
for women with large fibroids and other significant symptoms (such as dysmenorrhea or pressure symptoms) consider
surgery or uterine artery embolization as first-line treatment (NICE D(GPP) recommendation)
dilation and curettage (DampC) should not be used as therapeutic treatment (NICE C recommendation)
Description
Also called
IncidencePrevalence
Complications
Pregnancy-related
Hormonal causes
Medications
General Information
abnormaluterinebleeding includes(2)
infrequent unpredictable irregular bleeding that varies in amount duration and character (anovulatory bleeding)
heavy menstrual bleeding (flow gt 80 mL menses which last ge 7 days or have intervals le 21 days)
normal menstrual flow
usual duration of menstrual flow is 4-6 days with average volume blood loss 30 mL (Acta Obstet Gynecol Scand
196645(3)320)
15 of cycles in women of reproductive age are 28 days in length lt 1 have cycle lt 21 days or gt 35 days (Br J
Obstet Gynaecol 1992 May99(5)422)
common terms used include
abnormal vaginal bleeding
dysfunctional uterinebleeding (DUB)
functional uterinebleeding
irregular menstrual bleeding
prolonged menstrual bleeding
extensive disagreement worldwide in terminology describing symptoms signs and causes of abnormaluterinebleeding (Fertil Steril
2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007 Dec19(6)591)
10-30 prevalence of abnormaluterinebleeding among women of reproductive age (Value Health 2007 May-Jun10(3)183
EBSCOhost Full Text)
anemia including iron deficiency anemia(2)
Differential Diagnosis
pregnancy (see also Pregnancy testing)(2)
ectopic pregnancy(2)
miscarriage(2)
gestational trophoblastic disease(2)
irregular bleeding due to physiologic anovulatory cycles(1 2)
within 2 years of menarche (secondary to immature hypothalamic-pituitary-ovarian axis)
perimenopausal women
hypothyroidism(1 2)
hyperthyroidism(1 2)
hyperprolactinemia(1 2)
hyperandrogenic conditions(1 2)
polycystic ovarian syndrome (PCOS)
congenital adrenal hyperplasia
androgen-producing tumor such as Sertoli-Leydig cell tumor
premature ovarian failure(2)
hypothalamic dysfunction (including anorexia nervosa)(2)
contraception(1)
oral contraceptives
medroxyprogesterone acetate
intrauterine device (IUD)
(1)
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Gynecologic lesions
Bleeding disorders
History
contraception(1)
oral contraceptives
medroxyprogesterone acetate
intrauterine device (IUD)
anticoagulants(2)
phenytoin(1)
antipsychotics (for example olanzapine risperidone)(1)
tricyclic antidepressants(1)
corticosteroids
tamoxifen(2)
herbal supplements with estrogenic activity(2)
vaginal(2)
genital ulcers
squamous cell carcinoma of vagina
cervical(2)
ulcer
cervical polyp
squamous cell carcinoma of cervix
uterine(2)
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometrial hyperplasia
endometritis
adenomyomata or diffuse adenomyosis
endometrial polyp
congenital abnormalities
genital trauma(2)
foreign bodies(2)
anticoagulants(2)
von Willebrand disease(2)
other blood dyscrasias(2)
inherited bleeding disorders (most commonly von Willebrand disease) reported in 11-17 women with menorrhagia
cohort of 150 women referred for menorrhagia who had normal pelvic exam
women had measurements of activated partial thromboplastin time factor VIII activity von Willebrand factor antigen
and activity and factor XI
26 (17) had inherited bleeding disorder including
von Willebrand disease in 18
factor XI deficiency in 4
combined von Willebrand disease and factor XI deficiency in 1
combined von Willebrand disease factor XI deficiency and factor X deficiency in 1
hemophilia A carrier in 1
platelet dysfunction in 1
Reference - Lancet 1998 Feb 14351(9101)485 EBSCOhost Full Text
comparing 121 women with menorrhagia vs 123 controls
bleeding disorders diagnosed in 107 vs 32 (p = 002)
von Willebrand disease diagnosed in 8 (66) vs 1 (08) (p = 002)
prevalence of von Willebrand disease 159 white patients vs 14 black patients (p = 001)
Reference - Obstet Gynecol 2001 Apr97(4)630
History and Physical
women with heavy uterinebleeding should have a structured history to screen for inherited systemic disorders of hemostasis
(Kaiser Level A)(3)
patients with positive screening on structured history should be considered for further evaluation including consultation with a
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Physical
Testing overview
hematologist andor testing for von Willebrand disease
positive screen defined as any of
heavy menstrual bleeding since menarche
postpartum hemorrhage
surgery related bleeding
bleeding associated with dental work
2 or more of
family history of bleeding symptoms
bruising 1-2 timesmonth
epistaxis 1-2 timesmonth
frequent gum bleeding
each patient with chronic abnormaluterinebleeding should be assessed for ovulatory function (can be reliably confirmed with a
history of predictable cyclic menses with a cycle length of every 22-35 days) (Kaiser Level C)(3)
determine pattern of bleeding(1)
severe acute bleeding (bleeding requiring gt 1 pad or tampon per hour or vital signs indicating hypovolemia)
irregular bleeding (includes metrorrhagia menometrorrhagia oligomenorrhea prolonged bleeding intermenstrual bleeding
or other irregular pattern)
menorrhagia (heavy but regular cyclic bleeding plus gt 7 days of bleeding or clots or iron deficiency anemia) prolonged
bleeding gt 12 days should be considered irregular regardless of cyclic pattern
ask about
symptoms of anemia (fatigue lightheadedness weakness dyspnea on exertion)(2)
history of weight change(2)
history or symptoms of thyroid disorder(2)
medication use(2)
oral contraceptive
thyroid medications
other hormones
anticoagulants
check for signs of(2)
pregnancy
anemia (pallor tachycardia)
endocrine disorders
hyperandrogenism (acne hirsutism virilization)
hypothyroidism
hyperthyroidism
bleeding disorder (petechiae bruising recurrent or unexplained joint effusion)
abdominal mass (if large uterine fibroid)
gynecological exam for structural lesions(2)
vaginal
genital ulcers
squamous cell carcinoma of vagina
cervical
ulcer
polyp
squamous cell carcinoma of cervix
uterine
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometritis
adenomyomata or diffuse adenomyosis
polyp
congenital abnormalities
Diagnostic Testing
for all women with chronic abnormaluterinebleeding(3)
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Endometrial sampling
Imaging studies
pregnancy test (urine or blood) should be done (Kaiser Level C)
CBC should be considered (Kaiser Level C)
additional testing guided by patient history(3)
TSH is appropriate in women with suspected or known anovulatory dysfunctional uterinebleeding (DUB) (Kaiser Level C)
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
other endocrine tests if indicated
to rule out hyperprolactinemia - prolactin level
to rule out polycystic ovary syndrome or other hyperandrogenic state
17-hydroxyprogesterone
testosterone
dehydroepiandrosterone sulfate
testing for bleeding disorder if bleeding persists despite treatment(3)
platelets
bleeding time
factor VIII
routine transvaginal ultrasonography generally unnecessary for initial visit but should be considered for persisting symptoms and
especially for those who fail initial medical therapy (Kaiser Level C)(3)
indications for further evaluation with ultrasound saline infusion sonography andor hysteroscopy (Kaiser Level A) include(3)
persistent abnormaluterinebleeding despite normal and satisfactory endometrial sampling
irregular thickening of endometrium on ultrasound (suggesting presence of focal lesions)
endometrial cavity cannot be identified in its entirety
if polyps or fibroids involving endometrial cavity suspected
indications for endometrial sampling
endometrial sampling should be performed when there is an increased risk of endometrial hyperplasia or neoplasia (Kaiser
Level A)
women aged gt 40 years (Kaiser Level B)
women aged lt 40 years with additional risk factors (including features suggestive of chronic anovulation and weight greater
than 90 kg) (Kaiser Level B)
patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome) (Kaiser Level B)
sampling approach
outpatient endometrial biopsy with catheter techniques should be considered first line approach (Kaiser Level A)
if endometrial biopsy is indicated and cannot be obtained or is inadequate repeat sampling should be attempted if
necessary with DampC (Kaiser Level C)
Pipelle and Explora curettes associated with similar patient pain ratings in endometrial biopsy (level 2 [mid-
level] evidence)
based on randomized trial with use of means instead of medians for pain analysis
70 women having endometrial biopsy (abnormaluterinebleeding most common indication) randomized to Pipelle vs Explora
curette
no significant difference in subject-reported pain or provider-reported ease of use
Reference - Obstet Gynecol 2011 Mar117(3)636
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
considerations for imaging of endometrial cavity(3)
goals for evaluation of endometrial cavity in women with chronic abnormaluterinebleeding include detection of endometrial
hyperplasia or cancer in selected patients and identification of focal lesions such as polyps and leiomyomas (fibroids) which
might explain bleeding (Kaiser Level C)
if chronic abnormaluterinebleeding continues despite normal and satisfactory endometrial sampling consider ultrasound
saline infusion sonography andor hysteroscopy (Kaiser Level A)
transvaginal ultrasound considered adequate if entire endometrial echo shown in longitudinal and transverse planes through
widest part of endometrial cavity (Kaiser Level C)
no consensus on upper limit of endometrial thickness to be considered normal in premenopausal women (Kaiser Level B)
transvaginal ultrasound considered good screening test but may miss some focal lesions such as polyps (Kaiser Level B)
transvaginal ultrasound sonohysterography and hysteroscopy may be similarly effective in detection of
intrauterine pathology in premenopausal women with abnormaluterinebleeding (level 2 [mid-level] evidence)
based on systematic review with heterogeneity
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
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20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
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pregnancy size (NICE A recommendation)
for women with large fibroids and other significant symptoms (such as dysmenorrhea or pressure symptoms) consider
surgery or uterine artery embolization as first-line treatment (NICE D(GPP) recommendation)
dilation and curettage (DampC) should not be used as therapeutic treatment (NICE C recommendation)
Description
Also called
IncidencePrevalence
Complications
Pregnancy-related
Hormonal causes
Medications
General Information
abnormaluterinebleeding includes(2)
infrequent unpredictable irregular bleeding that varies in amount duration and character (anovulatory bleeding)
heavy menstrual bleeding (flow gt 80 mL menses which last ge 7 days or have intervals le 21 days)
normal menstrual flow
usual duration of menstrual flow is 4-6 days with average volume blood loss 30 mL (Acta Obstet Gynecol Scand
196645(3)320)
15 of cycles in women of reproductive age are 28 days in length lt 1 have cycle lt 21 days or gt 35 days (Br J
Obstet Gynaecol 1992 May99(5)422)
common terms used include
abnormal vaginal bleeding
dysfunctional uterinebleeding (DUB)
functional uterinebleeding
irregular menstrual bleeding
prolonged menstrual bleeding
extensive disagreement worldwide in terminology describing symptoms signs and causes of abnormaluterinebleeding (Fertil Steril
2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007 Dec19(6)591)
10-30 prevalence of abnormaluterinebleeding among women of reproductive age (Value Health 2007 May-Jun10(3)183
EBSCOhost Full Text)
anemia including iron deficiency anemia(2)
Differential Diagnosis
pregnancy (see also Pregnancy testing)(2)
ectopic pregnancy(2)
miscarriage(2)
gestational trophoblastic disease(2)
irregular bleeding due to physiologic anovulatory cycles(1 2)
within 2 years of menarche (secondary to immature hypothalamic-pituitary-ovarian axis)
perimenopausal women
hypothyroidism(1 2)
hyperthyroidism(1 2)
hyperprolactinemia(1 2)
hyperandrogenic conditions(1 2)
polycystic ovarian syndrome (PCOS)
congenital adrenal hyperplasia
androgen-producing tumor such as Sertoli-Leydig cell tumor
premature ovarian failure(2)
hypothalamic dysfunction (including anorexia nervosa)(2)
contraception(1)
oral contraceptives
medroxyprogesterone acetate
intrauterine device (IUD)
(1)
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Gynecologic lesions
Bleeding disorders
History
contraception(1)
oral contraceptives
medroxyprogesterone acetate
intrauterine device (IUD)
anticoagulants(2)
phenytoin(1)
antipsychotics (for example olanzapine risperidone)(1)
tricyclic antidepressants(1)
corticosteroids
tamoxifen(2)
herbal supplements with estrogenic activity(2)
vaginal(2)
genital ulcers
squamous cell carcinoma of vagina
cervical(2)
ulcer
cervical polyp
squamous cell carcinoma of cervix
uterine(2)
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometrial hyperplasia
endometritis
adenomyomata or diffuse adenomyosis
endometrial polyp
congenital abnormalities
genital trauma(2)
foreign bodies(2)
anticoagulants(2)
von Willebrand disease(2)
other blood dyscrasias(2)
inherited bleeding disorders (most commonly von Willebrand disease) reported in 11-17 women with menorrhagia
cohort of 150 women referred for menorrhagia who had normal pelvic exam
women had measurements of activated partial thromboplastin time factor VIII activity von Willebrand factor antigen
and activity and factor XI
26 (17) had inherited bleeding disorder including
von Willebrand disease in 18
factor XI deficiency in 4
combined von Willebrand disease and factor XI deficiency in 1
combined von Willebrand disease factor XI deficiency and factor X deficiency in 1
hemophilia A carrier in 1
platelet dysfunction in 1
Reference - Lancet 1998 Feb 14351(9101)485 EBSCOhost Full Text
comparing 121 women with menorrhagia vs 123 controls
bleeding disorders diagnosed in 107 vs 32 (p = 002)
von Willebrand disease diagnosed in 8 (66) vs 1 (08) (p = 002)
prevalence of von Willebrand disease 159 white patients vs 14 black patients (p = 001)
Reference - Obstet Gynecol 2001 Apr97(4)630
History and Physical
women with heavy uterinebleeding should have a structured history to screen for inherited systemic disorders of hemostasis
(Kaiser Level A)(3)
patients with positive screening on structured history should be considered for further evaluation including consultation with a
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Physical
Testing overview
hematologist andor testing for von Willebrand disease
positive screen defined as any of
heavy menstrual bleeding since menarche
postpartum hemorrhage
surgery related bleeding
bleeding associated with dental work
2 or more of
family history of bleeding symptoms
bruising 1-2 timesmonth
epistaxis 1-2 timesmonth
frequent gum bleeding
each patient with chronic abnormaluterinebleeding should be assessed for ovulatory function (can be reliably confirmed with a
history of predictable cyclic menses with a cycle length of every 22-35 days) (Kaiser Level C)(3)
determine pattern of bleeding(1)
severe acute bleeding (bleeding requiring gt 1 pad or tampon per hour or vital signs indicating hypovolemia)
irregular bleeding (includes metrorrhagia menometrorrhagia oligomenorrhea prolonged bleeding intermenstrual bleeding
or other irregular pattern)
menorrhagia (heavy but regular cyclic bleeding plus gt 7 days of bleeding or clots or iron deficiency anemia) prolonged
bleeding gt 12 days should be considered irregular regardless of cyclic pattern
ask about
symptoms of anemia (fatigue lightheadedness weakness dyspnea on exertion)(2)
history of weight change(2)
history or symptoms of thyroid disorder(2)
medication use(2)
oral contraceptive
thyroid medications
other hormones
anticoagulants
check for signs of(2)
pregnancy
anemia (pallor tachycardia)
endocrine disorders
hyperandrogenism (acne hirsutism virilization)
hypothyroidism
hyperthyroidism
bleeding disorder (petechiae bruising recurrent or unexplained joint effusion)
abdominal mass (if large uterine fibroid)
gynecological exam for structural lesions(2)
vaginal
genital ulcers
squamous cell carcinoma of vagina
cervical
ulcer
polyp
squamous cell carcinoma of cervix
uterine
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometritis
adenomyomata or diffuse adenomyosis
polyp
congenital abnormalities
Diagnostic Testing
for all women with chronic abnormaluterinebleeding(3)
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Endometrial sampling
Imaging studies
pregnancy test (urine or blood) should be done (Kaiser Level C)
CBC should be considered (Kaiser Level C)
additional testing guided by patient history(3)
TSH is appropriate in women with suspected or known anovulatory dysfunctional uterinebleeding (DUB) (Kaiser Level C)
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
other endocrine tests if indicated
to rule out hyperprolactinemia - prolactin level
to rule out polycystic ovary syndrome or other hyperandrogenic state
17-hydroxyprogesterone
testosterone
dehydroepiandrosterone sulfate
testing for bleeding disorder if bleeding persists despite treatment(3)
platelets
bleeding time
factor VIII
routine transvaginal ultrasonography generally unnecessary for initial visit but should be considered for persisting symptoms and
especially for those who fail initial medical therapy (Kaiser Level C)(3)
indications for further evaluation with ultrasound saline infusion sonography andor hysteroscopy (Kaiser Level A) include(3)
persistent abnormaluterinebleeding despite normal and satisfactory endometrial sampling
irregular thickening of endometrium on ultrasound (suggesting presence of focal lesions)
endometrial cavity cannot be identified in its entirety
if polyps or fibroids involving endometrial cavity suspected
indications for endometrial sampling
endometrial sampling should be performed when there is an increased risk of endometrial hyperplasia or neoplasia (Kaiser
Level A)
women aged gt 40 years (Kaiser Level B)
women aged lt 40 years with additional risk factors (including features suggestive of chronic anovulation and weight greater
than 90 kg) (Kaiser Level B)
patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome) (Kaiser Level B)
sampling approach
outpatient endometrial biopsy with catheter techniques should be considered first line approach (Kaiser Level A)
if endometrial biopsy is indicated and cannot be obtained or is inadequate repeat sampling should be attempted if
necessary with DampC (Kaiser Level C)
Pipelle and Explora curettes associated with similar patient pain ratings in endometrial biopsy (level 2 [mid-
level] evidence)
based on randomized trial with use of means instead of medians for pain analysis
70 women having endometrial biopsy (abnormaluterinebleeding most common indication) randomized to Pipelle vs Explora
curette
no significant difference in subject-reported pain or provider-reported ease of use
Reference - Obstet Gynecol 2011 Mar117(3)636
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
considerations for imaging of endometrial cavity(3)
goals for evaluation of endometrial cavity in women with chronic abnormaluterinebleeding include detection of endometrial
hyperplasia or cancer in selected patients and identification of focal lesions such as polyps and leiomyomas (fibroids) which
might explain bleeding (Kaiser Level C)
if chronic abnormaluterinebleeding continues despite normal and satisfactory endometrial sampling consider ultrasound
saline infusion sonography andor hysteroscopy (Kaiser Level A)
transvaginal ultrasound considered adequate if entire endometrial echo shown in longitudinal and transverse planes through
widest part of endometrial cavity (Kaiser Level C)
no consensus on upper limit of endometrial thickness to be considered normal in premenopausal women (Kaiser Level B)
transvaginal ultrasound considered good screening test but may miss some focal lesions such as polyps (Kaiser Level B)
transvaginal ultrasound sonohysterography and hysteroscopy may be similarly effective in detection of
intrauterine pathology in premenopausal women with abnormaluterinebleeding (level 2 [mid-level] evidence)
based on systematic review with heterogeneity
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
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20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
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copy 2014 EBSCO Industries Inc Todos los derechos reservados
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Gynecologic lesions
Bleeding disorders
History
contraception(1)
oral contraceptives
medroxyprogesterone acetate
intrauterine device (IUD)
anticoagulants(2)
phenytoin(1)
antipsychotics (for example olanzapine risperidone)(1)
tricyclic antidepressants(1)
corticosteroids
tamoxifen(2)
herbal supplements with estrogenic activity(2)
vaginal(2)
genital ulcers
squamous cell carcinoma of vagina
cervical(2)
ulcer
cervical polyp
squamous cell carcinoma of cervix
uterine(2)
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometrial hyperplasia
endometritis
adenomyomata or diffuse adenomyosis
endometrial polyp
congenital abnormalities
genital trauma(2)
foreign bodies(2)
anticoagulants(2)
von Willebrand disease(2)
other blood dyscrasias(2)
inherited bleeding disorders (most commonly von Willebrand disease) reported in 11-17 women with menorrhagia
cohort of 150 women referred for menorrhagia who had normal pelvic exam
women had measurements of activated partial thromboplastin time factor VIII activity von Willebrand factor antigen
and activity and factor XI
26 (17) had inherited bleeding disorder including
von Willebrand disease in 18
factor XI deficiency in 4
combined von Willebrand disease and factor XI deficiency in 1
combined von Willebrand disease factor XI deficiency and factor X deficiency in 1
hemophilia A carrier in 1
platelet dysfunction in 1
Reference - Lancet 1998 Feb 14351(9101)485 EBSCOhost Full Text
comparing 121 women with menorrhagia vs 123 controls
bleeding disorders diagnosed in 107 vs 32 (p = 002)
von Willebrand disease diagnosed in 8 (66) vs 1 (08) (p = 002)
prevalence of von Willebrand disease 159 white patients vs 14 black patients (p = 001)
Reference - Obstet Gynecol 2001 Apr97(4)630
History and Physical
women with heavy uterinebleeding should have a structured history to screen for inherited systemic disorders of hemostasis
(Kaiser Level A)(3)
patients with positive screening on structured history should be considered for further evaluation including consultation with a
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Physical
Testing overview
hematologist andor testing for von Willebrand disease
positive screen defined as any of
heavy menstrual bleeding since menarche
postpartum hemorrhage
surgery related bleeding
bleeding associated with dental work
2 or more of
family history of bleeding symptoms
bruising 1-2 timesmonth
epistaxis 1-2 timesmonth
frequent gum bleeding
each patient with chronic abnormaluterinebleeding should be assessed for ovulatory function (can be reliably confirmed with a
history of predictable cyclic menses with a cycle length of every 22-35 days) (Kaiser Level C)(3)
determine pattern of bleeding(1)
severe acute bleeding (bleeding requiring gt 1 pad or tampon per hour or vital signs indicating hypovolemia)
irregular bleeding (includes metrorrhagia menometrorrhagia oligomenorrhea prolonged bleeding intermenstrual bleeding
or other irregular pattern)
menorrhagia (heavy but regular cyclic bleeding plus gt 7 days of bleeding or clots or iron deficiency anemia) prolonged
bleeding gt 12 days should be considered irregular regardless of cyclic pattern
ask about
symptoms of anemia (fatigue lightheadedness weakness dyspnea on exertion)(2)
history of weight change(2)
history or symptoms of thyroid disorder(2)
medication use(2)
oral contraceptive
thyroid medications
other hormones
anticoagulants
check for signs of(2)
pregnancy
anemia (pallor tachycardia)
endocrine disorders
hyperandrogenism (acne hirsutism virilization)
hypothyroidism
hyperthyroidism
bleeding disorder (petechiae bruising recurrent or unexplained joint effusion)
abdominal mass (if large uterine fibroid)
gynecological exam for structural lesions(2)
vaginal
genital ulcers
squamous cell carcinoma of vagina
cervical
ulcer
polyp
squamous cell carcinoma of cervix
uterine
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometritis
adenomyomata or diffuse adenomyosis
polyp
congenital abnormalities
Diagnostic Testing
for all women with chronic abnormaluterinebleeding(3)
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Endometrial sampling
Imaging studies
pregnancy test (urine or blood) should be done (Kaiser Level C)
CBC should be considered (Kaiser Level C)
additional testing guided by patient history(3)
TSH is appropriate in women with suspected or known anovulatory dysfunctional uterinebleeding (DUB) (Kaiser Level C)
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
other endocrine tests if indicated
to rule out hyperprolactinemia - prolactin level
to rule out polycystic ovary syndrome or other hyperandrogenic state
17-hydroxyprogesterone
testosterone
dehydroepiandrosterone sulfate
testing for bleeding disorder if bleeding persists despite treatment(3)
platelets
bleeding time
factor VIII
routine transvaginal ultrasonography generally unnecessary for initial visit but should be considered for persisting symptoms and
especially for those who fail initial medical therapy (Kaiser Level C)(3)
indications for further evaluation with ultrasound saline infusion sonography andor hysteroscopy (Kaiser Level A) include(3)
persistent abnormaluterinebleeding despite normal and satisfactory endometrial sampling
irregular thickening of endometrium on ultrasound (suggesting presence of focal lesions)
endometrial cavity cannot be identified in its entirety
if polyps or fibroids involving endometrial cavity suspected
indications for endometrial sampling
endometrial sampling should be performed when there is an increased risk of endometrial hyperplasia or neoplasia (Kaiser
Level A)
women aged gt 40 years (Kaiser Level B)
women aged lt 40 years with additional risk factors (including features suggestive of chronic anovulation and weight greater
than 90 kg) (Kaiser Level B)
patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome) (Kaiser Level B)
sampling approach
outpatient endometrial biopsy with catheter techniques should be considered first line approach (Kaiser Level A)
if endometrial biopsy is indicated and cannot be obtained or is inadequate repeat sampling should be attempted if
necessary with DampC (Kaiser Level C)
Pipelle and Explora curettes associated with similar patient pain ratings in endometrial biopsy (level 2 [mid-
level] evidence)
based on randomized trial with use of means instead of medians for pain analysis
70 women having endometrial biopsy (abnormaluterinebleeding most common indication) randomized to Pipelle vs Explora
curette
no significant difference in subject-reported pain or provider-reported ease of use
Reference - Obstet Gynecol 2011 Mar117(3)636
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
considerations for imaging of endometrial cavity(3)
goals for evaluation of endometrial cavity in women with chronic abnormaluterinebleeding include detection of endometrial
hyperplasia or cancer in selected patients and identification of focal lesions such as polyps and leiomyomas (fibroids) which
might explain bleeding (Kaiser Level C)
if chronic abnormaluterinebleeding continues despite normal and satisfactory endometrial sampling consider ultrasound
saline infusion sonography andor hysteroscopy (Kaiser Level A)
transvaginal ultrasound considered adequate if entire endometrial echo shown in longitudinal and transverse planes through
widest part of endometrial cavity (Kaiser Level C)
no consensus on upper limit of endometrial thickness to be considered normal in premenopausal women (Kaiser Level B)
transvaginal ultrasound considered good screening test but may miss some focal lesions such as polyps (Kaiser Level B)
transvaginal ultrasound sonohysterography and hysteroscopy may be similarly effective in detection of
intrauterine pathology in premenopausal women with abnormaluterinebleeding (level 2 [mid-level] evidence)
based on systematic review with heterogeneity
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
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copy 2014 EBSCO Industries Inc Todos los derechos reservados
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Physical
Testing overview
hematologist andor testing for von Willebrand disease
positive screen defined as any of
heavy menstrual bleeding since menarche
postpartum hemorrhage
surgery related bleeding
bleeding associated with dental work
2 or more of
family history of bleeding symptoms
bruising 1-2 timesmonth
epistaxis 1-2 timesmonth
frequent gum bleeding
each patient with chronic abnormaluterinebleeding should be assessed for ovulatory function (can be reliably confirmed with a
history of predictable cyclic menses with a cycle length of every 22-35 days) (Kaiser Level C)(3)
determine pattern of bleeding(1)
severe acute bleeding (bleeding requiring gt 1 pad or tampon per hour or vital signs indicating hypovolemia)
irregular bleeding (includes metrorrhagia menometrorrhagia oligomenorrhea prolonged bleeding intermenstrual bleeding
or other irregular pattern)
menorrhagia (heavy but regular cyclic bleeding plus gt 7 days of bleeding or clots or iron deficiency anemia) prolonged
bleeding gt 12 days should be considered irregular regardless of cyclic pattern
ask about
symptoms of anemia (fatigue lightheadedness weakness dyspnea on exertion)(2)
history of weight change(2)
history or symptoms of thyroid disorder(2)
medication use(2)
oral contraceptive
thyroid medications
other hormones
anticoagulants
check for signs of(2)
pregnancy
anemia (pallor tachycardia)
endocrine disorders
hyperandrogenism (acne hirsutism virilization)
hypothyroidism
hyperthyroidism
bleeding disorder (petechiae bruising recurrent or unexplained joint effusion)
abdominal mass (if large uterine fibroid)
gynecological exam for structural lesions(2)
vaginal
genital ulcers
squamous cell carcinoma of vagina
cervical
ulcer
polyp
squamous cell carcinoma of cervix
uterine
leiomyoma (fibroids) most common
endometrial adenocarcinoma endometrial sarcoma
endometritis
adenomyomata or diffuse adenomyosis
polyp
congenital abnormalities
Diagnostic Testing
for all women with chronic abnormaluterinebleeding(3)
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Endometrial sampling
Imaging studies
pregnancy test (urine or blood) should be done (Kaiser Level C)
CBC should be considered (Kaiser Level C)
additional testing guided by patient history(3)
TSH is appropriate in women with suspected or known anovulatory dysfunctional uterinebleeding (DUB) (Kaiser Level C)
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
other endocrine tests if indicated
to rule out hyperprolactinemia - prolactin level
to rule out polycystic ovary syndrome or other hyperandrogenic state
17-hydroxyprogesterone
testosterone
dehydroepiandrosterone sulfate
testing for bleeding disorder if bleeding persists despite treatment(3)
platelets
bleeding time
factor VIII
routine transvaginal ultrasonography generally unnecessary for initial visit but should be considered for persisting symptoms and
especially for those who fail initial medical therapy (Kaiser Level C)(3)
indications for further evaluation with ultrasound saline infusion sonography andor hysteroscopy (Kaiser Level A) include(3)
persistent abnormaluterinebleeding despite normal and satisfactory endometrial sampling
irregular thickening of endometrium on ultrasound (suggesting presence of focal lesions)
endometrial cavity cannot be identified in its entirety
if polyps or fibroids involving endometrial cavity suspected
indications for endometrial sampling
endometrial sampling should be performed when there is an increased risk of endometrial hyperplasia or neoplasia (Kaiser
Level A)
women aged gt 40 years (Kaiser Level B)
women aged lt 40 years with additional risk factors (including features suggestive of chronic anovulation and weight greater
than 90 kg) (Kaiser Level B)
patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome) (Kaiser Level B)
sampling approach
outpatient endometrial biopsy with catheter techniques should be considered first line approach (Kaiser Level A)
if endometrial biopsy is indicated and cannot be obtained or is inadequate repeat sampling should be attempted if
necessary with DampC (Kaiser Level C)
Pipelle and Explora curettes associated with similar patient pain ratings in endometrial biopsy (level 2 [mid-
level] evidence)
based on randomized trial with use of means instead of medians for pain analysis
70 women having endometrial biopsy (abnormaluterinebleeding most common indication) randomized to Pipelle vs Explora
curette
no significant difference in subject-reported pain or provider-reported ease of use
Reference - Obstet Gynecol 2011 Mar117(3)636
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
considerations for imaging of endometrial cavity(3)
goals for evaluation of endometrial cavity in women with chronic abnormaluterinebleeding include detection of endometrial
hyperplasia or cancer in selected patients and identification of focal lesions such as polyps and leiomyomas (fibroids) which
might explain bleeding (Kaiser Level C)
if chronic abnormaluterinebleeding continues despite normal and satisfactory endometrial sampling consider ultrasound
saline infusion sonography andor hysteroscopy (Kaiser Level A)
transvaginal ultrasound considered adequate if entire endometrial echo shown in longitudinal and transverse planes through
widest part of endometrial cavity (Kaiser Level C)
no consensus on upper limit of endometrial thickness to be considered normal in premenopausal women (Kaiser Level B)
transvaginal ultrasound considered good screening test but may miss some focal lesions such as polyps (Kaiser Level B)
transvaginal ultrasound sonohysterography and hysteroscopy may be similarly effective in detection of
intrauterine pathology in premenopausal women with abnormaluterinebleeding (level 2 [mid-level] evidence)
based on systematic review with heterogeneity
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
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Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
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Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
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Endometrial sampling
Imaging studies
pregnancy test (urine or blood) should be done (Kaiser Level C)
CBC should be considered (Kaiser Level C)
additional testing guided by patient history(3)
TSH is appropriate in women with suspected or known anovulatory dysfunctional uterinebleeding (DUB) (Kaiser Level C)
endometrial sampling if increased risk of endometrial hyperplasia or neoplasia (Kaiser Level A)
other endocrine tests if indicated
to rule out hyperprolactinemia - prolactin level
to rule out polycystic ovary syndrome or other hyperandrogenic state
17-hydroxyprogesterone
testosterone
dehydroepiandrosterone sulfate
testing for bleeding disorder if bleeding persists despite treatment(3)
platelets
bleeding time
factor VIII
routine transvaginal ultrasonography generally unnecessary for initial visit but should be considered for persisting symptoms and
especially for those who fail initial medical therapy (Kaiser Level C)(3)
indications for further evaluation with ultrasound saline infusion sonography andor hysteroscopy (Kaiser Level A) include(3)
persistent abnormaluterinebleeding despite normal and satisfactory endometrial sampling
irregular thickening of endometrium on ultrasound (suggesting presence of focal lesions)
endometrial cavity cannot be identified in its entirety
if polyps or fibroids involving endometrial cavity suspected
indications for endometrial sampling
endometrial sampling should be performed when there is an increased risk of endometrial hyperplasia or neoplasia (Kaiser
Level A)
women aged gt 40 years (Kaiser Level B)
women aged lt 40 years with additional risk factors (including features suggestive of chronic anovulation and weight greater
than 90 kg) (Kaiser Level B)
patients with a family history of hereditary nonpolyposis colorectal cancer syndrome (Lynch Syndrome) (Kaiser Level B)
sampling approach
outpatient endometrial biopsy with catheter techniques should be considered first line approach (Kaiser Level A)
if endometrial biopsy is indicated and cannot be obtained or is inadequate repeat sampling should be attempted if
necessary with DampC (Kaiser Level C)
Pipelle and Explora curettes associated with similar patient pain ratings in endometrial biopsy (level 2 [mid-
level] evidence)
based on randomized trial with use of means instead of medians for pain analysis
70 women having endometrial biopsy (abnormaluterinebleeding most common indication) randomized to Pipelle vs Explora
curette
no significant difference in subject-reported pain or provider-reported ease of use
Reference - Obstet Gynecol 2011 Mar117(3)636
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
considerations for imaging of endometrial cavity(3)
goals for evaluation of endometrial cavity in women with chronic abnormaluterinebleeding include detection of endometrial
hyperplasia or cancer in selected patients and identification of focal lesions such as polyps and leiomyomas (fibroids) which
might explain bleeding (Kaiser Level C)
if chronic abnormaluterinebleeding continues despite normal and satisfactory endometrial sampling consider ultrasound
saline infusion sonography andor hysteroscopy (Kaiser Level A)
transvaginal ultrasound considered adequate if entire endometrial echo shown in longitudinal and transverse planes through
widest part of endometrial cavity (Kaiser Level C)
no consensus on upper limit of endometrial thickness to be considered normal in premenopausal women (Kaiser Level B)
transvaginal ultrasound considered good screening test but may miss some focal lesions such as polyps (Kaiser Level B)
transvaginal ultrasound sonohysterography and hysteroscopy may be similarly effective in detection of
intrauterine pathology in premenopausal women with abnormaluterinebleeding (level 2 [mid-level] evidence)
based on systematic review with heterogeneity
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
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Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
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Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
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Acute severe bleeding
19 prospective cohort studies reviewed including 2917 patients 408 (25) postmenopausal
for detection of any intrauterine pathology statistically significant heterogeneity prevented pooling of likelihood ratios
for detection of submucous fibroids
sonohysterography had pooled likelihood ratio 297 (95 CI 178-496)
hysteroscopy had pooled likelihood ratio 294 (95 CI 134-653)
pooled likelihood ratio for transvaginal ultrasound not calculated because of statistically significant heterogeneity
Reference - Acta Obstet Gynecol Scand 2003 Jun82(6)493 EBSCOhost Full Text
prophylactic vaginal misoprostol may reduce pain in women having outpatient hysteroscopy (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
150 women having outpatient hysteroscopy for diagnosis of infertility or abnormaluterinebleeding randomized to cervical
priming with misoprostol 200 mcg vaginally 3 hours before procedure vs no misoprostol
comparing misoprostol vs no misoprostol
mean pain scores (on 0-10 visual analog scale) 326 vs 487 (p lt 0001)
mean procedure time 2 minutes vs 25 minutes (p lt 0001)
misoprostol associated with increased ease of cervical entry and patient acceptability (p le 002 for each)
Reference - Fertil Steril 2011 Oct96(4)962
American Institute of Ultrasound in Medicine (AIUM) guideline on pelvic ultrasound examinations can be found in J Ultrasound
Med 2010 Jan29(1)166
review of evaluation of the endometrium can be found in Obstet Gynecol 2010 Jul116(1)168
Management
indications for hospitalization(1)
orthostatic hypotension
hemoglobin lt 10 gdL
profuse active bleeding
consider blood transfusion if severely anemic(1)
hormonal medication
estrogen
use often recommended but evidence for efficacy is limited(1 2)
IV conjugated equine estrogen may terminate endometrial bleeding in patients with dysfunctional
uterinebleeding (DUB) (level 2 [mid-level] evidence)
based on small randomized trial
34 patients who presented to emergency room with excessive or prolonged uterinebleeding were randomized to
conjugated estrogens (Premarin) 25 mg vs placebo in 5 mL normal saline injected IV over 2 minutes through IV
line running at 75 mLhour
dose repeated (double-blind Premarin or placebo) at 3 hours if bleeding continued
open-label dose of Premarin (regardless of original assignment) at 5 hours if bleeding continued
alternative treatment provided if bleeding continued at 8 hours
comparing estrogen vs placebo
mean duration of bleeding at presentation 141 days (range 1-78) vs 116 days (range 1-90)
bleeding stopped after first injection in 22 vs 36 (not significant)
bleeding stopped after first or second injection in 72 vs 38 (p = 0021 NNT 3)
adverse effects in 39 vs 13 (not significant)
Reference - Obstet Gynecol 1982 Mar59(3)285
DynaMed commentary -- patients had range of bleeding history unclear how many had acute severe bleeding
dose schedules suggested in review article(1)
for inpatient management
conjugated equine estrogens 25 mg in normal saline 50 mL given IV over 20 minutes every 4 hours for 24
hours
at same time start tapered dosing of combination oral contraceptive (ethinyl estradiol 30 mcgnorgestrel 03
mg)
for outpatient management
conjugated equine estrogens 25 mg orally 4 times daily
after acute bleeding stopped start tapered dosing of combination oral contraceptive (ethinyl estradiol 30
mcgnorgestrel 03 mg)
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
1142014 DynaMed
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Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
1142014 DynaMed
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
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Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
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Irregular menstrual bleeding
tapered dose schedule
1 tablet 4 times daily for 4 days then
1 tablet 3 times daily for 3 days then
1 tablet twice daily for 2 days then
1 tablet once daily for 3 weeks then
1 week off then cycle of oral contraceptives for at least 3 months
oral medroxyprogesterone acetate and combination oral contraceptives appear equally effective in
terminating acute uterinebleeding (level 2 [mid-level] evidence)
based on small randomized trial
40 hemodynamically stable patients with acute uterinebleeding (defined as sufficient to justify immediate medical or
surgical intervention) randomized to
medroxyprogesterone acetate 20 mg orally 3 times daily for 1 week then 20 mg once daily for 3 weeks
monophasic combination oral contraceptive containing norethindrone 1 mg plus ethinyl estradiol 35 mcg 1 tablet 3
times daily for 1 week then 1 tablet once daily for 3 weeks
33 patients (82) evaluated at 14 days
comparing medroxyprogesterone acetate vs combination oral contraceptive
cessation of bleeding achieved in 76 vs 88 (not significant)
median time to bleeding cessation 3 days vs 3 days
emergency surgical procedures avoided in 100 vs 95
no significant differences in incidence of treatment-related nausea and bloating
Reference - Obstet Gynecol 2006 Oct108(4)924
indications for dilatation and curettage or intrauterine Foley bulb placement(1 2)
hemodynamic instability and acute bleeding
lack of response to initial
2 doses of IV estrogen (if inpatient)
4 doses of oral estrogen (if outpatient)
evaluation once patient stabilized(1)
investigation for bleeding disorder (complete blood count platelet count prothrombin time activated partial thromboplastin
time platelet function analysis)
transvaginal ultrasound
medical therapy for irregular menstrual bleeding (presumed anovulatory)
empiric medical management can be started(2)
goal of treatment is to restore natural cycle of endometrial growth and shedding
withdrawal bleeding can be induced by progestin (medroxyprogesterone acetate 5-10 mg daily for 2 weeks every
month)
progestogens given alone (cyclically continuously or nearly continuously) or in combination with estrogens have limited
evidence for management of anovulatory irregular bleeding (Kaiser Level B)(3)
continuing therapy for at least 3 months after stabilization has been suggested for irregular bleeding in nonpregnant
women(1)
no randomized trials found evaluating progestogens alone or in combination with estrogens for irregular or
heavy menstrual bleeding due to anovulation
based on Cochrane review
Reference - Cochrane Database Syst Rev 2012 Sep 12(9)CD001895
metformin and other insulin-sensitizing drugs
role of metformin and other hypoglycemic agents for routine treatment of chronic anovulatory abnormaluterinebleeding
has not been established (Kaiser Level B)(3)
metformin may reduce menstrual abnormalities in women with polycystic ovarian syndrome (PCOS)
metformin may improve menstrual regularity (level 2 [mid-level] evidence) and hormonal markers
(level 3 [lacking direct] evidence) in normal weight normoinsulinemic women with PCOS
based on small randomized trial
28 normal-weight normoinsulinemic women with PCOS randomized to metformin 500 mg twice daily vs
placebo
metformin significantly associated with improved
testosterone levels at 3 and 6 months
17-hydroxyprogesterone levels at 6 months
hirsutism score at 6 months
1142014 DynaMed
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reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
1142014 DynaMed
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Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1013
Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
1142014 DynaMed
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ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1213
DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicalhellip 813
reduced ovarian volume at 3 and 6 months
70 in metformin group experienced restoration of menstrual cyclicity
no clinical or hormonal changes with placebo
Reference - Fertil Steril 2010 May 193(7)2303
metformin 850 mg twice daily does not appear to improve menstrual frequency or insulin sensitivity
in obese women with PCOS already making weight loss lifestyle changes (level 2 [mid-level]
evidence)
based on randomized trial with allocation concealment not stated
143 obese oligo-amenorrheic women with PCOS received dietary plan and were randomized to metformin
850 mg twice daily vs placebo for 6 months
metformin significantly reduced waist circumference and free androgen index
no significant difference in
menstrual frequency (both groups improved)
insulin sensitivity
lipid profiles
Reference - Hum Reprod 2006 Jan21(1)80 full-text
metformin may reduce markers of PCOS and menstrual abnormalities
based on small randomized trial
23 women with PCOS randomized to metformin 500 mg vs placebo orally 3 times daily for 6 months
metformin reduced menstrual abnormalities plasma insulin insulin resistance and ovarian hyperandrogenism
no changes in placebo group
warning that ovulation may resume and contraception may be necessary
Reference - J Clin Endocrinol Metab 2000 Jan85(1)139 in Prescribers Letter 2000 Mar7(3)16
metformin associated with higher rate of menses
based on 12-week randomized placebo-controlled trial with 22 patients aged 13-18 years with hyperinsulinemia
and PCOS
Reference - Arch Pediatr Adolesc Med 2006 Mar160(3)241 commentary can be found in Am Fam Physician
2006 Sep 174(5)862
metformin 500-1000 mg twice daily may improve menstrual cyclicity and quality of life in oligo-
amenorrheic women with PCOS (level 2 [mid-level] evidence)
based on cohort study of 64 women (mean age 29 years) with PCOS (all oligoamenorrheic) having
metformin 500-1000 mg twice daily (depending on weight) for 6 months
metformin associated with
normalized menstrual cycle (52 achieved 28-35 cycles)
improved quality of life scores (including domains of vitality social function mental and sexual health)
significant baseline reductions in
insulin resistance
testosterone levels (55 achieved normal levels)
free androgen index levels
body mass index (BMI) (mean decrease 11 kgm )2
no difference in alopecia or hirsutism scores
Reference - Hum Reprod 2006 Jul21(7)1925 full-text
ovulation induction is not indicated (Kaiser Level C)(3)
gonadotropin-releasing hormone (GnRH) agonists may have a role in management of selected women with chronic
anovulatory abnormaluterinebleeding (Kaiser Level B)(3)
lifestyle issues including stress reduction and weight loss might be important in management of abnormaluterinebleeding
associated with anovulatory state (Kaiser Level C)(3)
surgical therapy
surgical therapy for women with chronic dysfunctional uterinebleeding (DUB) is currently reserved for women not interested
in future fertility (Kaiser Level C)(3)
hysterectomy is more effective than endometrial ablation for resolution of symptoms of DUB but has more
adverse perioperative events (level 1 [likely reliable] evidence)
based on randomized trial
237 premenopausal women aged ge 18 years with dysfunctional uterinebleeding randomized to endometrial ablation vs
hysterectomy and followed for up to 5 years
85 were aged lt 45 years
due to funding concerns trial terminated early but gt 80 of women were followed for at least 2 years
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicalhellip 913
Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1013
Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1113
ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
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DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicalhellip 913
Heavy menstrual bleeding (menorrhagia)
Other management
primary outcome was resolution of the major reason for which women sought treatment (bleeding pain or fatigue)
comparing endometrial ablation vs hysterectomy
879 vs 932 had major problem solved at 1 year
849 vs 944 had major problem solved at 2 years (p = 0026 NNT 11 favoring hysterectomy)
933 vs 951 had major problem solved at 3 years
851 vs 98 had major problem solved at 4 years (p = 0026 NNT 8 favoring hysterectomy)
109 vs 406 had adverse perioperative events (NNT 4 favoring endometrial ablation)
29 (32 of 110 women) with endometrial ablation required reoperation by 48 months
Reference - STOP-DUB trial (Obstet Gynecol 2007 Dec110(6)1279) correction can be found in Obstet Gynecol 2008
Aug112(2 Pt 1)381 commentary can be found in Obstet Gynecol 2008 Apr111(4)992
for patients with abnormaluterinebleeding due to leiomyomas(3)
surgical management of abnormaluterinebleeding due to leiomyomas is determined by size location and number of
myomas (Kaiser Level C)
selected patients with leiomyoma-related abnormaluterinebleeding who do not wish to retain fertility may be considered
for endometrial ablation (Kaiser Level A)
abdominal myomectomy is the preferred procedure for women with abnormaluterinebleeding related to myomas
unsuitable for resectoscopic removal and who wish to retain their uterus (Kaiser Level C)
symptomatic endometrial polyps should be completely removed under hysteroscopic direction (Kaiser Level B)(3)
improvement in quality of life measures should be goal of any interventions (NICE D recommendation)
clarifying values and patient preferences may reduce hysterectomy rates for menorrhagia (level 2 [mid-level] evidence)
medications
levonorgestrel intrauterine system (LNG-IUS) appears effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
and is treatment of choice if (NICE A recommendation)
hormonal treatments are acceptable
at least 12 months use anticipated
combined oral contraceptives is second-line drug treatment option (NICE B recommendation)
either NSAID or tranexamic acid (Lysteda) considered
second-line treatment option if either hormonal or nonhormonal treatments are acceptable (NICE A recommendation)
preferred treatment option if hormonal treatments are not acceptable (NICE D(GPP) recommendation)
tranexamic acid should not be used before LNG-IUS if long-term use is anticipated (NICE A recommendation)
oral progestins (such as norethisterone 15 mg once daily on menstrual cycle days 5-26) or injected long-acting progestins
considered third-line treatment options (NICE A recommendation)
danazol may be effective for heavy menstrual bleeding (level 2 [mid-level] evidence)
surgeryprocedures
surgery reduces menstrual bleeding at 1 year more than medical therapy but levonorgestrel-intrauterine system improves
quality of life as effectively as surgery (level 1 [likely reliable] evidence)
endometrial ablation
preferable to hysterectomy in women with heavy menstrual bleeding alone and uterus le 10 week pregnancy size
(NICE A recommendation)
preprocedure endometrial thinning may improve operative conditions and amenorrhea at 12 months (level 2 [mid-level]
evidence)
referral for consideration of surgery or uterine artery embolization (UAE) as first-line treatment recommended for women
with large fibroids and heavy menstrual bleeding and other significant symptoms such as dysmenorrhea or pressure
symptoms (NICE D(GPP) recommendation)
UAE myomectomy or hysterectomy should all be considered discussed and documented when surgery for fibroid-related
heavy menstrual bleeding is considered necessary (NICE D(GPP) recommendation)
vaginal hysterectomy preferred over abdominal hysterectomy after incorporating individual assessment (NICE A
recommendation)
DampC should not be used as therapeutic treatment (NICE C recommendation)
see Heavy menstrual bleeding for treatment details
assess need for iron therapy
therapy should be individualized
if needed see Iron deficiency anemia in adults
insufficient evidence for evaluation of use of Chinese herbal medication for dysfunctional uterinebleeding (DUB)
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1013
Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1113
ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1213
DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1013
Guidelines
United States guidelines
United Kingdom guidelines
Canadian guidelines
European guidelines
Mexican guidelines
Review articles
based on meta-analysis
all except one trial had poor methodological quality
Reference - Evid Based Complement Alternat Med 2009 Mar6(1)99 full-text
Guidelines and Resources
American College of Obstetricians and Gynecologists (ACOG) guidelines
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin 128 on diagnosis of abnormaluterinebleeding
in reproductive-aged women can be found in Obstet Gynecol 2012 Jul120(1)197 or at National Guideline Clearinghouse
2013 Feb 1138623 commentary can be found in ACOG News Release 2012 Jun 21
American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 557 on management of acute
abnormaluterinebleeding in nonpregnant reproductive-aged women can be found in Obstet Gynecol 2013 Apr121(4)891
ACOG Practice Bulletin 136 on management of abnormaluterinebleeding associated with ovulatory dysfunction can be
found in Obstet Gynecol 2013 Jul122(1)176 or at National Guideline Clearinghouse 2014 Feb 1747451
ACOG Practice Bulletin 81 on endometrial ablation can be found in Obstet Gynecol 2007 May109(5)1233 reaffirmed 2012
Feb or at National Guideline Clearinghouse 2007 Dec 2410918
ACOG Committee Opinion 349 on menstruation on girls and adolescents can be found in Obstet Gynecol 2006
Nov108(5)1323 reaffirmed 2009 Jun also produced by American Academy of Pediatrics (Pediatrics 2006
Nov118(5)2245)
American College of Radiology (ACR) Appropriateness Criteria for abnormal vaginal bleeding can be found at ACR 2010 PDF or
at National Guideline Clearinghouse 2011 Sep 532629
Society of Gynecologic Surgeons (SGS) clinical practice guideline on abnormaluterinebleeding hysterectomy versus alternative
therapy can be found in J Minim Invasive Gynecol 2012 Jan-Feb19(1)81
American College of RadiologyAmerican College of Obstetricians and GynecologistsAmerican Institute of Ultrasound in Medicine
(ACRACOGAIUM) guideline on performance of sonohysterography can be found in J Ultrasound Med 2012 Jan31(1)165 full-
text or at ACRACOGAIUM 2011 PDF
National Institute for Health and Clinical Excellence (NICE) guideline on
heavy menstrual bleeding can be found in NICE 2007 JanCG44 PDF
fluid-filled thermal balloon and microwave endometrial ablation techniques for heavy menstrual bleeding can be found at
NICE 2004 AprTA78
Royal College of Obstetricians and Gynaecologists (RCOG) guideline on best practice in outpatient hysteroscopy can be found
at RCOG 2011 Mar PDF or at National Guideline Clearinghouse 2012 May 1434905
Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on abnormaluterinebleeding in pre-menopausal women
can be found at SOGC 2013 May 23 PDF or at National Guideline Clearinghouse 2014 Jan 646416
Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical guideline on female sexual health consensus can be
found at SOGC 2012 PDF or at National Guideline Clearinghouse 2013 Jun 338474
Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on asymptomatic endometrial thickening can
be found in J Obstet Gynaecol Can 2010 Oct32(10)990 PDF
Alberta Health Services (AHS) clinical practice guideline on uterine sarcoma can be found at AHS 2011 Aug PDF or at National
Guideline Clearinghouse 2013 Mar 438596
Collegravege National des Gyneacutecologues et Obsteacutetriciens Franccedilais (CNGOF) clinical practice guideline on menorrhagia management of
abnormaluterinebleeding before menopause can be found in Eur J Obstet Gynecol Reprod Biol 2010 Oct152(2)133
Mexican School of Obstetrics and Gynecology (Colegio Mexicano de Especialistas en Ginecologa y Obstetricia) clinical practice
guideline on dysfunctional uterinebleeding can be found in Ginecol Obstet Mex 2009 Sep77(9)S231 EBSCOhost Full Text
[Spanish]
review can be found in Am Fam Physician 2004 Apr 1569(8)1915
review can be found in Postgrad Med 2001 Jan109(1)137
review can be found in Am Fam Physician 1999 Oct 160(5)1371
review of managing unscheduled bleeding in non-pregnant premenopausal women can be found in BMJ 2013 Jun 4346f3251
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1113
ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1213
DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1113
ICD-9 codes
ICD-10 codes
General references used
Recommendation grading systems used
AHRQ Comparative Effectiveness Review on primary care management of abnormaluterinebleeding 2013 Mar96 PDF
review of abnormaluterinebleeding in premenopausal women can be found in Am Fam Physician 2012 Jan 185(1)35
EBSCOhost Full Text
reviews of terminology controversy can be found in Fertil Steril 2008 Dec90(6)2269 Curr Opin Obstet Gynecol 2007
Dec19(6)591
review of treatment of dysfunctional uterinebleeding can be found in Maturitas 2004 Mar 1547(3)159
review of health-related quality of life work impairment and health-care costs and utilization in abnormaluterinebleeding can be
found in Value Health 2007 May-Jun10(3)183 EBSCOhost Full Text
Patient Information
handout from American College of Obstetricians and Gynecologists PDF
handout from American Society for Reproductive Medicine PDF
handout from American Academy of Family Physicians or in Spanish
handout on dysfunctional uterinebleeding from TeensHealth or in Spanish
technical information on dysfunctional uterinebleeding from Patient Plus PDF
handout on reasons for problem bleeding from Cleveland Clinic
handout on vaginal bleeding from Mayo Clinic
handout on dysfunctional uterinebleeding questions to discuss with your doctor from Harvard Medical School
ICD-9ICD-10 Codes
6262 excessive or frequent menstruation
6263 puberty bleeding
6264 irregular menstrual cycle
6265 ovulation bleeding
6266 metrorrhagia
6267 postcoital bleeding
6268 other disorders of menstruation and other abnormalbleeding from female genital tract
6269 unspecified disorders of menstruation and other abnormalbleeding from female genital tract
N92 excessive frequent and irregular menstruation
N920 excessive and frequent menstruation with regular cycle
N921 excessive and frequent menstruation with irregular cycle
N922 excessive menstruation at puberty
N923 ovulation bleeding
N924 excessive bleeding in the premenopausal period
N925 other specified irregular menstruation
N926 irregular menstruation unspecified
N93 other abnormaluterine and vaginal bleeding
N930 postcoital and contact bleeding
N938 other specified abnormaluterine and vaginal bleeding
N939 abnormaluterine and vaginal bleeding unspecified
References
1 Ely JW Kennedy CM Clark EC Bowdler NC Abnormaluterinebleeding a management algorithm J Am Board Fam Med
2006 Nov-Dec19(6)590-602 full-text
2 Casablanca Y Management of dysfunctional uterinebleeding Obstet Gynecol Clin North Am 2008 Jun35(2)219-34 viii
3 Amann M Anguino H Bauman RA et al Chronic abnormaluterinebleeding in nongravid women Pasadena (CA) Kaiser
Permanente Southern California National Guideline Clearinghouse 2007 Oct 2910889
4 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Heavy menstrual bleeding National Institute for Health and
Clinical Excellence (NICE) 2007 JanCG44 PDF
Kaiser Permanente Southern California uses American College of Obstetricians and Gynecologists (ACOG) strength of
recommendation classification
grades of recommendation
Level A - based on good and consistent scientific evidence
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1213
DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1213
DynaMed editorial process
Special acknowledgements
How to cite
Level B - based on limited or inconsistent scientific evidence
Level C - based primarily on consensus and expert opinion
Reference - Kaiser Permanente Southern California guideline on chronic abnormaluterinebleeding in nongravid women
(National Guideline Clearinghouse 2007 Oct 2910889)
National Institute for Health and Clinical Excellence (NICE) grading system for recommendations
Grade A
at least 1 meta-analysis systematic review or randomized controlled trial (RCT) that is rated 1++ and is directly
applicable to target population or
systematic review of RCTs or body of evidence that consists principally of studies rated 1+ is directly applicable to
target population and demonstrates overall consistency of results or
evidence drawn from NICE technology appraisal
Grade B
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 1++ or 1+
Grade C
body of evidence that includes studies rated 2++ is directly applicable to target population and demonstrates overall
consistency of results or
extrapolated evidence from studies rated 2++
Grade D
evidence level 3 or 4 or
extrapolated evidence from studies rated 2+ or
formal consensus
Grade D (GPP) - a good practice point (GPP) is a recommendation for best practice based on experience of Guideline
Development Group
levels of evidence for intervention studies
1++ includes high-quality meta-analyses systematic reviews of RCTs or RCTs with very low risk of bias
1+ includes well-conducted meta-analyses systematic reviews of RCTs or RCTs with low risk of bias
1- includes meta-analyses systematic reviews of RCTs or RCTs with high risk of bias
2++ includes high-quality systematic reviews of case-control or cohort studies high-quality case-control or cohort
studies with very low risk of confounding bias or chance and high probability relationship is casual
2+ includes well-conducted case-control or cohort studies with low risk of confounding bias or chance and moderate
probability relationship is casual
2- includes case-control or cohort studies with high risk of confounding bias or chance and significant risk relationship is
not casual
3 includes nonanalytical studies (for example case reports case series)
4 includes expert opinion formal consensus
Reference - NICE guideline on heavy menstrual bleeding (NICE 2007 JanCG44 PDF)
DynaMed topics are created and maintained by the DynaMed Editorial Team
Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step
evidence-based method for systematic literature surveillance DynaMed topics are updated daily as newly discovered best
available evidence is identified
The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing
interests related to this topic
The participating reviewers have declared that they have no financial or other competing interests related to this topic unless
otherwise indicated
McMaster University is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 1000 practicing
physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your
practice
F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates Over 2000 practicing clinicians from
20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice
Linda Feng Chang PharmD MPH BCPS (EPC Course Director and Clinical Assistant Professor of Pharmacy University of Illinois
College of Medicine Illinois United States) provides peer review
1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
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1142014 DynaMed
httpwebbebscohostcomezproxysibdiucraccr2048dynameddeliveryprintcitationexpand=sec-General-Informationsec-Causessec-History-and-Physicahellip 1313
Estaacute viendo un resumen de DynaMed El uso de DynaMed indica la aceptacioacuten de las DynaMed Condiciones de uso Las limitaciones de
DynaMed se encuentran en las Condiciones de uso de DynaMed
Haga sus comentarios enviando un correo electroacutenico para DynaMed a DynaMedEditorebscohostcom
For attribution in other publications see How to Cite Information from DynaMed
Parte superior de la paacutegina Sitio de asistencia de EBSCO Claacuteusula de confidencialidad Teacuterminos de uso Copyright
copy 2014 EBSCO Industries Inc Todos los derechos reservados