General

Guideline Title

Management of abnormal uterine bleeding associated with ovulatory dysfunction.

Bibliographic Source(s)

  • American College of Obstetricians and Gynecologists (ACOG). Management of abnormal uterine bleeding associated with ovulatory dysfunction. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2013 Jul. 10 p. (ACOG practice bulletin; no. 136). [55 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of anovulatory bleeding. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2000 Mar. 9 p. (ACOG practice bulletin; no. 14). [38 references]

Recommendations

Major Recommendations

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

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

  • The levonorgestrel intrauterine device (IUD) has been shown to be effective in treating abnormal uterine bleeding (AUB) and should be considered for all age groups.
  • Medical treatment options for abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) include progestin therapy and combined hormonal contraception.
  • Women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation.
  • Because AUB-O is an endocrinologic abnormality, the underlying disorder should be treated medically rather than surgically. Surgical therapy is rarely indicated for the treatment of AUB-O, unless medical therapy fails, is contraindicated, is not tolerated by the patient, or the patient has concomitant significant intracavitary lesions.

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

  • Failure of medical management requires further investigation, including imaging or hysteroscopy.
  • The choice of treatment of AUB-O is guided by the goals of therapy, which may be to stop acute bleeding, avoid future irregular or heavy bleeding, simultaneously provide contraception, and prevent complications, such as anemia, unnecessary surgical intervention, and diminished quality of life.
  • Endometrial ablation is not recommended as a first-line therapy for AUB-O. Physicians must provide thorough informed consent and adequate counseling to women with AUB-O who desire endometrial ablation.

Definitions:

Grades of Evidence

I : Evidence obtained from at least one properly designed randomized controlled trial

II-1 : Evidence obtained from well-designed controlled trials without randomization

II-2 : Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 : Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

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

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O)

Guideline Category

  • Management
  • Treatment

Clinical Specialty

  • Endocrinology
  • Family Practice
  • Obstetrics and Gynecology

Intended Users

  • Advanced Practice Nurses
  • Nurses
  • Physician Assistants
  • Physicians

Guideline Objective(s)

To provide management guidelines for the treatment of patients with abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O)

Target Population

Women aged 13 and older with abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O)

Note : The diagnosis of abnormal uterine bleeding (AUB) in reproductive-aged women is discussed in another American College of Obstetricians and Gynecologists (ACOG) document.

Interventions and Practices Considered

  1. Levonorgestrel intrauterine device (IUD)
  2. Progestin therapy and combined hormonal contraception
  3. Hysterectomy without cervical preservation, as indicated
  4. Further investigation, including imaging or hysteroscopy
  5. Endometrial ablation (with informed consent and adequate counseling)

Major Outcomes Considered

  • Occurrence of acute bleeding
  • Anemia
  • Unnecessary surgical intervention
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence

  • Hand-searches of Published Literature (Primary Sources)
  • Hand-searches of Published Literature (Secondary Sources)
  • Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists’ own internal resources were used to conduct a literature search to locate relevant articles published between January 1990 and January 2013. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician-gynecologists were used.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

  • Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

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

I: Evidence obtained from at least one properly designed randomized controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

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

Methods Used to Analyze the Evidence

  • Review of Published Meta-Analyses
  • Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

  • Expert Consensus

Description of Methods Used to Formulate the Recommendations

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

Rating Scheme for the Strength of the Recommendations

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

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

  • Internal Peer Review

Description of Method of Guideline Validation

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

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management of abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O)

Potential Harms

Long-term complications of endometrial ablation that are now being recognized include post-ablation Asherman syndrome, synechiae, cervical stenosis, contracture of the endometrium, strictures, endometrial distortion, and delay in the detection of endometrial cancer.

Qualifying Statements

Qualifying Statements

The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

  • Foreign Language Translations
  • Patient Resources

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

  • Getting Better

IOM Domain

  • Effectiveness
  • Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

  • American College of Obstetricians and Gynecologists (ACOG). Management of abnormal uterine bleeding associated with ovulatory dysfunction. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2013 Jul. 10 p. (ACOG practice bulletin; no. 136). [55 references]

Adaptation

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

Date Released

2000 Mar (revised 2013 Jul)

Guideline Developer(s)

  • American College of Obstetricians and Gynecologists - Medical Specialty Society

Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

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

Composition of Group That Authored the Guideline

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

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of anovulatory bleeding. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2000 Mar. 9 p. (ACOG practice bulletin; no. 14). [38 references]

Guideline Availability

No electronic copies available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site.

Availability of Companion Documents

None available

Patient Resources

The following is available:

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

NGC Status

This NGC summary was completed by ECRI on September 14, 2004. The information was verified by the guideline developer on December 8, 2004. This NGC summary was updated by ECRI Institute on December 4, 2013.

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

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