A commentary on the recommendations in ACOG Practice Bulletin No. 136.
Committee on Practice Bulletins-Gynecology
ACOG Practice Bulletin Number 136: Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction, July 2013 (Replaces Practice Bulletin Number 14, March 2000). Obstet Gynecol. 2013;122:176-85. Full text of ACOG Practice Bulletins is available to ACOG members at http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_--_Gynecology/Management_of_Abnormal_Uterine_Bleeding_Associated_With_Ovulatory_Dysfunction.
Management of Abnormal Uterine Bleeding With Ovarian Dysfunction
Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is a condition for which women frequently seek gynecologic care. Anovulatory bleeding is common at the extremes of reproductive age. The choice of treatment of AUB-O depends on several factors, including the woman’s age, severity of her bleeding, her medical risk factors, her need for contraception, and her desire for future fertility (1). The purpose of this document is to provide management guidelines for the treatment of patients with AUB-O.
Dr. Einarsson is Associate Professor of Obstetrics and Gynecology, Harvard Medical School, and Director, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts. He is also the Deputy Editor of Contemporary OB/GYN.
The accepted nomenclature for abnormal uterine bleeding (AUB) changed in 2011 when ACOG adopted the PALM-COEIN system.1,2 Briefly, the PALM-COEIN system divides the etiology of AUB into structural and nonstructural causes with an additional qualifier indicating etiology or etiologies. Although many clinicians still use the term dysfunctional uterine bleeding (DUB) synonymously with AUB, the use of DUB is no longer recommended.
Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is one of the nonstructural causes of AUB and is most common at extremes of reproductive age. The Practice Bulletin on the management AUB-O published in July of 2013 brings much-needed updates in terminology and treatment options when compared to the prior Practice Bulletin from 2000. The evaluation and management is divided into age categories because etiology and treatment are age-dependent. The document also recommends ruling out structural causes of AUB.3
The limitations of endometrial sampling done as an office endometrial biopsy (EMB) or dilatation and curettage (D&C) in the operating room (OR) are well known, especially for detection of polyps or fibroids.4 Performance of a “blind” D&C in the operating room is not addressed in the Practice Bulletin, but in my opinion, it should no longer be considered the standard of care. I believe that patients who are being evaluated in the OR for AUB also should undergo hysteroscopy. Done in the office and coupled with endometrial biopsy, hysteroscopy offers a minimally invasive and cost-effective method of ruling out structural causes of AUB.5
Saline infusion sonohysterography coupled with EMB is another viable option. The ACOG Practice Bulletin recommends EMB in all women older than age 45 years with AUB and also patients aged 19 to 39 years who are not responding to medical therapy or who have prolonged periods of unopposed estrogen stimulation. It is important to highlight this, because clinicians may tend to overlook the possibility of endometrial malignancy in this younger age group.6
It is important to note that medical therapy remains the first-line therapy for AUB associated with ovulatory dysfunction since medical therapy is effective for the vast majority of patients. Combined hormonal contraceptives (COC) remain the mainstay of therapy in patients without contraindications while progesterone-only preparations are excellent alternatives. The COCs are particularly useful in younger patients. The levonorgestrel intrauterine system has a relatively favorable side-effect profile and can be a very effective treatment option for all women of reproductive age. Patients who have completed their childbearing and have failed medical management have the option of undergoing hysterectomy or endometrial ablation.
The new Practice Bulletin recommends against endometrial ablation as first-line therapy for AUB, in part, because of concerns about difficulties with future endometrial evaluation.
It is also worth noting-although it is not mentioned in the Practice Bulletin-that the age of the patient is an important factor for the success rate of endometrial ablation, with one study finding that over 40% of patients who had endometrial ablation at age 40 or younger ultimately needed a hysterectomy for symptomatic relief.7
The Practice Bulletin indicates that hysterectomy without cervical preservation may be appropriate for women who have completed childbearing, in whom medical therapy has failed or who have contraindications to it.
1. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet. 2011;113:3–13.
2. Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:197–206.
3. McKenzie LJ. Abnormal uterine bleeding: It’s about coming to terms (or terminology). ACOG Guidelines at a Glance. Contemporary OB/GYN. 2012;57(10):62–64.
4. Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer.
J Reprod Med. 1995;40:553–555.
5. Keyhan S, Munro MG. Office Diagnostic and Operative Hysteroscopy Using Local Anesthesia Only: An Analysis of Patient Reported Pain and Other Procedural Outcomes. J Minim Invasive Gynecol. 2014 Mar 25. pii: S1553-4650(14)00201-5. doi: 10.1016/j.jmig.2014.03.006. [Epub ahead of print]
6. Haidopoulos D, Simou M, Akrivos N, Rodolakis A, Vlachos G, Fotiou S, et al. Risk factors in women 40 years of age and younger with endometrial carcinoma. Acta Obstet Gynecol Scand. 2010;89:1326–1330.
7. Longinotti MK, Jacobson GF, Hung YY, Learman LA. Probability of hysterectomy after endometrial ablation. Obstet Gynecol. 2008;112(6):1214-1220.
ACOG Abstract Reference
1. Liu Z, Doan QV, Blumenthal P, Dubois RW. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health. 2007;10:183–194. (Systematic Review)