Uterine Bleeding: ACOG Updates Guidelines

Linda Roach

June 21, 2013

The American College of Obstetricians and Gynecologists has issued updated guidelines for treating abnormal uterine bleeding caused by ovulatory dysfunction.

This type of heavy, irregular bleeding is associated with impairment of the hypothalamic–pituitary–ovarian axis and occurs most commonly in teenagers and perimenopausal women. It is known by the acronym AUB-O under a new classification system proposed in 2011 by the International Federation of Gynecology and Obstetrics and subsequently adopted by the US association.

The new guidelines were published in the July issue Obstetrics & Gynecology.

The association's Committee on Practice Bulletins—Gynecology developed the guidelines after examining the available evidence from clinical studies and other documents published during a 24-year period ending in January 2013. Where studies were lacking, the panel gathered expert opinions from obstetrician-gynecologists.

The panel concluded that after a diagnostic workup has excluded structural and endometrial pathology, medical therapy is the preferred first-line treatment for uterine bleeding associated with ovulatory dysfunction. Their recommendations include that:

  • Surgery should be considered only if medical therapy fails, is not tolerated by the patient, or is contraindicated. Contraindications include significant intracavity lesions.

  • Endometrial ablation also should not be a primary therapy because the procedure can make it difficult or impossible later to use other common methods of monitoring the endometrium.

  • Because of its effectiveness, progestin therapy with the levonorgestrel intrauterine device should be considered for all age groups. Other progestin-only therapies include oral medroxyprogesterone acetate, megestrol acetate and norethindrone acetate, and depot medroxyprogesterone acetate. Combined contraceptives containing both estrogen and progesterone are also effective.

  • In adolescents up to age 18 years, low-dose combination hormonal contraceptive (20 - 35 μg ethinyl estradiol) is the mainstay treatment.

  • Women aged 19 to 39 years generally respond well to low-dose combined hormonal contraceptive therapy or to progestin therapy. If there is extremely heavy menstrual flow or the woman is hemodynamically unstable, high-dose estrogen therapy may be beneficial.

  • From age 40 years to menopause, medical treatment can consist of cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or cyclic hormone therapy. In addition to treating the bleeding problem, these treatments can relieve perimenopausal symptoms such as hot flashes, night sweats, and vaginal atrophy.

  • Failed medical therapy indicates a need for further tests, such as imaging or hysteroscopy.

  • If an endometrial biopsy is necessary for diagnosing endometrial hyperplasia or cancer, an office procedure is preferred over dilation and curettage because office biopsies are less invasive, safer, and less costly. However, they take fewer samples and consequently are more likely to miss uterine pathologies, including malignant disease.

  • If childbearing is complete, women who have failed medical therapy may be considered for hysterectomy without cervical preservation.

The updated guidelines replace the college's previous treatment recommendations, which were contained in Practice Bulletin 14, published in March 2000.

Obstet Gynecol. 2013;122:176-185. Abstract

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