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Care Process Model
ap r i l
2012
MANAGEMENT OF
Abnormal Uterine Bleeding
This care process model (CPM) was developed by Intermountain Healthcare’s Gynecology Development Team under the guidance
of the Women and Newborns Clinical Program. It recommends an evidence-based approach for assessing and treating ovulatory
or anovulatory abnormal uterine bleeding in women of reproductive age.
Why Focus ON ABNORMAL UTERINE BLEEDING?
Abnormal uterine bleeding (AUB) — irregular menstrual bleeding or unusually
heavy or prolonged bleeding — warrants our attention for several reasons.
• It’s common. In the general population, abnormal uterine bleeding is
estimated to affect 11% to 13% of reproductive-age women at any given time;
this prevalence increases with age, reaching 24% in those 36 to 40 years of age.1
AUB is on par with urinary tract infections and vaginitis as one of the
most common health concerns prompting a medical visit. Gynecologists,
pediatricians, family physicians, internists and other providers caring for
female patients will all encounter and manage this condition.
• It’s costly. Estimated annual direct and indirect economic costs of AUB are
$1 billion and $12 billion, respectively, not accounting for intangible costs and
productivity loss.2
• It’s complex. AUB has numerous possible causes, and management can involve
many decisions about diagnosis and treatment. Changing terminology in the
medical literature, narrow recommendations focused on particular age groups
or symptoms, and guidelines specific to select AUB causes have done little to
clarify or simplify clinical practice.1,3
• A systematic, practical, and broad-based approach may improve
treatment and outcomes. The process outlined in this CPM — one that
helps physicians investigate the type and cause of AUB and use resources wisely
to address it — may ensure that treatment matches the condition and that
surgical approaches are ventured appropriately.
what’s iNside
algorithm:
management of AUB. . . . . . . . . . 2
Notes
on the algorithm . . . . . . . . . . . .
Initial work-up. . . . . . . . . . . . . . . . . . . .
Identifying patients
at lower-risk for pathology . . . . . . . . . .
Medical management . . . . . . . . . . . . . .
Surgical management . . . . . . . . . . . . . .
3
3
3
3
3
Patient education. . . . . . . . . . . . 4
References . . . . . . . . . . . . . . . . . . 4
Goals of this cpm
The overarching goal of this model is
to promote clinical best practice and
clinical consistency in the management
of abnormal uterine bleeding. Specific
goals include:
• Optimize use of resources applied to
the assessment and treatment of AUB
• Eliminate ablations performed without
prior biopsy
ABnormal uterine bleeding
a p r i l 2 012
A lg o r i t h m : m a n ag e m e n t o f A b n o r m a l u t e r i n e b l e e d i n g
Patient presents with
abnormal uterine bleeding
Perform initial workup
see (a)
LOW-RISK
patient?
see (b)
yes
MEDICAL MANAGEMENT
see (c)
Success?
see (c)
yes
watchful
waiting
no
no
1.BIOPSY endometrial tissue
2.Obtain iMAGes: transvaginal/abdominal ultrasound, saline infusion sonography (SIS), hysteroscopy, or MRI
Negative biopsy:
Identify next steps based on all
imaging & pathology findings
POSITIVE biopsy :
•Atypical hyperplasia
•Endometrial cancer
Hysterectomy
with possible
oncology consult
• Simple hyperplasia
• Nonsecretory (proliferative ) endometrium
• Polyps ≤ 1 cm (will often regress spontaneously)
• Myomata or suspected adenomyosis AND
–– uterus <12 week size, or
–– fibroids <8 cm and not submucosal
• Polyps > 1 cm
• Significant pelvic pain or pressure
• Myomata or suspected adenomyosis AND
–– uterus >12 week size, or
–– fibroids >8 cm and not submucosal
MEDICAL MANAGEMENT
(may have been tried previously)
see (c)
surgical MANAGEMENT
Success?
see (c)
yes
watchful
waiting
2 no
• Polypectomy/D&C with or without
hysteroscopy
• Endometrial ablation
• Myomectomy
• Hysteroscopic resection
• Uterine arterial embolization (UAE)
• Hysterectomy
See (d) for comments
©2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
ABnormal uterine bleeding
a p r i l 2 012
Notes on the algorithm4,5,6
(d) Surgical management
(a) Initial work-up: Key activities and goals for initial visit(s)
•• Medical history: timing & quantity of bleeding,
menstrual history including menarche and recent
periods, associated symptoms, family history of
bleeding disorders
•• Physical exam: bimanual may reveal bulky uterus/
discrete fibroids
•• Lab: pregnancy testing, pap smear, CBC, PT/PTT,
possible cervical culture, TSH ( t4 if abnormal)
•• Consider ultrasound depending on AUB severity,
patient’s age, presence of fibroids
•• Rule out other causes of AUB:
––Pregnancy
––Medications
––Infection
––Trauma
––Coagulopathy
––Extrinsic sources of bleeding
––Systemic disease: hepatic, renal, leukemia,
endocrinopathies (hypothyroidism,
hyperprolactinemia, Cushings, PCOS,
adrenal tumors, etc.)
(b) Identifying patients at lower risk for pathology
Patients may be considered at LOWER risk for endometrial cancer if ALL of the following are true:
•• Age <35
•• NO findings (history, physical, or lab) suggestive of uterine/cervical pathology
•• NO risk factors such as obesity, hypertension, diabetes mellitus, PCOS, family history of
breast or colon cancer, chronic anovulation, history of unopposed estrogen
(c) Medical management
Success with medical management: Control of bleeding for 3 consecutive cycles (NO persistent bleeding for more than 8 days;
NO profuse bleeding (e.g., large clots, gushes, significant limitations on activity); NO persistent anemia (Hct <30%, Hgb <10))
Med
category
estrogen
and/or
progestin
1 tablet daily
Tier 1, $
for all
those
listed at
left
••43-53%  in blood loss
••First choice if short-term
contraception desired
••Estradiol >35 mcg more
effective
••First choice if
pregnancy is not
desired
inserted, replaced
every 5 years
medical
benefit
copay
(usually
~20%),
$$$$
••86-97%  in blood loss (97% achieved after 1 yr of
use)
••First choice if LONG-term contraception desired
••Cost-effective in long-term
••Aygestin:
2.5-10 mg 1x/
day for 5-10 days
••Provera:
5-10 mg 1x/day
for 5-10 days
Tier 1, $
for both
listed at
left
••32-50%  in blood loss
••Use is NOT superior to other
medical treatments including
NSAIDs
••Second choice due to lower
efficacy and adverse effects
••Second choice, but
preferred in smokers
age >35 or with risk
of thromboembolism
•• 1.25 mg oral,
may repeat
every 4 hours for
24 hours, then
1.25 mg 1x/day
for 7-10 days
•• 25 mg IM/IV,
may repeat in
6-12 hours as
needed
••oral:
Tier 2,
$$
••IV:
medical
benefit
copay
(usually
~20%),
$$$
~
••First choice for
acute severe
bleeding episodes
••Administered orally
for outpatient, IV for
hospital admit
1300 mg 3x/day
for 5 days of the
menstrual cycle
Requires dose
decrease (renal
dose) if SCr >1.4
Tier 2, $$$
••40-50%  in blood loss
••First choice if NO
contraception desired
••Cautions: thrombosis, renal
insufficiency
Tier 1, $
for all
listed at
left
••Adjunctive therapy
••Inexpensive and convenient
(only taken during menses)
••Cautions: PUD/GERD, renal
insufficiency, RAD, bleeding
disorders, HTN, HF
estrogen-progestin OC
Zovia (Demulen equiv.),
Apri/Solia (Desogen), TriPrevifem (Ortho Tri-cyclen
Lo), Previfem (Ortho-Cyclen)
LNG-IUD
progestin
••norethindrone acetate
(Aygestin)
••medroxyprogesterone
(Provera)
estrogen
Premarin
NSAIDS
use for
dose
Mirena
antifibrinoltytics
agents
tier, est. use for
ovulatory AUB
cost*
type, name
tranexamic acid (Lysteda)
diclofenac (Voltaren)
50 mg 3x/day
ibuprofen (Motrin)
800 mg 3x/day
naproxen sodium(Anaprox)
275 - 500 mg
every 6-12 hrs
anovulatory AUB
* 2012 from SelectHealth; Tier defines patient copay for 30-day supply: Tier 1 = $5-10, Tier 2 = $25-30, Tier 3 = $50 or 20%.
$ symbol gives total prescription cost (copay + insurance payment): $= <$25, $$= ~$25-$99, $$$= >$100, $$$$= >$250 .
©2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
~
~
Surgical intervention to treat
abnormal uterine bleeding should
be done only after imaging and
endometrial sampling; surgery may
be warranted when other treatment
modalities have failed or when significant
uterine anatomic abnormalities are
present. The list below presents general
recommendations for surgical treatment
of possible causes/complications of AUB:
• Polyps: polypectomy/D&C with
or without hysteroscopy; consider
combining with endometrial ablation
• Uterus <12 cm: global endometrial
ablation
• Uterus>12 cm OR failed ablation:
hysterectomy
• Myomata, submucosal (2 or
fewer) and uterus <12 cm in
length: hysteroscopic resection or
hysterectomy
• Myomata, intramural or serosal:
myomectomy or hysterectomy
With
patients
Withablation,
ablation,ensure
ensurethat
that
patient
understand
ablation that
is NOT
candidatesthat
understand
ablation
sterilization
or a formor
ofacontraception
—
is NOT sterilization
form of
and
that they must
not that
become
contraception
— and
theypregnant
must
after
ablation.pregnant
(Consider recommending
not become
after ablation.
sterilization
with ablation.) Use
the patient
(Consider recommending
sterilization
with
education
fact
sheet
referenced
on pagefact
4
ablation.) Use the patient education
of this CPM.
sheet referenced on page 4 of this CPM.
Discussion
Both endometrial ablation and
hysterectomy provide satisfactory
results for women with AUB that has not
responded to medication. While almost
one third of women having endometrial
ablation will have reoperation within 5
years, hysterectomy is associated with
more perioperative morbidity.
Transcervical resection of
submucosal myomata is a safe and
effective treatment for women with a
normal uterine size and not more than
two submucosal fibroids (procedure does
not affect fertility).
New technologies to treat myomata include
uterine artery embolization, MRIguided focused ultrasonography,
laparocopic uterine artery occlusion,
and cryomyolysis. Embolization appears
to be effective for up to 5 years in reducing
bulk symptoms and menorrhagia associated
with myomata. However, the chance of
reoperation for myoma-related symptoms
within 5 years is 20% to 29%. The other
modalities listed above are considered
investigational and trial studies are ongoing.
3
ABnormal uterine bleeding
a p r i l 2 012
patient EDUCATION
Patient education is critical for obtaining informed consent for invasive
procedures and for providing good care in general. To support this
education, the following Fact Sheet handouts are available (in English
and Spanish) on intermountain.net/clinicalprograms on the “GYN” topic page.
• Clean Intermittent Catheterization (CIC) for Women After Surgery
• Dilation and Curettage (D&C)
• Endometrial ablation
• Hysterectomy
• Hysteroscopy
• Sterilization
REFERENCES
1. Primary care management of abnormal uterine bleeding (AUB). AHRQ Evidence-based Practice
Center (EPC) Systematic Review Protocol. http://www.effectivehealthcare.ahrq.gov/index.cfm/
search-for-guides-reviews-and-reports/?productid=850&pageaction=displayproduct. Published
November 21, 2011. Accessed March 20, 2012.
RESOURCES
Patient and provider tools relating
to gynecologic care are available on
the Clinical Programs website at:
intermountain.net/clinicalprograms.
Select the “GYN” topic page to access
the following tools:
• This CPM
• Other gynecology-related CPMs:
VBAC, Nonsurgical Management of
Ectopic Pregnancy, Use of Synthetic
Mesh in Pelvic Support Procedures, etc.
• Forms and regulations from CMS on
hysterectomy, sterilization and abortion
• GYN Blood Utilization Guidelines
• Patient education
• Links to other resources and references
4
2. 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(3):183-194.
3. Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal uterine bleeding: a management
algorithm. J Am Board Fam Med. 2006;19(6):590-602.
4. Goodman A. Initial approach to the premenopausal woman with abnormal uterine bleeding.
UpToDate. http://www.uptodate.com/contents/initial-approach-to-the-premenopausal-womanwith-abnormal-uterine-bleeding?source=search_result&search=abnormal+uterine+bleeding&sel
ectedTitle=1%7E150 . Updated September 24, 2010. Accessed March 21, 2012.
5. Kemp JD, Boardman A. Abnormal uterine bleeding [5-minute clinical suite]. Clin-eguide.
http://clineguide.ovid.com/clinicalresource/re/bookFT?xpath=%2Fbookdb%2F01241372%2F6
th_Edition%2F3%2FOVIDBOOK%5B1%5D%2FTXTBKBD%5B1%5D%2FDIVISIONA%5B10%5D%
2FDIVISIONB%5B1%5D%2FCHAPTER%5B2%5D&title=-35324312&odasn=app&tocid=none&act
ionIndex=1. Accessed March 21, 2012.
6. American College of Obstetricians and Gynecologists; ACOG Committee on Practice Bulletins—
Gynecology. ACOG practice bulletin no. 14: management of anovulatory bleeding. Int J Gynaecol
Obstet. 2001;72(3):263-271.
©2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801.442.2963 CPM048 - 4/12