Guideline for management of heavy menstrual bleeding

Sa Ra Lee; Jung-Ho Shin; Jung Ryeol Lee; Si Hyun Cho; Heedong Chae; Byung Seok Lee

doi:10.5468/kjog.2010.53.3.203

Journal List > Korean J Obstet Gynecol > v.53(3) > 1006382

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Shin, Lee, Cho, Chae, and Lee: Guideline for management of heavy menstrual bleeding

Review

Korean J Obstet Gynecol 2010;53(3):203-210.

Published online: 31 March 2011

DOI: https://doi.org/10.5468/kjog.2010.53.3.203

Guideline for management of heavy menstrual bleeding

Sa Ra Lee¹, Jung-Ho Shin², Jung Ryeol Lee³, Si Hyun Cho⁴, Heedong Chae⁵, Byung Seok Lee⁴

¹Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea

²Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea

³Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea

⁴Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea

⁵Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Corresponding author： E-mail dr222@yumc.yonsei.ac.kr

Received 18 December 2009 Accepted 11 January 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Heavy menstrual bleeding (HMB) is a common problem in primary care clinic of gynecology. HMB could cause adverse effect on the quality of life of many women. This guideline will provide evidence based information concerning diagnosis and management of HMB. Constructive dialogue should allow patients to be able to trust the advice given by their practitioner as they will be confident that they have and will be able to use it to inform this decision-making process. This guideline has been developed with the aim of providing guidance on HMB. The effectiveness of the various treatments as well as their risks and benefits are discussed in relation to their use in the treatment of HMB. We wish the information contained in this guideline will help clinicians reach a reasonable and beneficial decision with the latest information.

Keywords: Diagnosis, Treatment, Menorrhagia, Guideline

REFERENCES

1. Harbour RT, Forsyth L, editors. Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer\'s handbook. Ediburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2008.

2. Sackett DL, editor. Evidence-based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh; New York: Churchill Livingstone; 2000.

3. Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. JAMA. 1997; 277:973–976.

4. Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss and iron deficiency. Acta Med Scand. 1966; 180:639–650.

5. Andrade AT, Souza JP, Shaw ST Jr, Belsey EM, Rowe PJ. Menstrual blood loss and body iron stores in Brazilian women. Contraception. 1991; 43:241–249.

6. Janssen CA, Scholten PC, Heintz AP. Reconsidering menorrhagia in gynecological practice. Is a 30-year-old definition still valid? Eur J Obstet Gynecol Reprod Biol. 1998; 78:69–72.

7. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand. 2003; 82:493–504.

8. Cepni I, Ocal P, Erkan S, Saricali FS, Akbas H, Demirkiran F, et al. Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies. Aust N Z J Obstet Gynaecol. 2005; 45:30–35.

9. Critchley HO, Warner P, Lee AJ, Brechin S, Guise J, Graham B. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status. Health Technol Assess. 2004; 8:iii–iv.

10. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol. 1988; 158(3 Pt 1):489–492.

11. Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005; CD002126.

12. Reid PC, Virtanen-Kari S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. BJOG. 2005; 112:1121–1125.

13. Lethaby AE, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000; CD000249.

14. Lethaby A, Augood C, Duckitt K, Farquhar C. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007; CD000400.

15. Fraser IS, McCarron G. Randomized trial of 2 hormonal and 2 prostaglandin-inhibiting agents in women with a complaint of menorrhagia. Aust N Z J Obstet Gynaecol. 1991; 31:66–70.

16. Iyer V, Farquhar C, Jepson R. Oral contraceptive pills for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000; CD000154.

17. Coulter A, Kelland J, Peto V, Rees MC. Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice. Int J Technol Assess Health Care. 1995; 11:456–471.

18. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008; CD001016.

19. Friedman AJ, Hoffman DI, Comite F, Browneller RW, Miller JD. Treatment of leiomyomata uteri with leuprolide acetate depot: a double-blind, placebo-controlled, multicenter study. The Leuprolide Study Group. Obstet Gynecol. 1991; 77:720–725.

20. Beaumont H, Augood C, Duckitt K, Lethaby A. Danazol for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007; CD001017.

21. World Health Organization. Reproductive Health and Research. Medical Eligibility Criteria for Contraceptive Use. Geneva: Reproductive Health and Research, World Health Organization; 2004.

22. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006; CD003855.

23. Cook JR, Seman EI. Pregnancy following endometrial ablation: case history and literature review. Obstet Gynecol Surv. 2003; 58:551–556.

24. El-Toukhy T, Hefni M. Pregnancy after hydrothermal endometrial ablation and laparoscopic sterilisation. Eur J Obstet Gynecol Reprod Biol. 2003; 106:222–224.

25. Kir M, Hanlon-Lundberg KM. Successful pregnancy after thermal balloon endometrial ablation. Obstet Gynecol. 2004; 103(5 Pt 2):1070–1073.

26. Lethaby A, Shepperd S, Cooke I, Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000; CD000329.

27. Iverson RE Jr, Chelmow D, Strohbehn K, Waldman L, Evantash EG. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol. 1996; 88:415–419.

28. Myers ER, Barber MD, Gustilo-Ashby T, Couchman G, Matchar DB, McGrory DC. Management of uterine leiomyomata: what do we really know. Obstet Gynecol. 2002; 100:8–17.

29. Fedele L, Parazzini F, Luchini L, Mezzopane R, Tozzi L, Villa L. Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Hum Reprod. 1995; 10:1795–1796.

30. Malone LJ. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol. 1969; 34:200–203.

31. Roopnarinesingh S, Suratsingh J, Roopnarinesingh A. The obstetric outcome of patients with previous myomectomy or hysterotomy. West Indian Med J. 1985; 34:59–62.

32. Spies JB, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin S, Mauro M, et al. The FIBROID Registry: symptom and quality-of-life status 1 year after therapy. Obstet Gynecol. 2005; 106:1309–1318.

33. Gupta JK, Sinha AS, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2006; CD005073.

34. Siskin GP, Shlansky-Goldberg RD, Goodwin SC, Sterling K, Lipman JC, Nosher JL, et al. UAE versus Myomectomy Study Group. A prospective multicenter comparative study between myomectomy and uterine artery embolization with polyvinyl alcohol microspheres: long-term clinical outcomes in patients with symptomatic uterine fibroids. J Vasc Interv Radiol. 2006; 17:1287–1295.

Fig. 1.

Surgical treatment for heavy menstrual bleeding

Fig. 2.

Algorithm for management of heavy menstrual bleeding

Table 1.

Levels of evidence for intervention studies [1]

Level	Source of evidence
1++	High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs) or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies; high-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+	Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2-	Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3	Non-analytical studies (for example, case reports, case series)
4	Expert opinion, formal consensus

Table 2.

Classification of recommendations [2]

Class	Evidence
A	At least one meta-analysis, systematic review, or randomised controlled trial (RCT) that is rated as 1++, and is directly applicable to the target population, or a systematic review of RCTs or a body of evidence that consists principally of studies rated as 1+, is directly applicable to the target population and demonstrates overall consistency of results, or evidence drawn from a NICE technology appraisal.
B	A body of evidence that includes studies rated as 2++, is directly applicable to the target population and demonstrates overall consistency of results, or extrapolated evidence from studies rated as 1++ or 1+.
C	A body of evidence that includes studies rated as 2+, is directly applicable to the target population and demonstrates overall consistency of results, or extrapolated evidence from studies rated as 2++.
D	Evidence level 3 or 4, or extrapolated evidence from studies rated as 2+, or formal consensus.
D (GPP)	A good practice point (GPP) is a recommendation for best practice based on the experience of the Guideline Development Group.

TOOLS

Similar articles