Clinical Review

2018 Update on abnormal uterine bleeding

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Coverage and clinical perspective on recent AUB studies, including optimal procedure order for evaluation, cost-effectiveness of 4 treatment options, and ulipristal for leiomyoma-related bleeding


Over the past year, a few gems have been published to help us manage and treat abnormal uterine bleeding (AUB). One study suggests an order of performing hysteroscopy and endometrial biopsy, another emphasizes the continued cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS), while a third provides more evidence that ulipristal acetate is effective in the management of leiomyomas.

Optimal order of office hysteroscopy and endometrial biopsy?

Sarkar P, Mikhail E, Schickler R, Plosker S, Imudia AN. Optimal order of successive office hysteroscopy and endometrial biopsy for the evaluation of abnormal uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2017;130(3):565-572.

Office hysteroscopy and endometrial biopsy are frequently used in the evaluation of women presenting with AUB. Sarkar and colleagues conducted a study aimed at estimating the optimal order of office hysteroscopy and endometrial biopsy when performed successively among premenopausal women.

Pain perception, procedure duration, and other outcomes

This prospective single-blind randomized trial included 78 consecutive patients. The primary outcome was detection of any difference in patients' global pain perception based on the order of the procedures. Secondary outcome measures included determining whether the procedure order affected the duration of the procedures, the adequacy of the endometrial biopsy sample, the number of attempts to obtain an adequate tissue sample, and optimal visualization of the endometrial cavity during office hysteroscopy.

Illustration: Kimberly Martens for OBG Management

Uterine leiomyomas are common in reproductive-age women, affecting up to 70% of white women and more than 80% of black women. A recent study suggested that an oral medication currently under investigation in the United States may be useful for the medical management of abnormal uterine bleeding associated with uterine leiomyomas.

Order not important, but other factors may be

Not surprisingly, the results showed that the order in which the procedures were performed had no effect on patients' pain perception or on the overall procedure duration. Assessed using a visual analog scale scored from 1 to 10, global pain perception in the hysteroscopy-first patients (group A, n = 40) compared with the biopsy-first patients (group B, n = 38) was similar (7 vs 7, P = .57; 95% confidence interval [CI], 5.8-7.1). Procedure duration also was similar in group A and group B (3 vs 3, P = .32; 95% CI, 3.3-4.1).

However, when hysteroscopy was performed first, the quality of endometrial cavity images was superior compared with images from patients in whom biopsy was performed first. The number of endometrial biopsy curette passes required to obtain an adequate tissue sample was lower in the biopsy-first patients. The endometrial biopsy specimen was adequate for histologic evaluation regardless of whether hysteroscopy or biopsy was performed first.

Sarkar and colleagues suggested that their study findings emphasize the importance of individualizing the order of successive procedures to achieve the most clinically relevant result with maximum ease and comfort. They proposed that patients who have a high index of suspicion for occult malignancy or endometrial hyperplasia should have a biopsy procedure first so that adequate tissue samples can be obtained with fewer attempts. In patients with underlying uterine anatomic defects, performing hysteroscopy first would be clinically relevant to obtain the best images for optimal surgical planning.

Read next: Which treatment for AUB is most cost-effective?

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