UPDATE: MINIMALLY INVASIVE GYNECOLOGY

One primary suggestion from the study group is patient counseling that must first determine the type of AUB and the degree of burden or distress for the patient, as well as the presence of any additional cycle-related symptoms. Consideration should be given to variables that may modify the inherent risks or benefits of each intervention for the particular patient, as well as her values and preferences regarding treatment harms, benefits, and potential outcomes. Counseling should assess the patient’s need for contraception, desire for future childbearing, and proximity to menopause, as well as any cultural preferences for management.

Based on the clinical evidence related to hysterectomy versus endometrial ablation, the SRG made the following recommendations:

• If the patient desires amenorrhea and less pain and wants to avoid additional therapy, hysterectomy is preferred
• If the patient wants to avoid adverse events and seeks a shorter hospital stay, endometrial ablation is preferred
• If the patient’s main desire is for improvement in overall quality of life or sexual health, either intervention is appropriate, depending on patient preferences.

There were no data available in the systematic review concerning newer technologies for nonhysteroscopic endometrial ablation versus hysterectomy.

Based on the clinical evidence related to hysterectomy versus the LNG-IUS, the SRG made the following recommendations:

• If the patient desires amenorrhea or seeks to avoid additional therapy, hysterectomy is preferred
• If the patient’s main preference is to avoid adverse events, the LNG-IUS is preferred
• If her preference is for improved quality of life or sexual health, either treatment can be offered.

Based on the clinical evidence related to hysterectomy versus systemic medication, the SRG made the following recommendations:

• If the patient wants to become amenorrheic or hopes to avoid further intervention, hysterectomy is recommended
• If she wants to avoid adverse events, medications are recommended
• If her main preference is overall improvement in quality of life, less pain, or improvement in sexual health, either hysterectomy or medication is appropriate.

Note that no standard therapy was given; medical agents included combined oral contraceptive pills, cyclic or continuous progestin, conjugated estrogen with or without progestin, and prostaglandin synthetase inhibitors, usually with hormonal therapy. There are no randomized, controlled trials of other medications such as nonsteroidal anti-inflammatory drugs or tranexamic acid versus hysterectomy.

The SRG cited three main difficulties in the development of clinical guidelines:

• a lack of well-developed randomized, controlled trials of alternative management versus hysterectomy, as well as inconsistent measurement and reporting among the few trials that exist
• a lack of uniformity in AUB diagnoses among the randomized, controlled trials evaluated
• inconsistent use of terminology related to AUB within the trials.

All of these challenges were addressed by the FIGO nomenclature and AUB classification recommendations. Adherence to the FIGO guidelines for future clinical research would eliminate the difficulties faced by this study group and lead to higher-quality clinical evidence that could form the basis of solid clinical recommendations for the treatment of AUB related to ovulatory disorders or endometrial hemostatic dysfunction.

ACKNOWLEDGMENT. Thank you to Dr. Malcolm Munro and Dr. Anita Lee Sloan for their thoughtful reviews of this manuscript.

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