Professional Documents
Culture Documents
PRINCIPAL AUTHORS
George A. Vilos. MD. FRCSC. London. ON; Guylaine Lefebvre. MD. FRCSC. Toronto. ON; Gillian R. Graves. MD. FRCSC. Halifax. NS
.
2. Women presenting with menorrhagia should have a current
INTRODUCTION
cervical cytology and a complete blood count. Further inves-
tigations are individualized. It is useful to delineate if the
bleeding results from ovulatory or anovulatory causes. both in The normal menstrual cycle lasts 28 ± 7 days, the flow lasts
terms of tailoring the investigations and in choosing a treat- 4 ± 2 days, and the average blood loss is 40 ± 20 m!. I
ment. (III B) Abnormal uterine bleeding (AUB) is defined as changes
3. Clinicians should perform endometrial sampling based on the
in frequency of menses, duration of flow or amount of blood
methods available to them. An office endometrial biopsy
should be obtained if possible in all women presenting with loss. Dysfunctional uterine bleeding (DUB) is a diagnosis of
abnormal uterine bleeding. over 40 years of age or weighing exclusion when there is no pelvic pathology or underlying med-
more than or equal to 90 kg. (II B) ical cause. DUB is typically characterized by heavy prolonged
4. Hysteroscopically-directed biopsy is indicated for women with flow with or without breakthrough bleeding. It may occur with
persistent erratic menstrual bleeding. failed medical therapy or or without ovulation.
transvaginal saline sonography suggestive of focal intrauterine
These guidelines reflect emerging clinical and scientific advances as of the date issued and are subject to change. The information should not be construed as
dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well doc-
umented if modified at the local level. None of the contents may be reproduced in any form without prior written permission of SOGc.
Menorrhagia (hypermenorrhoea) is defined as heavy cycli- pattern following a course of therapy of three months. The
cal menstrual bleeding occurring over several consecutive cycles SOGC guidelines Diagnosis ofEndometrial Cancer in WOmen
during the reproductive years. Objectively menorrhagia is defined With Abnormal vaginal Bleeding (2000) reviewed the evidence for
as blood loss of more than 80 ml per cycle, the 90th percentile in endometrial sampling and contained an algorithm which sug-
a study of 476 Gothenberg women published by Hallberg et al. gests a course of management in assessing the endometrium. 12
in 1966. 2 Monthly blood loss in excess of 60 ml may result in
iron deficiency anemia and may affect the quality oflife. 3 TECHNIQUES FOR ENDOMETRIAL SAMPLING
Office endometrial biopsy results in adequate samples 87 to
DIAGNOSTIC APPROACH TO AUB 97 percent of the time l3 ,15 and detects 67 to 96 percent of
li! ."iiII*lI!iI'"I!lI"''''~
ing: nulliparity with a history of infertility; new onset of heavy, Nulliparity - 2.8 (1.1-7.2) 0.0267
irregular bleeding; obesity (~ 90 kg)/,8 polycystic ovaries;9 a Family history of - 5.8 (1.1-28.6) 0.0392
family history of endometrial and colonic cancer;7 and on endometrial
tamoxifen therapy. IO,l! cancer
It is also important to evaluate the endometrial histopatho- Farquhar et 01., 1999. 7 Multivariate analysiS of 1033 women.
logy in a woman who has no improvement in her bleeding
TABLE 3
QUALITY OF EVIDENCE ASSESSMENT59 CLASSIFICATION OF RECOMMENDATIONS59
The quality of evidence reported in these guidelines has been Recommendations included in these guidelines have been adapt-
described using the Evaluation of Evidence criteria outlined in ed from the ranking method described in the Classification of
the Report of the Canadian Task Force on the Periodic Recommendations found in the Report of the Canadian Task
Health Exam. 59 Force on the Periodic Health Exam. 59
I: Evidence obtained from at least one properly random- A. There is good evidence to support the recommendation
ized controlled trial. that the condition be specifically considered in a periodic
II-I: Evidence from well-designed controlled trials without health examination.
randomization. B. There is fair evidence to support the recommendation
11-2: Evidence from well-designed cohort (prospective or that the condition be specifically considered in a periodiC
retrospective) or case-control studies, preferably from health examination.
more than one centre or research group. e. There is poor evidence regarding the inclusion or exclu-
11-3: Evidence obtained from comparisons between times or
sion of the condition in a periodic health examination,
places with or without the intervention. Dramatic
but recommendations may be made on other grounds.
results in uncontrolled experiments (such as the results
D. There is fair evidence to support the recommendation
of treatment with penicillin in the 1940) could also be
that the condition not be considered in a periodiC health
included in this category.
examination.
III: Opinions of respected authorities, based on clinical
E. There is good evidence to support the recommendation
experience, descriptive studies, or reports of expert
that the condition be excluded from consideration in a
committees.
periodic health examination.