Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials

A randomized trial comparing the 52-mg levonorgestrel system with combination oral contraceptives for treatment of heavy menstrual bleeding

BACKGROUND

The levonorgestrel intrauterine system and combined oral contraceptives are the 2 most commonly used nonsurgical treatments for heavy menstrual bleeding in the United States. However, there are limited data on their relative effectiveness and on their impact on bleeding-specific quality of life.

OBJECTIVE

This study aimed to compare the effectiveness of the 52-mg levonorgestrel intrauterine system with that of combined oral contraceptives for improving quality of life among individuals who self-report heavy menstrual bleeding. We hypothesized that the levonorgestrel intrauterine system would be more effective than combined oral contraceptives at 6 and 12 months after treatment.

STUDY DESIGN

We conducted a pragmatic randomized trial of individuals who self-reported heavy menstrual bleeding. Individuals were eligible if they did not have contraindications to either the levonorgestrel intrauterine system or combined oral contraceptives and were determined to have a nonstructural cause of heavy menstrual bleeding. Eligible and consenting participants were randomly assigned in a 1:1 ratio to receive a 52-mg levonorgestrel intrauterine system or a monophasic 30- or 35-μg ethinyl estradiol-containing combined oral contraceptive. The main outcome was mean change in bleeding-related quality of life, measured by the 20-question Menstrual Bleeding Questionnaire (score range, 0-75) at 6 and 12 months. Differences in group means and confidence intervals for the Menstrual Bleeding Questionnaire score were computed by multivariable linear mixed-effects regression; 24 participants per group were needed to detect a 10-point difference in change in mean Menstrual Bleeding Questionnaire score between individuals treated with the levonorgestrel intrauterine system and those treated with combined oral contraceptives at each follow-up time point.

RESULTS

A total of 62 individuals were randomly assigned to treatment (n=29 allocated to levonorgestrel intrauterine system and n=33 allocated to combined oral contraceptives) and included in the intention-to-treat analyses; 19 of 29 received the levonorgestrel intrauterine system and 31 of 33 received combined oral contraceptives. Eleven percent identified as Black or African American and 44% identified as Hispanic or Latina. Participant characteristics were similar among study groups. Bleeding-related quality of life increased in both study arms, as reflected by a significant decrease in Menstrual Bleeding Questionnaire scores beginning at 6-week follow-up. In the main intention-to-treat analyses (n=62), there were no differences in mean change in Menstrual Bleeding Questionnaire scores at 6 months (difference=-2.5; 95% confidence interval, -10.0 to +5.0) or 12 months (difference=-1.1; 95% confidence interval, -8.7 to +6.5). Findings were similar in the subsets of participants with any follow-up visits (n=52) and who completed all follow-up visits (n=42). In the per-protocol analyses (n=47), a significantly greater decrease in Menstrual Bleeding Questionnaire score was observed in the levonorgestrel intrauterine system arm at 6 months after treatment (difference=-7.0; 95% confidence interval, -13.8 to -0.2) but not at 12 months (difference=-4.8; 95% confidence interval, -11.8 to 2.3) compared with the combined oral contraceptive arm.

CONCLUSION

No differences in change of bleeding-related quality of life were observed between the levonorgestrel intrauterine system and combined oral contraceptives at 6 or 12 months. Patients should be counseled that the levonorgestrel intrauterine system and combined oral contraceptives are both effective options for improving bleeding-related quality of life.

Standardising outcome reporting for clinical trials of interventions for heavy menstrual bleeding: Development of a core outcome set

OBJECTIVE

To develop a core outcome set for heavy menstrual bleeding (HMB).

DESIGN

Core outcome set (COS) development methodology described by the COMET initiative.

SETTING

University hospital gynaecology department, online international survey and web-based international consensus meetings.

POPULATION OR SAMPLE

An international collaboration of stakeholders (clinicians, patients, academics, guideline developers) from 20 countries and 6 continents.

METHODS

Phase 1: Systematic review of previously reported outcomes to identify potential core outcomes. Phase 2: Qualitative studies with patients to identify outcomes most important to them. Phase 3: Online two-round Delphi survey to achieve consensus about which outcomes are most important. Phase 4: A consensus meeting to finalise the COS.

MAIN OUTCOME MEASURES

Outcome importance was assessed in the Delphi survey on a 9-point scale.

RESULTS

From the 'long list' of 114, 10 outcomes were included in the final COS: subjective blood loss; flooding; menstrual cycle metrics; severity of dysmenorrhoea; number of days with dysmenorrhoea; quality of life; adverse events; patient satisfaction; number of patients going on to have further treatment for HMB and haemoglobin level.

CONCLUSIONS

The final COS includes variables that are feasible for use in clinical trials in all resource settings and apply to all known underlying causes of the symptom of HMB. These outcomes should be reported in all future trials of interventions, their systematic reviews, and clinical guidelines to underpin policy.

More than blood: app-tracking reveals variability in heavy menstrual bleeding construct

BACKGROUND

Heavy menstrual bleeding (HMB) is associated with impaired quality of life and may signal serious health problems. Unresolved challenges in measuring menstrual bleeding and identifying HMB have hampered research and clinical care. Self-reported bleeding histories are commonly used but these may be influenced by recall bias, personal beliefs regarding "normal" flow volume, and the experience of other physical symptoms or disruptions to daily life. The potential usefulness of menstrual-tracking mobile applications, which allow real-time user-entered data recording, for assessing HMB has not been studied. We evaluated recall bias in reported period duration, the relationship of tracked period duration and daily flow volume to subsequently reported period heaviness, variation in quality of life associated with increasing period heaviness, and the advantages and limitations of using app-tracked data for clinical and research purposes.

METHODS

An online questionnaire was distributed to current users of Clue, a commercially available menstrual health tracking app, asking them to characterize their last period. We compared responses to the user's corresponding Clue app-tracked data. The study sample comprised 6546 U.S.-based users (aged 18-45 years).

RESULTS

Increasing reported heaviness was associated with increasing app-tracked period length and days of heavy flow, impaired quality-of-life (especially body pain severity), and disrupted activities. Of those reporting having had a heavy/very heavy period, ~ 18% had not tracked any heavy flow, but their period length and quality-of-life indicators were similar to those who had tracked heavy flow. Sexual/romantic activities were the most affected across all flow volumes. Compared to app-tracked data, 44% recalled their exact period length; 83% recalled within ± 1 day. Overestimation was more common than underestimation. However, those with longer app-tracked periods were more likely to underestimate period length by ≥ 2 days, a pattern which could contribute to under-diagnosis of HMB.

CONCLUSION

Period heaviness is a complex construct that encapsulates flow volume and, for many, several other bleeding-associated experiences (period length, bodily impairments, disruptions of daily activities). Even very precise flow volume assessments cannot capture the multi-faceted nature of HMB as experienced by the individual. Real-time app-tracking facilitates quick daily recording of several aspects of bleeding-associated experiences. This more reliable and detailed characterization of bleeding patterns and experiences can potentially increase understanding of menstrual bleeding variability and, if needed, help to guide treatment.

Medroxyprogesterone Acetate for Abnormal Uterine Bleeding Due to Ovulatory Dysfunction: The Effect of 2 Different-Duration Regimens

Background

Abnormal uterine bleeding (AUB) lowers the quality of life of women. This study attempted to determine which treatment protocol of medroxyprogesterone acetate (MPA), 15 vs 10 day-administration in a luteal phase, provides better outcomes in women with ovulatory dysfunction-related AUB (AUB-O).

Material/Methods

The study included a total of 52 patients with AUB-O: Women in Group A were given MPA between days 11 and 25 of the menstrual cycle (15-day protocol), whereas women in Group B were given MPA between days 16 and 25 (10-day protocol). Outcomes were compared between the 2 groups.

Results

Women in group B, compared with those in group A, more often showed regular menstrual cycles and decrement of AUB. In group B, 3 cycles of treatment were sufficient to achieve AUB-stop (p<0.05). Post-treatment hemogram parameters and surgical treatment requirements were not different between the 2 groups.

Conclusions

In the second half of the cycle/predicted luteal phase, 10-day cyclic use of MPA (the group B) better regulated the menstrual cycle and more frequently stopped AUB-O.

Quality of life in adolescents with heavy menstrual bleeding: Validation of the Adolescent Menstrual Bleeding Questionnaire (aMBQ)

BACKGROUND/OBJECTIVES

Heavy menstrual bleeding (HMB) affects 34% to 37% of adolescent girls. The Menstrual Bleeding Questionnaire (MBQ) is a validated measure of menstrual bleeding-specific health-related quality of life (HRQoL) for women aged ≥18 years. No similar measure existed for adolescents with HMB.

PATIENTS/METHODS

HMB was defined by the Pictorial Bleeding Assessment Chart (PBAC) score ≥100. In Phase 1, a focus group of adolescents with HMB adapted the MBQ, to generate the Adolescent MBQ (aMBQ). In phase 2, participants with and without HMB were recruited from clinics and self-referral. Each participant completed 3 questionnaires (aMBQ, Pediatric Quality of Life module [PedsQL]©, PBAC) at two time points. Validity of the aMBQ was assessed by Pearson's correlation with the PedsQL©. Reliability was calculated using intra-class correlation (ICC) in those without HMB. The receiver operating characteristic curve assessed the aMBQ's ability to identify those with HMB.

RESULTS

Phase 1 included five girls with a mean age of 17.1 (13-18) years. The aMBQ was adapted from the MBQ by substituting four words/phrases that altered 8 of the 20 questions and by adding 1 new question. The 21-item aMBQ has a score range of 0 to 77 (77 = worst HRQoL). Phase 2 included 52 participants: 20 with and 32 without HMB, with a mean age of 14.8 (11-17) years. The validity of the aMBQ was confirmed by a moderate correlation with PedsQL© (r = -0.63; P < .001). Test-retest reliability was substantial (ICC = 0.73; P = .04). An aMBQ score of >30 identified those with HMB with excellent discrimination (area under the curve = 0.82; sensitivity, 70.0%; specificity, 84.4%).

CONCLUSIONS

The aMBQ is a valid and reliable tool to assess HRQoL in adolescents with HMB.

Low dose dexamethasone as treatment for women with heavy menstrual bleeding: A response-adaptive randomised placebo-controlled dose-finding parallel group trial (DexFEM)

BACKGROUND

The symptom of heavy menstrual bleeding (HMB) diminishes quality-of-life for many mid-age women and imposes substantial societal burden. We investigated our hypothesis that HMB reflects impaired endometrial vasoconstriction due to endometrial glucocorticoid deficiency. Does reversing this deficiency, by short-term luteal-phase treatment with exogenous glucocorticoid (dexamethasone), ameliorate HMB?

METHODS

In our Bayesian response-adaptive parallel-group placebo-controlled randomised trial, five pre-planned interim analyses used primary outcome data to adjust randomisation probabilities to favour doses providing most dose-response information. Participants with HMB, recruited from Lothian (Scotland) NHS clinics and via community invitations/advertisements, were aged over 18 years; reported regular 21-42 day menstrual cycles; and had measured menstrual blood loss (MBL) averaging ≥ 50 mL over two screening periods. Identically encapsulated placebo, or one of six Dexamethasone doses (0·2 mg, 0·4 mg, 0·5 mg, 0·6 mg, 0·75 mg, 0·9 mg), were taken orally twice-daily over five days in the mid-luteal phase of three menstrual cycles. Participants, investigators, and those measuring outcomes were masked to group assignment. Primary outcome, change in average MBL from screening to 'treatment', was analysed by allocated treatment, for all with data.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01769820; EudractCT 2012-003,405-98 FINDINGS: Recruitment lasted 29/01/2014 to 25/09/2017; 176 were screened, 107 randomised and 97 provided primary outcome data (n = 24,5,9,21,8,14,16 in the seven arms, placebo to 1·8 mg total daily active dose). In Bayesian normal dynamic linear modelling, 1·8 mg dexamethasone daily showed a 25 mL greater reduction in MBL from screening, than placebo (95% credible interval 1 to 49 mL), and probability 0·98 of benefit over placebo. Adverse events were reported by 75% (58/77) receiving dexamethasone, 58% (15/26) taking placebo. Three serious adverse events occurred, two during screening, one in a placebo participant. No woman withdrew due to adverse effects.

INTERPRETATION

Our adaptive trial in HMB showed that dexamethasone 1·8 mg daily reduced menstrual blood loss. The role of dexamethasone in HMB management deserves further investigation.

FUNDING

UK MRC DCS/DPFS grant MR/J003611/1.

Menstruation: science and society

Women's health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation-a fast, scarless healing process in healthy individuals-will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, "Menstruation: Science and Society" with an aim to "identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field." Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration-and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids-to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent "menstrual equity" and "period poverty" movements spreading across high-income countries.

Ultrasound-Guided High Intensity Focused Ultrasound Ablation for Symptomatic Uterine Fibroids: Preliminary Clinical Experience

OBJECTIVE

 To evaluate the middle-term efficacy and complications of ultrasound-guided high intensity focused ultrasound (USgHIFU) for the treatment of symptomatic uterine fibroids in an NHS population.

METHODS

 A prospective observational single-center study at a single university hospital in Oxford, UK. Patients with symptomatic uterine fibroids who declined standard surgical/radiological intervention and were referred to the HIFU unit were considered for USgHIFU treatment. Clinical evaluation, adverse event monitoring, uterine fibroid symptoms and health-related quality of life questionnaire (UFS-QOL) and contrast-enhanced pelvic magnetic resonance imaging (MRI) were performed before and at regular intervals after treatment to assess patient outcome.

RESULTS

 12 of 22 referred patients underwent one session of USgHIFU ablation of 14 fibroids overall and received a two-year follow-up. No serious adverse events were reported, but a second-degree skin burn was observed in one patient who had a surgical scar from a previous caesarean section. Mean symptom severity scores (SSS-QOL) improved significantly from 56.5 ± 29.1 (SD) at baseline to 33.4 ± 23.3 (p < 0.01) at three months, 45.0 ± 35.4 (p < 0.05) at one year and 40.6 ± 32.7 (p < 0.01) at two years post-treatment. The mean non-perfused volume ratio was 67.7 ± 39.0 % (SD) in the treated fibroids (n = 14) within three months of treatment. The mean volume reduction rates of the treated fibroids were 23.3 ± 25.5 % (SD) at 3 months post-treatment (p < 0.01, n = 14), 49.3 ± 23.7 % at 12 months (p < 0.05, n = 8), and 51.9 ± 11.1 % at 24 months (p < 0.005, n = 8).

CONCLUSION

 This study demonstrates the clinical efficacy of USgHIFU ablation of uterine fibroids and the low risk of complications. We believe that this noninvasive approach may offer an alternative therapy for women with symptomatic uterine fibroids. While HIFU is fast becoming the standard of care for fibroid ablation in other countries, to our knowledge, this study is the first to present clinical experience of US-guided HIFU ablation of symptomatic uterine fibroids in an NHS population.

PLAIN LANGUAGE SUMMARY

High intensity focused ultrasound (HIFU) can be used for the noninvasive ablation of symptomatic uterine fibroids, and MR-guided treatment has already gained FDA approval. Ultrasound-guided HIFU has the advantage of offering practicalities in anesthesia and considerable cost-savings over MR-guided treatments. In this prospective study we have demonstrated the middle-term efficacy and favorable safety profile of ultrasound-guided HIFU for the treatment of symptomatic uterine fibroids for the first time in an NHS population.

Optimal management of hormonal contraceptives after an episode of venous thromboembolism

Optimal management of hormonal contraception in patients with venous thromboembolism (VTE) requires an individualized approach considering its potential benefits and complications during and after anticoagulant treatment. Potential benefits include prevention of pregnancy and mitigation of menstrual bleeding that is often worsened after start of anticoagulation therapy. Current evidence suggests that patients may opt for a continuation of (all forms of) hormonal contraception during anticoagulant treatment, provided that they are adequately informed by the treating physicians. Combined oral contraceptives should be stopped before anticoagulant therapy may be discontinued, preferably after the second last menstrual cycle of the intended anticoagulant treatment period. If hormonal contraceptive treatment needs to be initiated in patients with a history of VTE, oral prostagen-only therapy or intra-uterine devices are to be preferred: this may be independent of the anticoagulation status and in light of a negligible risk of (recurrent) VTE associated with their use.

PROMIS PF correlates with HOOS, JR in patients with hip pain

Background

Patient-reported outcome measures (PROMs) are increasingly integrated into reporting requirements tied to reimbursement. There may be advantages to computer adaptive tests that apply to many different anatomical regions and diseases, provided that important information is not lost.

Questions

1) Does the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computer adaptive test correlate with the Hip injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR: a hip-specific PROM); 2) Is there any difference in the amount of variation explained by various factors (e.g. age, BMI, presence of concomitant knee pain) for both measures?

Methods

In this prospective, cross-sectional study of 213 patients, we assessed the Pearson correlation of PROMIS PF and HOOS, JR. To investigate the variation explained by various patient-level factors, we constructed two multivariable linear regression models.

Results

We found a large correlation between PROMIS PF and HOOS, JR (r 0.58, P < 0.001). Disabled or unemployed status was independently associated with both lower PROMIS PF and HOOS, JR scores (regression coefficient [β] -3.4; 95% confidence interval [CI] -5.8 to -1.0; P = 0.006 and β -11; 95% CI -17 to -5.0; P < 0.001, respectively). Private rather than public insurance was associated with both higher PROMIS PF and HOOS, JR scores (β 4.5; 95% CI 2.2 to 6.8; P < 0.001 and β 6.4; 95% CI 0.49 to 12; P = 0.034, respectively). No floor or ceiling effects were observed for PROMIS PF. HOOS, JR scores showed 4.2% floor and 0.5% ceiling effect.

Conclusions

This study adds to the evidence that general measures of physical limitations may provide similar information as joint- or region-specific measures.

Level of evidence

Level III.

Influence of Ethnicity on Clinical Presentation and Quality of Life in Women With Uterine Fibroids: Results From a Prospective Observational Registry

OBJECTIVE

This study sought to evaluate ethnic variations in the clinical presentation of women with uterine fibroids.

METHODS

A total of 996 premenopausal women with symptomatic uterine fibroids were enrolled in a prospective, non-interventional, observational registry at 19 clinical sites across Canada (CAPTURE Registry). Patient-reported outcomes were assessed using Uterine Fibroid Symptom and Health-Related Quality of Life Symptom Severity questionnaires and the Aberdeen Menorrhagia Severity Scale (Ruta score). Linear and logistic regression models, adjusted for patient and fibroid characteristics, were used to examine differences among ethnicities for continuous and binary outcomes of interest.

RESULTS

Black women were 4.9 years younger (P < 0.001), were more likely to be nulligravid (P = 0.046), had a 41% longer duration of symptoms before enrolment (P = 0.01), had a 49% larger fibroid volume (P = 0.01), and were more likely to be anemic (P < 0.001) compared with White women. Black women reported lower health-related quality of life scores (-5.19 points; 95% CI -9.90 to -0.48, P = 0.03) compared with White women. East Asian women were 2.0 years younger (P = 0.01), were more likely to be nulligravid (P < 0.001), had a 53% longer duration of symptoms (P = 0.01), had 67% larger fibroid volume (P = 0.01), and were more likely to be anemic (P = 0.003) compared with White women. East Asian women had lower symptom severity scores (-5.95 points; 95% CI -11.16 to -0.75, P = 0.02). Non-White women preferred uterine-preserving treatment options (P < 0.001).

CONCLUSION

Black and East Asian women have an increased burden of disease compared with White women and prefer uterine preservation. There is a discrepancy between disease burden and patient-reported outcomes that may reflect ethnocultural differences in disease experience.

The COMET Handbook: version 1.0

The selection of appropriate outcomes is crucial when designing clinical trials in order to compare the effects of different interventions directly. For the findings to influence policy and practice, the outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. It is now widely acknowledged that insufficient attention has been paid to the choice of outcomes measured in clinical trials. Researchers are increasingly addressing this issue through the development and use of a core outcome set, an agreed standardised collection of outcomes which should be measured and reported, as a minimum, in all trials for a specific clinical area.Accumulating work in this area has identified the need for guidance on the development, implementation, evaluation and updating of core outcome sets. This Handbook, developed by the COMET Initiative, brings together current thinking and methodological research regarding those issues. We recommend a four-step process to develop a core outcome set. The aim is to update the contents of the Handbook as further research is identified.

PALM-COEIN Nomenclature for Abnormal Uterine Bleeding

Approximately 30% of women will experience abnormal uterine bleeding (AUB) during their life time. Previous terms defining AUB have been confusing and imprecisely applied. As a consequence, both clinical management and research on this common problem have been negatively impacted. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group (FMDG) published PALM-COEIN, a new classification system for abnormal bleeding in the reproductive years. Terms such as menorrhagia, menometrorrhagia, metrorrhagia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea, and uterine hemorrhage are no longer recommended. The PALM-COEIN system was developed to standardize nomenclature to describe the etiology and severity of AUB. A brief description of the PALM-COEIN nomenclature is presented as well as treatment options for each etiology. Clinicians will frequently encounter women with AUB and should report findings utilizing the PALM-COEIN system.

Comparison of Therapeutic Efficacies of Norethisterone, Tranexamic Acid and Levonorgestrel-Releasing Intrauterine System for the Treatment of Heavy Menstrual Bleeding: A Randomized Controlled Study

BACKGROUND

Our aim was to compare the therapeutic efficacies of norethisterone acid (NETA), tranexamic acid and levonorgestrel-releasing intrauterine system (LNG-IUS) in treating idiopathic heavy menstrual bleeding (HMB).

METHODS

Women with heavy uterine bleeding were randomized to receive NETA, tranexamic acid or LNG-IUS for 6 months. The primary outcome was a decrease in menstrual bleeding as assessed by pictorial blood loss assessment charts and hematological parameters analyzed at the 1st, 3rd and 6th months. Health-related quality of life (QOL) variables were also recorded and analyzed.

RESULTS

Twenty-eight patients were enrolled in each treatment group, but the results of only 62 were evaluated. NETA, tranexamic acid, and LNG-IUS reduced menstrual blood loss (MBL) by 53.1, 60.8, and 85.8%, respectively, at the 6th month. LNG-IUS was more effective than NETA and tranexamic acid in decreasing MBL. LNG-IUS was also more efficient than tranexamic acid in correcting anemia related to menorrhagia. Satisfaction rates were comparable among the NETA (70%), tranexamic acid (63%) and LNG-IUS (77%) groups. QOL in physical aspects increased significantly in the tranexamic acid and LNG-IUS groups.

CONCLUSION

The positive effect of LNG-IUS on QOL parameters, as well as its high efficacy, makes it a first-line option for HMB.

Radiofrequency endometrial ablation for the treatment of heavy menstrual bleeding among women at high surgical risk

OBJECTIVE

To evaluate quality of life (QoL) after radiofrequency endometrial ablation (RFEA) for heavy menstrual bleeding among women at high surgical risk.

METHODS

An observational study was undertaken among women aged at least 18 years who underwent RFEA at Hanover Medical School, Germany, between June 2010 and November 2012. A validated menorrhagia outcomes questionnaire (MOQ) was used to evaluate QoL and global outcomes among patients at high risk and low risk of complications after major surgery. The high-risk group included women with anemia, coagulopathy, anticoagulation, thromboembolism, transplantation, malignancy, severe cardiovascular or pulmonary disease, and obesity.

RESULTS

Overall, 235 women underwent RFEA during the study period. Median follow-up was 13 months (range 3-30). Questionnaire responses were received from 202 (86.0%) women, including 132 (65.3%) high-risk patients. The MOQ total outcome (mean difference 2.0; P = 0.166) and QoL/satisfaction (mean difference 0.8; P = 0.601) scores were similar in the two groups. Success (i.e. symptom relief and no further surgery) was recorded for 119 (90.2%) patients in the high-risk group and 67 (95.7%) patients in the low-risk group (P = 0.155).

CONCLUSION

RFEA improved QoL and achieved a high rate of satisfaction for both high- and low-risk patients. RFEA offers a less invasive alternative to hysterectomy and its associated perioperative risks, particularly among high-risk patients.

The menstrual bleeding questionnaire: development and validation of a comprehensive patient-reported outcome instrument for heavy menstrual bleeding

OBJECTIVE

To develop and validate a patient-reported outcome measure for women with heavy menstrual bleeding (HMB).

STUDY DESIGN

Prospective cohort and cross-sectional studies.

SETTING

Outpatient women's health facility.

POPULATION

Women aged between 18 and 55 years with and without self-reported HMB.

METHODS

Using data from patients and clinicians, we developed a patient-reported outcome measure for HMB; the Menstrual Bleeding Questionnaire (MBQ). Participants in the validation studies completed demographic and general health questionnaires and either (1) bleeding and quality of life data collected daily on handheld computers and the MBQ after 1 month or (2) the MBQ at enrolment only. A subset of women also completed the Short-form-36 (SF-36) generic quality of life questionnaire. We performed psychometric analyses of the MBQ to assess its internal consistency as well as its content and concurrent validity and ability to discriminate between women with and without HMB.

MAIN OUTCOME MEASURES

Psychometric properties of the questionnaire.

RESULTS

Overall, 182 women participated in the MBQ validation studies. We found that the MBQ domains were internally consistent (Cronbach's α = 0.87-0.94). There was excellent correlation between daily bleeding-related symptom data and the MBQ completed at 1 month (ρ > 0.7 for all domains). We found low to moderate correlation between the MBQ scores and SF-36 scores (ρ = -0.15 to -0.45). The MBQ clearly discriminated between women with and without HMB (mean MBQ score = 10.6 versus 30.8, P < 0.0001).

CONCLUSIONS

The MBQ is a valid patient-reported outcome measure for HMB that has the potential to improve the evaluation of women with self-reported HMB in research and clinical practice.

Low-dose dexamethasone as a treatment for women with heavy menstrual bleeding: protocol for response-adaptive randomised placebo-controlled dose-finding parallel group trial (DexFEM)

INTRODUCTION

Heavy menstrual bleeding (HMB) diminishes individual quality-of-life and poses substantial societal burden. In HMB endometrium, inactivation of cortisol (by enzyme 11β hydroxysteroid dehydrogenase type 2 (11βHSD2)), may cause local endometrial glucocorticoid deficiency and hence increased angiogenesis and impaired vasoconstriction. We propose that 'rescue' of luteal phase endometrial glucocorticoid deficiency could reduce menstrual bleeding.

METHODS AND ANALYSIS

DexFEM is a double-blind response-adaptive parallel-group placebo-controlled trial in women with HMB (108 to be randomised), with active treatment the potent oral synthetic glucocorticoid dexamethasone, which is relatively resistant to 11βHSD2 inactivation. Participants will be aged over 18 years, with mean measured menstrual blood loss (MBL) for two screening cycles ≥50 mL. The primary outcome is reduction in MBL from screening. Secondary end points are questionnaire assessments of treatment effect and acceptability. Treatment will be for 5 days in the mid-luteal phases of three treatment menstrual cycles. Six doses of low-dose dexamethasone (ranging from 0.2 to 0.9 mg twice daily) will be compared with placebo, to ascertain optimal dose, and whether this has advantage over placebo. Statistical efficiency is maximised by allowing randomisation probabilities to 'adapt' at five points during enrolment phase, based on the response data available so far, to favour doses expected to provide greatest additional information on the dose-response. Bayesian Normal Dynamic Linear Modelling, with baseline MBL included as covariate, will determine optimal dose (re reduction in MBL). Secondary end points will be analysed using generalised dynamic linear models. For each dose for all end points, a 95% credible interval will be calculated for effect versus placebo.

ETHICS AND DISSEMINATION

Dexamethasone is widely used and hence well-characterised safety-wise. Ethical approval has been obtained from Scotland A Research Ethics Committee (12/SS/0147). Trial findings will be disseminated via open-access peer-reviewed publications, conferences, clinical networks, public lectures, and our websites.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01769820; EudractCT 2012-003405-98.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence that is based on case controlled studies and case reports. This is an update of the review previously published in 2012.

OBJECTIVES

To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.

SEARCH METHODS

We searched sources including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries. The search was last conducted in April 2014. We contacted authors of eligible randomised controlled trials to request unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids. The primary outcomes of the review were patient satisfaction and live birth rate (among women seeking live birth).

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) independently selected studies, assessed quality and extracted data. Evidence quality was assessed using GRADE methods.

MAIN RESULTS

Seven RCTs with 793 women were included in this review. Three trials compared UAE with abdominal hysterectomy, two trials compared UAE with myomectomy, and two trials compared UAE with either type of surgery (53 hysterectomies and 62 myomectomies).With regard to patient satisfaction rates, our findings were consistent with satisfaction rates being up to 41% lower or up to 48% higher with UAE compared to surgery within 24 months of having the procedure (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.59 to 1.48, 6 trials, 640 women, I(2) = 5%, moderate quality evidence). Findings were also inconclusive at five years of follow-up (OR 0.90; 95% CI 0.45 to 1.80, 2 trials, 295 women, I(2) = 0%, moderate quality evidence). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy, but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution (live birth: OR 0.26; 95% CI 0.08 to 0.84; pregnancy: OR 0.29; 95% CI 0.10 to 0.85, 1 study, 66 women).Similarly, for several safety outcomes our findings showed evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups. This applied to intra-procedural complications (OR 0.91; 95% CI 0.42 to 1.97, 4 trials, 452 women, I(2) = 40%, low quality evidence), major complications within one year (OR 0.65; 95% CI 0.33 to 1.26, 5 trials, 611 women, I(2) = 4%, moderate quality evidence) and major complications within five years (OR 0.56; CI 0.27 to 1.18, 2 trials, 268 women). However, the rate of minor complications within one year was higher in the UAE group (OR 1.99; CI 1.41 to 2.81, 6 trials, 735 women, I(2) = 0%, moderate quality evidence) and two trials found a higher minor complication rate in the UAE group at up to five years (OR 2.93; CI 1.73 to 4.93, 2 trials, 268 women).UAE was associated with a higher rate of further surgical interventions (re-interventions within 2 years: OR 3.72; 95% CI 2.28 to 6.04, 6 trials, 732 women, I(2) = 45%, moderate quality evidence; within 5 years: OR 5.79; 95% CI 2.65 to 12.65, 2 trials, 289 women, I(2) = 65%). If we assumed that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE.The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery (OR 0.07; 95% CI 0.01 to 0.52, 2 trials, 277 women, I(2) = 0%). UAE was also associated with a shorter procedural time (two studies), shorter length of hospital stay (seven studies) and faster resumption of usual activities (six studies) in all studies that measured these outcomes; however, most of these data could not be pooled due to heterogeneity between the studies.The quality of the evidence varied, and was very low for live birth, moderate for satisfaction ratings, and moderate for most safety outcomes. The main limitations in the evidence were serious imprecision due to wide confidence intervals, failure to clearly report methods, and lack of blinding for subjective outcomes.

AUTHORS' CONCLUSIONS

When we compared patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) our findings are that there is no evidence of a difference between the interventions. Findings at five year follow-up were similarly inconclusive. There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE, but this information was only available from a selected subgroup in one small trial.We found no clear evidence of a difference between UAE and surgery in the risk of major complications, but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. If we assume that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE. This increase in the surgical re-intervention rate may balance out any initial cost advantage of UAE. Thus although UAE is a safe, minimally invasive alternative to surgery, patient selection and counselling are paramount due to the much higher risk of requiring further surgical intervention.

Variations in the reporting of outcomes used in systematic reviews of treatment effectiveness research in bladder pain syndrome

This paper investigates the quality of outcomes reported in systematic reviews and randomised controlled trials (RCTs) of bladder pain syndrome and its relationship with study quality and journal impact factor. We searched until August 2013 the Cochrane Library, EMBASE, Medline, CINAHL, LILACS and SIGLE, without language restrictions. Quality of outcome reporting in systematic reviews and constituent RCTs was assessed using a 6-point scale. Overall study quality was assessed using the AMSTAR and Jadad scoring systems, and impact factor in the year of publication was noted. Spearman's rank correlation was calculated. There were 8 systematic reviews, with a total of 28 RCTs (1732 patients), reporting 5 outcomes using 19 different measurement scales. The outcomes reported in individual RCTs were urinary symptoms (100%), pain (64%), quality of life (39%), general wellbeing (36%) and bladder capacity (36%). The mean quality of outcomes reported was 1.63 (95% CI 0.29-2.96) for systematic reviews and 3.25 (95% CI 2.80-3.70) for RCTs. The quality of outcomes reported showed correlation with overall study quality (0.90, 95% CI 0.79-0.95, p<0.0001) but not with journal impact factor (0.07, 95% CI -0.31-0.43, p=0.35). Multivariable linear regression showed a relationship between quality of outcome reporting and study quality (β=0.05, p<0.0001), adjusting for effects of study type, impact factor and journal type. There is a need to generate consensus over a set of core outcomes in bladder pain syndrome using standardised reporting tools and to disseminate these through good publication practice.

A framework for crafting clinical practice guidelines that are relevant to the care and management of people with multimorbidity

Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.

Quantitative serial MRI of the treated fibroid uterus

Objective

There are no long-term medical treatments for uterine fibroids, and non-invasive biomarkers are needed to evaluate novel therapeutic interventions. The aim of this study was to determine whether serial dynamic contrast-enhanced MRI (DCE-MRI) and magnetization transfer MRI (MT-MRI) are able to detect changes that accompany volume reduction in patients administered GnRH analogue drugs, a treatment which is known to reduce fibroid volume and perfusion. Our secondary aim was to determine whether rapid suppression of ovarian activity by combining GnRH agonist and antagonist therapies results in faster volume reduction.

Methods

Forty women were assessed for eligibility at gynaecology clinics in the region, of whom thirty premenopausal women scheduled for hysterectomy due to symptomatic fibroids were randomized to three groups, receiving (1) GnRH agonist (Goserelin), (2) GnRH agonist+GnRH antagonist (Goserelin and Cetrorelix) or (3) no treatment. Patients were monitored by serial structural, DCE-MRI and MT-MRI, as well as by ultrasound and serum oestradiol concentration measurements from enrolment to hysterectomy (approximately 3 months).

Results

A volumetric treatment effect assessed by structural MRI occurred by day 14 of treatment (9% median reduction versus 9% increase in untreated women; P = 0.022) and persisted throughout. Reduced fibroid perfusion and permeability assessed by DCE-MRI occurred later and was demonstrable by 2–3 months (43% median reduction versus 20% increase respectively; P = 0.0093). There was no apparent treatment effect by MT-MRI. Effective suppression of oestradiol was associated with early volume reduction at days 14 (P = 0.041) and 28 (P = 0.0061).

Conclusion

DCE-MRI is sensitive to the vascular changes thought to accompany successful GnRH analogue treatment of uterine fibroids and should be considered for use in future mechanism/efficacy studies of proposed fibroid drug therapies. GnRH antagonist administration does not appear to accelerate volume reduction, though our data do support the role of oestradiol suppression in GnRH analogue treatment of fibroids.

Trial Registration

ClinicalTrials.gov NCT00746031

Abnormal uterine bleeding, health status, and usual source of medical care: analyses using the Medical Expenditures Panel Survey

BACKGROUND

Traditionally, research on abnormal uterine bleeding (AUB) focused on measured menstrual blood loss. However, the main burden of this symptom from the patient perspective is its impact on quality of life. Better describing the demographic characteristics, quality of life, and utilization of medical care of women with AUB could assist with health resource planning for this population.

METHODS

We analyzed data from the Medical Expenditures Panel Survey from 2002 to 2010. AUB was identified by International Classification of Diseases, ninth edition (ICD-9) code group 626, disorders of menstruation and other abnormal bleeding from the female genital tract. Health-related quality of life was assessed by the Short-form 12 Health Survey (SF-12, QualityMetric) physical and mental component summary scores (PCS and MCS). Poorer health-related quality of life was defined as PCS or MCS <50. Odds ratios (OR) and 95% confidence intervals (CI) for the association of AUB with poorer SF-12 scores and having a usual source of care were estimated by multivariable logistic regression models.

RESULTS

Data analyzed represented an annual average of 56.2 million nonpregnant women between ages 18 and 50 years. We estimate that 1.4 million women per year (95% CI: 1.3-1.5 million) reported AUB. Women with AUB were more likely to be younger, Caucasian, and obese than women without AUB. Compared to women without AUB, women with AUB had greater odds of a poorer PCS score (OR=1.30, 95% CI: 1.10-1.55), a poorer MCS score (OR=1.28, 95% CI: 1.10-1.51), and a usual source of care (OR=1.85, 95% CI: 1.44-2.38).

CONCLUSIONS

AUB is associated with diminished physical and mental health status and having a usual source of medical care.

Predicting anatomical urological abnormalities in children who present with their first urinary tract infection

OBJECTIVES

Classically, presence of fever≥38.0°C is used to distinguish pyelonephritis from cystitis. We analyzed whether this is an appropriate marker to initiate further workup and whether temperature is correlated with urological abnormalities and further surgical or pharmacological intervention.

METHODS

Children who presented for their first workup of urinary tract infection between October 1, 2008, and September 30, 2009 were retrospectively selected from our institution. Demographics and clinical details were correlated with the diagnosis of urological abnormalities and requirement for intervention.

RESULTS

Age was the most important variable to predict urological abnormalities. The temperature value of 38.3°C maximized the balance between sensitivity (90%) and specificity (46%) for predicting the need to intervene and the presence of anatomical urological abnormalities.

CONCLUSION

Young age (≤2 years) and temperature are the best factors to predict further intervention and urological abnormalities, with a temperature value of 38.3°C being a better predictive value than the currently used 38.0°C.

Nonsurgical management of heavy menstrual bleeding: a systematic review

OBJECTIVE

To compare the effectiveness of nonsurgical abnormal uterine bleeding treatments for bleeding control, quality of life (QOL), pain, sexual health, patient satisfaction, additional treatments needed, and adverse events.

DATA SOURCES

MEDLINE, Cochrane databases, and Clinicaltrials.gov were searched from inception to May 2012. We included randomized controlled trials of nonsurgical treatments for abnormal uterine bleeding presumed secondary to endometrial dysfunction and abnormal uterine bleeding presumed secondary to ovulatory dysfunction. Interventions included the levonorgestrel intrauterine system, combined oral contraceptive pills (OCPs), progestins, nonsteroidal anti-inflammatory drugs (NSAIDs), and antifibrinolytics. Gonadotropin-releasing hormone agonists, danazol, and placebo were allowed as comparators.

METHODS OF STUDY SELECTION

Two reviewers independently screened 5,848 citations and extracted eligible trials. Studies were assessed for quality and strength of evidence.

TABULATION, INTEGRATION, AND RESULTS

Twenty-six articles met inclusion criteria. For reduction of menstrual bleeding in women with abnormal uterine bleeding presumed secondary to endometrial dysfunction, the levonorgestrel intrauterine system (71-95% reduction), combined OCPs (35-69% reduction), extended cycle oral progestins (87% reduction), tranexamic acid (26-54% reduction), and NSAIDs (10-52% reduction) were all effective treatments. The levonorgestrel intrauterine system, combined OCPs, and antifibrinolytics were all superior to luteal-phase progestins (20% increase in bleeding to 67% reduction). The levonorgestrel intrauterine system was superior to combined OCPs and NSAIDs. Antifibrinolytics were superior to NSAIDs for menstrual bleeding reduction. Data were limited on other important outcomes such as QOL for women with abnormal uterine bleeding presumed secondary to endometrial dysfunction and for all outcomes for women with abnormal uterine bleeding presumed secondary to ovulatory dysfunction.

CONCLUSION

For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, we recommend the use of the levonorgestrel intrauterine system over OCPs, luteal-phase progestins, and NSAIDs. For other outcomes (QOL, pain, sexual health, patient satisfaction, additional treatments needed, and adverse events) and for treatment of abnormal uterine bleeding presumed secondary to ovulatory dysfunction, we were unable to make recommendations based on the limited available data.

Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy

STUDY OBJECTIVE

To develop recommendations in selecting treatments for abnormal uterine bleeding (AUB).

DESIGN

Clinical practice guidelines.

SETTING

Randomized clinical trials compared bleeding, quality of life, pain, sexual health, satisfaction, the need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.

PATIENTS

Women with AUB, predominantly from ovulatory disorders and endometrial causes.

INTERVENTIONS

On the basis of findings from a systematic review, clinical practice guidelines were developed. Rating the quality of evidence and the strength of recommendations followed the Grades for Recommendation Assessment, Development, and Evaluation system.

MEASUREMENTS AND MAIN RESULTS

This paper identified few high-quality studies that directly compared uterus-preserving treatments (endometrial ablation, levonorgestrel intrauterine system and systemically administered medications) with hysterectomy. The evidence from these randomized clinical trials demonstrated that there are trade-offs between hysterectomy and uterus-preserving treatments in terms of efficacy and adverse events.

CONCLUSION

Selecting an appropriate treatment for AUB requires identifying a woman's most burdensome symptoms and incorporating her values and preferences when weighing the relative benefits and harms of hysterectomy versus other treatment options.

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding

STUDY OBJECTIVE

To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains.

DESIGN

Systematic review.

SETTING

Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.

PATIENTS

Women with AUB, predominantly from ovulatory disorders and endometrial causes.

INTERVENTIONS

Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system.

MEASUREMENTS AND MAIN RESULTS

Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found.

CONCLUSION

Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Practice patterns and attitudes about treating abnormal uterine bleeding: a national survey of obstetricians and gynecologists

OBJECTIVE

We sought to examine the practice patterns and attitudes of obstetricians and gynecologists surrounding treatment of abnormal uterine bleeding (AUB).

STUDY DESIGN

We conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys, which were distributed using a sequential mixed method (both web- and mail-based) approach, included questions about practice characteristics, practice patterns, and knowledge about treatment options for AUB.

RESULTS

Of 802 questionnaires, 417 were returned (52%). The most commonly selected first-line choice for AUB treatment was combined oral contraceptives (97% anovulatory, 98% ovulatory). The levonorgestrel intrauterine system was the next most frequently selected option (63% anovulatory, 53% ovulatory). Respondents did not score high on questions about the effectiveness of treatments for AUB. Only 25% (n = 86) answered at least 2 of the 3 questions correctly.

CONCLUSION

Continued education is necessary to increase the utilization of the most effective treatment options for AUB.