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    ACOG Guidelines at a Glance: Bulletin on AUB-O: Much-Needed Updates

    Committee on Practice Bulletins—Gynecology

    ACOG Practice Bulletin Number 136: Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction, July 2013 (Replaces Practice Bulletin Number 14, March 2000). Obstet Gynecol. 2013;122:176-85. Full text of ACOG Practice Bulletins is available to ACOG members at http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_--_Gynecology/Management_of_Abnormal_Uterine_Bleeding_Associated_With_Ovulatory_Dysfunction.

    Management of Abnormal Uterine Bleeding With Ovarian Dysfunction

    Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is a condition for which women frequently seek gynecologic care. Anovulatory bleeding is common at the extremes of reproductive age. The choice of treatment of AUB-O depends on several factors, including the woman’s age, severity of her bleeding, her medical risk factors, her need for contraception, and her desire for future fertility (1). The purpose of this document is to provide management guidelines for the treatment of patients with AUB-O.

    Commentary by Jon I. Einarsson, MD, PhD, MPH

     

     

    Dr. Einarsson is Associate Professor of Obstetrics and Gynecology, Harvard Medical School, and Director, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts. He is also the Deputy Editor of Contemporary OB/GYN.

     

    The accepted nomenclature for abnormal uterine bleeding (AUB) changed in 2011 when ACOG adopted the PALM-COEIN system.1,2 Briefly, the PALM-COEIN system divides the etiology of AUB into structural and nonstructural causes with an additional qualifier indicating etiology or etiologies. Although many clinicians still use the term dysfunctional uterine bleeding (DUB) synonymously with AUB, the use of DUB is no longer recommended. 

    Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is one of the nonstructural causes of AUB and is most common at extremes of reproductive age. The Practice Bulletin on the management AUB-O published in July of 2013 brings much-needed updates in terminology and treatment options when compared to the prior Practice Bulletin from 2000. The evaluation and management is divided into age categories because etiology and treatment are age-dependent. The document also recommends ruling out structural causes of AUB.3

    The limitations of endometrial sampling done as an office endometrial biopsy (EMB) or dilatation and curettage (D&C) in the operating room (OR) are well known, especially for detection of polyps or fibroids.4 Performance of a “blind” D&C in the operating room is not addressed in the Practice Bulletin, but in my opinion, it should no longer be considered the standard of care. I believe that patients who are being evaluated in the OR for AUB also should undergo hysteroscopy. Done in the office and coupled with endometrial biopsy, hysteroscopy offers a minimally invasive and cost-effective method of ruling out structural causes of AUB.5

    Saline infusion sonohysterography coupled with EMB is another viable option. The ACOG Practice Bulletin recommends EMB in all women older than age 45 years with AUB and also patients aged 19 to 39 years who are not responding to medical therapy or who have prolonged periods of unopposed estrogen stimulation. It is important to highlight this, because clinicians may tend to overlook the possibility of endometrial malignancy in this younger age group.6

    Jon I. Einarsson, MD, PhD, MPH
    Dr. Einarsson, Deputy Editor, is Associate Professor of Obstetrics ad Gynecology, Harvard Medical School, and Director, Division of ...

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