Carolyn Best

Endometriosis: Diagnosis and Management

OBJECTIVE To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis. OUTCOMES OUTCOMES evaluated include the impact of the medical and surgical management of endometriosis on womens experience of morbidity and infertility. METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. CONCLUSIONS Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy. EVIDENCE Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1. BENEFITS, HARMS, AND COSTS Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.

Adhesion Prevention in Gynaecological Surgery

OBJECTIVES To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery. OPTIONS Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation. OUTCOMES The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease. EVIDENCE Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care SUMMARY STATEMENTS: 1. Meticulous surgical technique is a means of preventing adhesions. This includes minimizing tissue trauma, achieving optimal hemostasis, minimizing the risk of infection, and avoiding contaminants (e.g., fecal matter) and the use of foreign materials (e.g., talcum powder) when possible. (II-2). 2. The risk of adhesions increases with the total number of abdominal and pelvic surgeries performed on one patient; every surgery needs to be carefully considered in this context. (II-2). 3. Polytetrafluoroethylene (Gore-Tex) barrier is more effective than no barrier or oxidized regenerated cellulose in preventing adhesion formation. (I). 4. Oxidized regenerated cellulose (Interceed) adhesion barrier is associated with a reduced incidence of pelvic adhesion formation at both laparoscopy and laparotomy when complete hemostasis is achieved. Oxidized regenerated cellulose may increase the risk of adhesions if optimal hemostasis is not achieved. (II-2). 5. Chemically modified sodium hyaluronate/carboxymethylcellulose (Seprafilm) is effective in preventing adhesion formation, especially following myomectomies. There is insufficient evidence on the effect of sodium hyaluronate/carboxymethylcellulose on long-term clinical outcomes such as fertility, chronic pelvic pain or small bowel obstruction. (II-2). 6. No adverse effects have been reported with the use of oxidized regenerated cellulose, polytetrafluoroethylene, or sodium hyaluronate/carboxymethylcellulose. (II-1). 7. Various pharmacological agents have been marketed as a means of preventing adhesions. None of these agents are presently available in Canada. There is insufficient evidence for the use of pharmacological agents in preventing adhesions. (III-C). RECOMMENDATIONS 1. Surgeons should attempt to perform surgical procedures using the least invasive method possible in order to decrease the risk of adhesion formation. (II-1B ). When feasible, for example, a laparoscopic surgical approach is preferable to an abdominal approach, and a vaginal or laparoscopic hysterectomy is preferable to an abdominal hysterectomy. 2. Precautions should be taken at surgery to minimize tissue trauma in order to decrease the risk of postoperative adhesions. These precautions include limiting packing, crushing, and manipulating of tissues to what is strictly required for safe completion of the procedure. (III-B). 3. Surgeons could consider using an adhesion barrier for patients who are at high risk of forming clinically significant adhesions (i.e., patients who have endometriosis or pelvic inflammatory disease or who are undergoing a myomectomy). If there is a risk of ongoing bleeding from the surgical site, oxidized regenerated cellulose (Interceed) should not be used as it may increase the risk of adhesions in this situation. (II-2B).

Abnormal Uterine Bleeding in Pre-Menopausal Women

BACKGROUND Abnormal uterine bleeding is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. This guideline replaces previous clinical guidelines on the topic and is aimed to enable health care providers with the tools to provide the latest evidence-based care in the diagnosis and the medical and surgical management of this common problem. OBJECTIVE To provide current evidence-based guidelines for the diagnosis and management of abnormal uterine bleeding (AUB) among women of reproductive age. OUTCOMES Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB. METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada, type of practice, subspecialty expertise, and general gynaecology background. The committee reviewed relevant evidence in the English medical literature including published guidelines. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of AUB. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. CONCLUSIONS Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age. Standardization of related terminology, a systematic approach to diagnosis and investigation, and a step-wise approach to intervention is necessary. Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions. EVIDENCE Published literature was retrieved through searches of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary (e.g. uterine hemorrhage, menorrhagia) and key words (e.g. menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1999 to March 2011. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding, their families, and society. The economic cost of implementing these guidelines in the Canadian health care system was not considered.

Female Genital Cosmetic Surgery

OBJECTIVE To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2011 and 2012 using appropriate controlled vocabulary and key words (female genital cosmetic surgery). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A) 2. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B) 3. Counselling should be a priority for women requesting female genital cosmetic surgery. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process. (III-L) 4. There is little evidence to support any of the female genital cosmetic surgeries in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided (III-L) 5. Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L) 6. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L).

Oral contraceptives and the risk of venous thromboembolism: An update

To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism.

Adhesion prevention in gynaecological surgery: No. 243, June 2010

To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery.

Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians

OBJECTIVE To describe the current practice, experience, and confidence of Canadian obstetricians in the management of obstetric anal sphincter injuries (OASIS) and to explore the need for national practice guidelines on this topic. METHODS We conducted a cross-sectional, Internet-based survey between December 2010 and March 2011. The survey was initially tested among a sample population and then distributed electronically to 665 Canadian obstetricians. Data were analyzed descriptively. The main outcome measures were the self-reported confidence and experience of Canadian obstetricians in OASIS management and the frequency of performing specific OASIS management steps. RESULTS The survey response rate was 28.7%. The majority of the respondents (95%) reported confidence in performing OASIS repairs. In the event of a perineal laceration, 47.9% of respondents routinely performed a rectal examination. Most OASIS repairs were performed in the delivery room (89.4%) under local anaesthesia (60.6%) when regional anaesthesia was not already present. If lacerated, the internal anal sphincter was repaired separately by 63.4% of respondents, and intraoperative antibiotics were ordered by 51.1% of respondents. Most (92%) reported the absence of a local protocol to guide OASIS repair. CONCLUSION The confidence of Canadian obstetricians who participated in this survey in performing OASIS repairs was high. However, their experience in performing repairs and their use of management steps varied. The need for national guidelines and an increase in awareness is suggested.

Sexual and Reproductive Health Counselling by Health Care Professionals

This document reflects emerging clinical and scientific advances on the date issued, and is 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 documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. This policy statement was prepared by the Social and Sexual Issues Committee, reviewed by the Family Physicians Advisory Committee and the Clinical Practice Gynaecology Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SOCIAL AND SEXuAL ISSuES COMMITTEE Margaret Burnett, MD (Chair), Winnipeg MB Anjali Aggarwal, MD, Toronto ON Victoria Davis, MD, Scarborough ON Jeffrey Dempster, MD, Halifax NS William Fisher, PhD, London ON Karen MacKinnon, RN, PhD, Victoria BC Rosana Pellizzari, MD, Peterborough ON Viola Polomeno, RN, PhD, Ottawa ON Maegan Rutherford, MD, Halifax NS Vyta Senikas, MD, Ottawa ON Marie-Soleil Wagner, MD, Montreal QC FAMILY PHYSICIANS ADVISORY COMMITTEE William Ehman, MD (Chair), Nanaimo BC Anne Biringer, MD, Toronto ON Andrée Gagnon, MD, Blainville QC Lisa Graves, MD, Sudbury ON Jonathan Hey, MD, Saskatoon SK Jill Konkin, MD, Edmonton AB Francine Léger, MD, Montreal QC Cindy Marshall, MD, Lower Sackville NS

No 292-Saignements utérins anormaux chez les femmes préménopausées

Comité de pratique clinique Gynécologie : Nicholas Leyland, MD (coprésident), North York (Ont.); Wendy Wolfman, MD (coprésidente), Toronto (Ont.); Catherine Allaire, MD, Vancouver (C.-B.); Alaa Awadalla, MD, Winnipeg (Man.); Carolyn Best, MD, Toronto (Ont.); Sheila Dunn, MD, Toronto (Ont.); Mark Heywood, MD, Vancouver (C.-B.); Madeleine Lemyre, MD, Québec (Québec); Violaine Marcoux, MD, Ville Mont-Royal (Québec); Chantal Menard, inf. aut., Ottawa (Ont.); Frank Potestio, MD, Thunder Bay (Ont.); David Rittenberg, MD, Halifax (N.-É.); Sukhbir Singh, MD, Ottawa (Ont.). Tous les membres du comité nous ont fait parvenir une déclaration de divulgation. Mots clés : Menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy, endometrial ablation