Chantal Menard

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.

Human Papilloma Virus Testing Knowledge and Attitudes Among Women Attending Colposcopy Clinic with ASCUS/LGSIL Pap Smears

OBJECTIVE To study womens knowledge regarding the role of human papilloma virus (HPV) in cervical intraepithelial neoplasia and their attitudes toward the integration of HPV testing as part of routine follow-up of atypical squamous cell of uncertain significance/low-grade squamous intraepithelial lesion (ASCUS/LGSIL) abnormalities. METHODS Over a 12-month period, all women attending the University of Ottawa colposcopy clinic for evaluation and follow-up of ASCUS/LGSIL Pap smears were recruited. Demographic data included age, nature of the Pap smear abnormality, gravidity, parity, occupation and education level, smoking history, previous history of abnormal smears, colposcopic examination and treatment, and current method of contraception. The women were asked to rate their level of concern over their Pap smear abnormality, from 0 (not concerned) to 10 (very concerned). Womens knowledge regarding the role of HPV in cervical intraepithelial neoplasia and the rationale behind the use of HPV testing was assessed by the clinic nurse as being minimal, moderate, or good, as defined by pre-specified criteria. Upon explanation by the nurses of the results of the recent ALTS (ASCUS/LGSIL Triage Study) trial, the women were asked to state whether they preferred to continue with regular colposcopic surveillance every 6 months, or to use the results of the HPV test, if negative, to reduce the number of colposcopy examinations to one annually. Descriptive statistics and logistic regression analysis were used to identify significant demographic factors associated with the womens preference for incorporation of HPV testing in their follow-up. All P values less than.10 were considered to be statistically significant, due to the exploratory nature of the study. RESULTS Of the 100 women who participated in the study, 42% presented with ASCUS. The mean age (+/- SD) of the women was 33.63 +/- 11.25 years (range, 18-75 years); 66% were office workers with at least a community college degree, 86% reported previous abnormal Pap smears, and 67% had previously been seen for colposcopy. Fifty-eight percent of the women rated their concern level as being 6 or more, while 15% ranked their concerns as maximal at 10. In terms of knowledge about HPV, 75% of the women had no or very minimal knowledge of the role of HPV in cervical intraepithelial neoplasia. With regard to HPV testing, 84% of the study group had either never heard of the test or had only a minimal knowledge of HPV testing. After being informed of the ALTS results, 64% of the women chose to use HPV testing to help in triaging the needs for frequent colposcopy. Logistic regression modelling showed that a college level education (odds ratio [OR], 2.27; 95% confidence interval [CI], 0.95-;5.45; P =.06) and history of previous treatment for abnormal Pap smears (OR, 3.31; CI, 0.88- 12.46; P =.07) were closely associated with the adoption of HPV testing in clinical management. CONCLUSION There exists a significant lack of knowledge about HPV and its role in the pathogenesis of cervical intraepithelial neoplasia. Women who have received previous treatments for cervical intraepithelial neoplasia and those with college-level educations were more likely to adopt this new technology as part of their care.

Variations in Ultrasound Reporting on Patients Referred for Investigation of Ovarian Masses

OBJECTIVE Ultrasound characteristics play an important role in the evaluation and management of patients with an ovarian mass. We sought to quantify the variability in the reporting practices of radiologists in different practice environments. METHOD We carried out a prospective audit of all patients referred to a tertiary care gynaecologic oncology clinic over a three-month period for management of an ovarian mass. Each patients presenting symptoms, level of CA125 in serum, and previous ultrasound report were reviewed in detail, and both the environment where the ultrasound examination had been performed and the description of important predictive ultrasound characteristics for underlying risk of malignancy were noted. Descriptive statistics were used to summarize demographic variables. Cross-tabulations and chi-square tests were used to detect significant associations between categorical variables. RESULTS In the three-month period, 42 patients were referred to our clinic. The most common presenting symptom was abdominal or pelvic pain (65% of patients). Ultrasound examinations had been conducted in private clinics, community hospitals, and teaching hospitals. Significant variations in the reporting were noted. The important ultrasound characteristic most often not reported (approximately 80% of reports) was Doppler flow assessment of the mass. Five reports (12%) did not include information that would be needed to make a recommendation resulting in repeat ultrasound examination. We found no significant variation in reporting practices between private clinics and community hospitals. CONCLUSION Current reporting practices for ultrasound assessments in women with an ovarian mass vary considerably. They could be improved by use of a standardized synoptic reporting template.

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

Preliminary Results of 5% Imiquimod Cream in the Primary Treatment of Vulva Intraepithelial Neoplasia Grade 2/3

OBJECTIVE This study was undertaken to study the tolerability and efficacy of 5% imiquimod cream in the primary treatment of vulva intraepithelial neoplasia (VIN) grade 2/3. STUDY DESIGN VIN grade 2/3 patients were recruited from regional colposcopy units. Imiquimod cream was applied over the abnormal area by the patient using an escalating dose regime for total treatment duration of 16 weeks. At the end of study, repeat colposcopy and biopsy of the target lesion were performed to assess for response. RESULTS Twenty-three patients participated. Twenty patients (87%) had VIN grade 3. Nine patients (39%) had multifocal disease on colposcopy. Therapy was well tolerated with the most commonly observed side effects being irritation at the application site. Responses were evaluable in 17 patients. Complete responses were observed in 9 patients with partial responses in another 5 (relative risk 82%). The median time to response was 7 weeks. CONCLUSION Imiquimod cream can induce histologic regression of high-grade VIN lesions and is well tolerated using a slow dose-escalating regime.