2016 Update on abnormal uterine bleeding

How abnormal uterine bleeding (AUB) is managed has a significant impact on health care. In the United States, almost one-third of all gynecologic visits are related to AUB, with estimated annual direct costs of up to $1.55 billion and indirect costs as high as $36 billion.¹ Not surprisingly, office-based procedures for AUB are being emphasized. While in the short term it is more cost efficient to perform surgery in the office rather than in the operating room, questions have arisen regarding the long-term efficacy and durability of in-office procedures. Insurers are undoubtedly raising these questions as well.

Notably, some ObGyns are early adopters of office-based surgery while others tend to adopt in-office procedures more slowly. As the literature for such procedures for AUB matures to provide more data on efficacy and acceptability, we will have a greater evidence base for understanding which procedures are more appropriate for the office. And while practice shifts sometimes occur due to cost-containment initiatives, some shifts are patient driven. Studies that address these driving variables, as well as efficacy considerations, are helpful. As we counsel women about procedures for AUB, the relative advantages and disadvantages of available treatment settings likely will become a greater part of that discussion so that they can make an informed decision.

In this Update, we discuss the results of 3 studies that examined various procedures and settings for AUB management:

Outpatient vs inpatient polypectomy: Similar success rates in the short term

Cooper NA, Clark TJ, Middleton L, et al; OPT Trial Collaborative Group. Outpatient versus inpatient uterine polyp treatment for abnormal uterine bleeding: randomised controlled non-inferiority study. BMJ. 2015;350:h1398. doi:10.1136/bmj.h1398.

A collaborative group in the United Kingdom studied the common problem of endometrial polyps. Their objective was to evaluate whether outpatient polypectomy was as effective and well accepted as polypectomy performed in the operating room (OR).

Patients with a hysteroscopically diagnosed polyp were randomly assigned to hysteroscopic polyp removal in either a hysteroscopy clinic or an OR; polyp removal was performed using miniature mechanical or electrosurgical instruments. The primary outcome was successful treatment, determined by the participants’ assessment of their bleeding at 6 months.

Overall, 73% of women (166 of 228) in the clinic group and 80% (168 of 211) in the OR group reported a successful response to surgery at 6 months, with treatment effects being maintained at 12 and 24 months. A “see and treat” approach—that is, treatment carried out at the same time as diagnosis—was possible in 72% of women (174 of 242).

Partial or failed polyp removal occurred in 46 of 242 women (19%) in the clinic group, mostly because of pain issues, and in 18 of 233 women (7%) in the OR group (relative risk, 2.5; 95% confidence interval, 1.5−4.1; P<.001). Four uterine perforations (2% of patients) occurred in the OR group.

Mean pain scores were higher in the clinic group, and treatment was unacceptable for 2% of the women in each group.

The results of this trial show that clinic polypectomy has some limitations, but the outpatient procedure was deemed noninferior to polypectomy performed in the OR for the successful alleviation of uterine bleeding associated with uterine polyps.

What this EVIDENCE means for practice
Office-based polypectomy allowed a “see and treat” model in 72% of cases. Office polypectomy had similar successful therapeutic responses as inpatient polypectomy; however, over a 2-year follow-up period, women treated in the office were twice as likely to undergo at least 1 further polyp removal and were 1.6 times more likely to have further gynecologic surgery.

In-office hysteroscopic morcellation of polyps and myomas improves health-related quality of life

Rubino RJ, Lukes AS. Twelve-month outcomes for patients undergoing hysteroscopic morcellation of uterine polyps and myomas in an office or ambulatory surgical center. J Minim Invasive Gynecol. 2015;22(2):285–290.

Is it feasible to morcellate fibroids, as well as polyps, in the clinic? Rubino and colleagues investigated this question in a randomized, prospective clinical trial. They examined the efficacy of hysteroscopic removal of polyps and myomas on health-related quality of life and symptom severity at 1-year postprocedure. Women aged 18 to 55 years, with hysteroscopic and saline-infusion sonogram–assessed polyps and/or type 0 or I myomas (1.5−3.0 cm), were enrolled from 9 US clinical sites. Some patient populations were excluded, such as women with a long narcotic abuse history, current intrauterine device (IUD), type II submucous myomas, and type I fundal myomas.