Clinical perspectives on the menstrual pictogram for the assessment of heavy menstrual bleeding.

Heavy menstrual bleeding (HMB) has an estimated prevalence of 18-32% but is known to be under-reported due to poor recognition and estimation of menstrual blood loss (MBL). HMB can negatively impact quality of life, affecting social interactions, work productivity and sexual life. Abnormal menstrual bleeding may have an underlying structural or systemic cause, such as endometrial and myometrial disorders; however, for some, there is no identified pathological cause. Several methods are available for assessing MBL, including the alkaline hematin (AH) method and the menstrual pictogram (MP). The AH method is considered to be the most accurate way to monitor MBL; however, it is associated with inconvenience and expense, therefore limiting its value outside of research. The MP requires the user to select an icon from a chart that reflects the appearance of a used sanitary product; the icon is associated with a blood volume that can be used to determine MBL. Validation studies have demonstrated that the results of the MP and AH method are well correlated, showing that the MP can measure MBL with sufficient accuracy. Additionally, the MP is more convenient for users, less expensive than the AH method, may be used in regions where the AH method is unavailable and may also be used as part of a digital application. Overall, the MP offers a convenient approach to monitor MBL both in research and clinical practice settings.

What Are Patients Reading? Quality Assessment of Endometriosis Information on the Internet.

OBJECTIVE: Evaluate the quality of information reported online about endometriosis and period pain. METHODS: An online search identified the top 20 websites for 4 search engines (Google, Ask, Bing, Yahoo). Videos, duplicates, and websites not containing information related to endometriosis and period pain were excluded. Three independent authors screened websites and systematically extracted data on website characteristics and on diagnosis and treatment mentions. Website accuracy and completeness were rated for a score out of 15. The Flesch readability ease score (FRES) was used to assess readability. RESULTS: Of 34 websites included, most were news related (44.1%) and health care affiliated (26.5%). Websites with affiliations had significantly higher accuracy scores than those without. Those with references had significantly higher completeness than those without. Non-news-related websites had significantly higher accuracy and completeness than news-related websites. The most commonly reported symptoms were dysmenorrhea (97.1% of websites), infertility (88.2%), and dyspareunia (82.4%). Cancer was mentioned on 41.1% of websites. Diagnostic laparoscopy (91.0%) and ultrasound (88.3%) were the most commonly mentioned diagnostic tools. Commonly reported therapeutics included the oral contraceptive pill (79.4%), laparoscopy (70.6%), non-steroidal anti-inflammatory drugs (NSAIDs; 67.6%), and gonadotropin-releasing hormone (GnRH) agonists (64.7%). Hysterectomy (59.0%) was mentioned more than progestins (53.0%). Overall, 18 of 34 websites (53%) contained 1 or more inaccurate or misleading statements. CONCLUSION: While most websites contained accurate statements, commonly reported misconceptions included an emphasized risk of cancer, lack of use/benefit of ultrasound for diagnosis, and a bias for surgical over medical management, where laparoscopy was mentioned more than first-line medications. This study highlights the importance of directing patients to evidence-based resources.

Assessment of knowledge of COVID-19 among health care workers-a questionnaire-based cross-sectional study in a tertiary care hospital of India.

BACKGROUND: Health Care Workers (HCW) are among the primary stakeholders and front liners in the fight against COVID-19. They are in direct contact with the patients as primary caregivers and, therefore, are at a higher risk of infection. This Pandemic offers a unique opportunity to explore the level of knowledge among ground-level HCWs during this global health crisis. OBJECTIVE: We conducted this study to assess the knowledge and awareness among HCW regarding the COVID-19 Pandemic in a tertiary care hospital. METHODS: It was a cross-sectional study done on HCW comprising faculty, senior residents, junior residents, demonstrators, and nursing staff of various specialties directly involved in the care of suspected/confirmed COVID-19 patients. A pretested questionnaire consisting of 20 questions was used as a study tool and was circulated through the digital platform. RESULTS: There were a total of 437 respondents. In the subgroup analysis, the respondents in the age group of 55-64 years had a higher mean knowledge score, followed by the respondents in the age group of 18-24 years. For years of experience, the mean knowledge score varied from 13.89 (10-20 years of experience) to 13.83 (5-10 years of experience). The mean knowledge score was the highest for consultants (14.10), followed by Resident Doctors (13.96). CONCLUSIONS: This study has shed some critical clues for further research and interventions. Firstly, as health care workers are probably learning about COVID-19 from their practical exposure rather than formal teaching, it is pertinent to address this issue through well-planned formal sessions of training workshops and lectures.

Assessment of pandemic (COVID-19) preparedness in a teaching hospital in northern India using available (CDC-Atlanta) checklist.

BACKGROUND: Hospitals are at the forefront of dealing infectious public health emergencies. Recently, COVID-19 has been declared as pandemic by the World Health Organization. Dealing with COVID-19 pandemic requires high intensity of administrative activity. OBJECTIVE: We conducted this study to assess and compare, objectively, hospital preparedness with available Centre of Disease Control and Prevention (CDC) standards. METHODS: CDC has issued checklist for the assessment of hospital preparedness for COVID-19 pandemic, globally. This list contains 10 elements with sub-sections. We objectified the same and scored the hospital preparations accordingly. Various financial efforts made by the hospital to procure COVID19-specified items was also recorded. RESULTS: As per the CDC checklist, the hospital scored 197 points (72.06%) out of 270 points with highest points in element two and eight. Element two is for the development for written COVID-19 plan. Element eight consists of addressing the occupational health of healthcare workers. Lowest scoring was in the element seven represented visitor access and movement within facility. During the study period, the hospital procured items of approximately 55 lakhs. In the study period, doctors, nursing staff, housekeeping staff, and security staff were channelized for doing COVID-19 duties. CONCLUSIONS: We obtained a score above 70% (good) which is quite encouraging, and we concluded that pandemic preparations in hospitals are necessary and it can be assessed objectively against prevailing standards. It is important in poor countries like India where spending on healthcare is minimal compared to other countries. Additionally, this assessment can be used to guide us further changes in policies and identifying the gaps in pandemic preparedness in hospitals which require special attention.

Bioinformatics Accelerates the Major Tetrad: A Real Boost for the Pharmaceutical Industry.

With advanced technology and its development, bioinformatics is one of the avant-garde fields that has managed to make amazing progress in the pharmaceutical-medical field by modeling the infrastructural dimensions of healthcare and integrating computing tools in drug innovation, facilitating prevention, detection/more accurate diagnosis, and treatment of disorders, while saving time and money. By association, bioinformatics and pharmacovigilance promoted both sample analyzes and interpretation of drug side effects, also focusing on drug discovery and development (DDD), in which systems biology, a personalized approach, and drug repositioning were considered together with translational medicine. The role of bioinformatics has been highlighted in DDD, proteomics, genetics, modeling, miRNA discovery and assessment, and clinical genome sequencing. The authors have collated significant data from the most known online databases and publishers, also narrowing the diversified applications, in order to target four major areas (tetrad): DDD, anti-microbial research, genomic sequencing, and miRNA research and its significance in the management of current pandemic context. Our analysis aims to provide optimal data in the field by stratification of the information related to the published data in key sectors and to capture the attention of researchers interested in bioinformatics, a field that has succeeded in advancing the healthcare paradigm by introducing developing techniques and multiple database platforms, addressed in the manuscript.

Understanding Minimally Invasive Gynaecologic Surgery Fellowship Training in Canada: A National Survey of Recent Graduates.

OBJECTIVE: To characterize fellowship training experiences in the 11 Canadian minimally invasive gynaecologic surgery (MIGS) programs and compare the surgical exposure of fellows in these programs to that of the American Association of Gynecologic Laparoscopists (AAGL) accredited fellowship in MIGS (FMIGS). METHODS: In this cross-sectional study, 2017 and 2018 MIGS fellowship graduates across Canada were given a web-based survey via SurveyMonkey software to evaluate 5 key components of postgraduate fellowship curricula: 1) surgical exposure; 2) teaching and evaluation methods; 3) research experience; 4) clinical responsibilities; and 5) pursuit of other academic endeavours. Interest in creating a national standardized curriculum and seeking accreditation for MIGS fellowships were also examined. RESULTS: The survey attained a 91% (20/22) response rate of the target population. All Canadian MIGS programs met the minimum standards for at least 62% (8/13) of the surgical competencies listed by the AAGL, with office hysteroscopy being the procedure with the largest discordance. Half of respondents (10/20) attended a program with an established curriculum, and 75% (15/20) believed there would be a benefit to standardizing training nationwide. Seventy percent (14/20) had published at least one manuscript during their fellowship and 60% (12/20) pursued postgraduate degrees. The majority (55%; 11/20) felt certain that MIGS should become a credentialed fellowship in Canada. CONCLUSION: Canada has made meaningful progress in MIGS training over the past decade with 11 well-established fellowship programs. Although this survey identifies a general interest in standardized training and accreditation for Canadian MIGS programs, more research is needed on how best to accomplish this.

Impact of Endometriosis on Fatigue and Productivity Impairment in a Cross-Sectional Survey of Canadian Women.

OBJECTIVE: To evaluate fatigue burden and productivity impairments in Canadian women with a self-reported diagnosis of endometriosis (DxE). METHODS: From December 2018 to January 2019, Canadian women aged 18-49 years completed an online survey assessing fatigue via the Patient-Reported Outcomes Measurement Information System (PROMIS) Fatigue Short Form 6a questionnaire. Fatigue T-scores were compared between women with and without a DxE, by age and endometriosis symptom severity, using t tests. Women with a DxE completed the Work Productivity and Activity Impairment - Specific Health Problem (WPAI-SHP) questionnaire. The effects of age and hallmark endometriosis symptoms on productivity impairments were assessed via analysis of variance. RESULTS: Survey data included 2004 women with and 26 528 women without a DxE. Mean fatigue T-scores were 58.5 ± 10.1 in women with a DxE and 59.2 ± 10.1 in women with hallmark endometriosis symptoms (i.e., menstrual or non-menstrual pelvic pain/cramping, dyspareunia) versus 55.2 ± 9.4 in women without a DxE (both P < 0.001). Women with moderate or severe endometriosis symptoms had a mean T-score of 61.2 ± 9.4 versus 55.9 ± 10.1 for women with mild symptoms (P < 0.001). Women with moderate or severe hallmark endometriosis symptoms had mean T-scores of 59.6-62.9 versus 57.0-58.2 for women with mild or no symptoms (all comparisons P < 0.01). Women with a DxE reported 17.1% of work time missed, 41.8% impaired work ability, 46.5% overall work impairment, and 41.4% activity impairment per the WPAI-SHP. Women with a DxE aged 30-34 and 35-39 years consistently experienced the greatest effects of fatigue and productivity impairments. CONCLUSIONS: Canadian women with a DxE experience a substantial fatigue burden and significant productivity impairments.

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study.

BACKGROUND: Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women. METHODS: We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars. RESULTS: Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient. INTERPRETATION: From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Behind the times: revisiting endometriosis and race.

Endometriosis is a common gynecologic condition, affecting approximately 10% of reproductive-aged women. It commonly presents with pelvic pain, painful periods, and infertility and can significantly have an impact on one's quality of life. Early exploration into the pathophysiology of this condition identified race as a risk factor for endometriosis, with the condition predominantly identified in white women. It is still unclear whether there is a biological basis for this conviction or whether it can be explained by methodological and social bias that existed in the literature at that time. Although there is more recent literature exploring the association between endometriosis and race/ethnicity, studies have continued to focus on the prevalence of disease and have not taken into account possible variation in disease presentation among women of different ethnicities. Furthermore, information on diverse populations by race/ethnicity, other than white or black, is quite limited. This paper explores the history of how the association between endometriosis and whiteness was established and whether we still ascribe to a certain stereotype of a typical endometriosis patient today. Furthermore, we discuss the potential implications of such a racial bias on patient care and suggest areas of focus to achieve a personalized and patient focused approach in endometriosis care.

No. 292-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 1). 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. SUMMARY STATEMENTS: RECOMMENDATIONS.

Increasing Minimally Invasive Hysterectomy: A Canadian Academic Health Centre Experience.

OBJECTIVE: An institution wide strategic plan was established to improve minimally invasive surgery (MIS) across all surgical divisions at The Ottawa Hospital (TOH). The primary objective of this study is to determine the change in MIS hysterectomy rate between 2005 and 2012 at this centre. Secondary objectives include determining the impact on overall length of stay (LOS) in hospital, complications, return to hospital, operating room time, and cost. METHODS: We performed a retrospective analysis of all hysterectomies for benign disease performed at TOH between 2005 and 2012. Cases were excluded if they were related to pregnancy or classified as "partial hysterectomy." The outcomes and cost of the approaches were compared. RESULTS: A total of 4337 hysterectomy cases were reviewed. The MIS hysterectomy rate increased from 40.1% in 2005 to 74.2% in 2012. There was a decrease in mean LOS from 2.5 to 1.6 days. This translated to a saving of 1898 inpatient bed days. Compared with laparotomy, laparoscopic hysterectomy was associated with a reduced risk of transfusion and a reduced risk of ileus, and vaginal hysterectomy was associated with an increased risk of postoperative abscess. There was no difference in rates of returning to hospital or other complications between women undergoing abdominal hysterectomy and women undergoing MIS hysterectomy (which included both laparoscopic and vaginal approaches). The mean (SD) cost per approach was $7241 ($1985), $4532 ($1718), and $5637 ($1579) for abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy, respectively. CONCLUSION: The initiatives implemented at TOH in 2007 resulted in a significant increase in the MIS hysterectomy rate, a decrease in mean LOS, and substantial theoretical cost savings for the hospital.

Endometrial ablation in the management of abnormal uterine bleeding.

BACKGROUND: Abnormal uterine bleeding (AUB) 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 the problem during their reproductive years. OBJECTIVE: To provide current evidence-based guidelines on the techniques and technologies used in endometrial ablation (EA), a minimally invasive technique for the management of AUB of benign origin. 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 and general background in gynaecology. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated surgical and patient outcomes for the various EA techniques. Recommendations were established by consensus. EVIDENCE: Published literature was retrieved through searches of MEDLINE and The Cochrane Library in 2013 and 2014 using appropriate controlled vocabulary and key words (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, AUB, hysterectomy). RESULTS were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English from January 2000 to November 2014. Searches were updated on a regular basis and incorporated in the guideline to December 2014. Grey (unpublished) literature was identifies 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 1). RESULTS: This document reviews the evidence regarding the available techniques and technologies for EA, preoperative and postoperative care, operative set-up, anaesthesia, and practical considerations for practice. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve the provision of EA as an effective treatment of AUB. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. CONCLUSIONS: EA is a safe and effective minimally invasive option for the treatment of AUB of benign etiology. Summary Statements 1. Endometrial ablation is a safe and effective minimally invasive surgical procedure that has become a well-established alternative to medical treatment or hysterectomy to treat abnormal uterine bleeding in select cases. (I) 2. Endometrial preparation can be used to facilitate resectoscopic endometrial ablation (EA) and can be considered for some non-resectoscopic techniques. For resectoscopic EA, preoperative endometrial thinning results in higher short-term amenorrhea rates, decreased irrigant fluid absorption, and shorter operative time than no treatment. (I) 3. Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and allow the use of local rather than general anaesthesia. However, both techniques have comparable patient satisfaction and reduction of heavy menstrual bleeding. (I) 4. Both resectoscopic and non-resectoscopic endometrial ablation (EA) have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with resectoscopic EA; perioperative nausea/vomiting, uterine cramping, and pain are more common with non-resectoscopic EA. (I) 5. All non-resectoscopic endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. The choice of which device to use depends primarily on surgical judgement and the availability of resources. (I) 6. The use of local anaesthetic and blocks, oral analgesia, and conscious sedation allows for the provision of non-resectoscopic EA in lower resource-intense environments including regulated non-hospital settings. (II-2) 7. Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centres. (II-2) 8. Both resectoscopic and non-resectoscopic endometrial ablation are relatively safe procedures with low complication rates. The complications perforation with potential injury to contiguous structures, hemorrhage, and infection. (II-2) 9. Combined hysteroscopic sterilization and endometrial ablation can be safe and efficacious while favouring a minimally invasive approach. (II-2) Recommendations 1. Preoperative assessment should be comprehensive to rule out any contraindication to endometrial ablation. (II-2A) 2. Patients should be counselled about the need for permanent contraception following endometrial ablation. (II-2B) 3. Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment. (II-2B) 4. Clinicians should be vigilant for complications unique to resectoscopic endometrial ablation such as those related to fluid distention media and electrosurgical injuries. (III-A) 5. For resectoscopic endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risk of complications of distension medium overload. (III-A) 6. If uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without electrosurgery), the procedure should be abandoned and the patient should be closely monitored for signs of intraperitoneal hemorrhage or visceral injury. If the perforation occurs with electrosurgery or if the mechanism of perforation is uncertain, abdominal exploration is warranted to obtain hemostasis and rule out visceral injury. (III-B) 7. With resectoscopic endometrial ablation, if uterine perforation has been ruled out acute hemorrhage may be managed by using intrauterine Foley balloon tamponade, injecting intracervical vasopressors, or administering rectal misoprostol. (III-B) 8. If repeat endometrial ablation (EA) is considered following non-resectoscopic or resectoscopic EA, it should be performed by a hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat EA. (II-2A) 9. If significant intracavitary pathology is present, resectoscopic endometrial ablation combined with hysteroscopic myomectomy or polypectomy should be considered in a non-fertility sparing setting. (II-3A).

Contexte : Les saignements utérins anormaux (SUA) sont directement à l'origine d'un fardeau de santé considérable que doivent porter les femmes, leur famille et la société en général. Jusqu'à 30 % des femmes chercheront à obtenir l'aide d'un médecin pour contrer ce problème au cours de leurs années de fertilité. Objectif : Fournir des lignes directrices factuelles à jour quant aux techniques et aux technologies utilisées aux fins de l'ablation de l'endomètre (AE), soit une intervention à effraction minimale permettant la prise en charge des SUA d'origine bénigne. Méthodes : Les membres du comité sur la directive clinique ont été sélectionnés en fonction de leurs spécialisations respectives en vue de représenter une gamme d'expériences pratiques et universitaires : le milieu de pratique au Canada, le type de pratique, la sous-spécialité et les antécédents généraux en gynécologie ont donc été pris en considération. Le comité a analysé les données pertinentes issues de la littérature médicale anglophone (y compris les lignes directrices publiées), en plus d'évaluer les issues chirurgicales et les issues qu'ont connues les patientes à la suite de l'utilisation de diverses techniques d'AE. Les recommandations ont été formulées par consensus. Données : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE et The Cochrane Library en 2013 et en 2014 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « endometrial ablation ¼, « hysteroscopy ¼, « menorrhagia ¼, « heavy menstrual bleeding ¼, « AUB ¼, « hysterectomy ¼). Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 2000 et novembre 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en décembre 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Résultats : Le présent document passe en revue les données quant aux techniques et aux technologies disponibles en ce qui concerne l'AE, les soins préopératoires et postopératoires, le milieu d'intervention, l'anesthésie et les facteurs pratiques à prendre en considération. Avantages, désavantages et coûts : La mise en œuvre des recommandations de la présente directive clinique entraînera une amélioration de l'offre de l'AE à titre de traitement efficace contre les SUA. Le respect de ces recommandations permettrait l'exécution de l'intervention chirurgicale en cause de façon sûre et en maximiserait la réussite pour les patientes. Conclusions : L'AE est une option à effraction minimale sûre et efficace pour la prise en charge des SUA d'étiologie bénigne. Déclarations sommaires 1. L'ablation de l'endomètre est une intervention chirurgicale à effraction minimale sûre et efficace qui en est venue à constituer, dans certains cas, une solution de rechange bien établie au traitement médical ou à l'hystérectomie pour la prise en charge des saignements utérins anormaux. (I) 2. Une préparation de l'endomètre peut être mise en œuvre pour en faciliter l'ablation résectoscopique et peut également être envisagée dans le cas de certaines techniques non résectoscopiques. Lorsque l'on a recours à l'ablation résectoscopique de l'endomètre, l'amincissement préopératoire de ce dernier donne lieu à une hausse des taux d'aménorrhée à court terme, à une atténuation de l'absorption du liquide de distension et à une réduction de la durée opératoire, par comparaison avec l'absence de traitement. (I) 3. Les techniques non résectoscopiques sont techniquement plus faciles à utiliser que les techniques résectoscopiques, nécessitent des temps opératoires plus courts et permettent l'utilisation d'une anesthésie locale (plutôt que d'avoir recours à une anesthésie générale). Toutefois, ces deux techniques comptent des taux comparables de satisfaction des patientes et d'atténuation des saignements menstruels abondants. (I) 4. Les techniques résectoscopiques et non résectoscopiques d'ablation de l'endomètre comptent toutes de faibles taux de complication. La perforation utérine, la surcharge liquidienne, l'hématomètre et les lacérations cervicales sont plus courantes dans le cas de l'AE résectoscopique; les crampes utérines, la douleur et les nausées / vomissements périopératoires sont plus courants dans le cas de l'AE non résectoscopique. (I) 5. L'efficacité de tous les dispositifs d'ablation non résectoscopique de l'endomètre disponibles au Canada a été démontrée en ce qui concerne l'atténuation du flux menstruel; de plus, ils mènent tous à des taux élevés de satisfaction des patientes. Le choix du dispositif à utiliser dépend principalement de l'opinion du chirurgien et de la disponibilité des ressources. (I) 6. L'utilisation d'anesthésiques et de blocs locaux, d'une analgésie orale et d'une sédation consciente permet la tenue d'une ablation non résectoscopique de l'endomètre au sein de milieux nécessitant des ressources moindres, y compris dans des milieux non hospitaliers réglementés. (II-2) 7. Les patientes n'étant exposées qu'à de faibles risques et présentant une tolérance satisfaisante à la douleur sont de bonnes candidates pour ce qui est de la tenue d'une ablation endométriale dans un milieu autre qu'en salle d'opération ou dans un centre chirurgical autonome. (II-2) 8. Les techniques d'ablation de l'endomètre tant résectoscopiques que non résectoscopiques sont relativement sûres et ne comptent que de faibles taux de complication. Parmi les complications les plus graves, on trouve la perforation (s'accompagnant de lésions potentielles aux structures adjacentes), l'hémorragie et l'infection. (II-2) 9. La tenue concomitante d'une stérilisation hystéroscopique et d'une ablation endométriale peut être sûre et efficace tout en favorisant une approche à effraction minimale. (II-2) Recommandations 1. L'évaluation préopératoire devrait être exhaustive, de façon à pouvoir écarter toute contre-indication à l'ablation de l'endomètre. (II-2A) 2. Les patientes devraient être avisées de la nécessité d'une contraception permanente à la suite de l'ablation de l'endomètre. (II-2B) 3. Les évaluations recommandées en présence de saignements utérins anormaux (dont, entre autres, le prélèvement endométrial et l'évaluation de la cavité utérine) sont des composantes nécessaires de l'évaluation préopératoire. (II-2B) 4. Les cliniciens devraient demeurer à l'affût des complications propres à l'ablation résectoscopique de l'endomètre, comme celles qui sont associées au produit de distension et aux lésions électrochirurgicales. (III-A) 5. Dans le cas de l'ablation résectoscopique de l'endomètre, un protocole strict devrait être respecté pour ce qui est de la surveillance liquidienne et de la prise en charge, et ce, afin de minimiser le risque de voir se manifester des complications associées à la surcharge de produit de distension. (III-A) 6. Lorsque l'on soupçonne qu'une perforation utérine s'est manifestée au cours de la dilatation cervicale ou dans le cadre de l'utilisation du résectoscope (sans électrochirurgie), l'intervention devrait être abandonnée et la patiente devrait faire l'objet d'une surveillance étroite de façon à ce que l'on puisse demeurer à l'affût des signes d'hémorragie intrapéritonéale ou de lésion viscérale. Lorsque la perforation se manifeste dans le cadre d'une électrochirurgie ou lorsque le mécanisme de la perforation demeure incertain, la tenue d'une exploration abdominale est justifiée pour assurer l'hémostase et écarter la présence de lésions viscérales. (III-B) 7. Dans le cas de l'AE résectoscopique, lorsque la présence d'une perforation utérine a été écartée, l'hémorragie aiguë pourrait être prise en charge au moyen d'un tamponnement intra-utérin par sonde de Foley, d'une injection intracervicale de vasopresseurs ou de l'administration de misoprostol par voie rectale. (III-B) 8. Lorsqu'une nouvelle ablation de l'endomètre est envisagée à la suite d'une intervention non résectoscopique ou résectoscopique, elle devrait être menée par un chirurgien hystéroscopique sous visualisation directe de la cavité. Les patientes devraient bénéficier de services de counseling au sujet des risques de complications qui sont associés à la tenue d'une nouvelle ablation de l'endomètre. (II-2A) 9. En présence d'une pathologie intracavitaire considérable, la tenue concomitante d'une ablation résectoscopique de l'endomètre et d'une myomectomie / polypectomie hystéroscopique devrait être envisagée. (II-3A).

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.

Contexte : Les saignements utérins anormaux sont directement à l'origine d'un fardeau considérable imposé aux femmes, à leur famille et à la société tout entière en matière de soins de santé. Jusqu'à 30 % des femmes chercheront à obtenir l'aide d'un médecin pour contrer ce problème au cours de leurs années de fertilité. La présente directive clinique remplace les directives cliniques précédentes sur le sujet et a pour but d'outiller les fournisseurs de soins de santé pour qu'ils puissent offrir des soins reposant sur les toutes dernières données probantes au moment de procéder au diagnostic de ce problème courant, et d'en assurer la prise en charge médicale et chirurgicale. Objectif : Fournir une directive clinique factuelle à jour pour le diagnostic et la prise en charge des saignements utérins anormaux (SUA) chez les femmes en âge de procréer. Issues : Parmi les issues évaluées, on trouve les effets des SUA sur la qualité de vie et les résultats des interventions (y compris la prise en charge médicale et chirurgicale des SUA). Méthodes : Les membres du comité sur la directive clinique ont été sélectionnés en fonction de leurs spécialisations respectives en vue de représenter une gamme d'expériences pratiques et universitaires : le milieu de pratique au Canada, le type de pratique, la sous-spécialité et les antécédents généraux en gynécologie ont donc été pris en considération. Le comité a analysé les données pertinentes issues de la littérature médicale anglophone (y compris les lignes directrices publiées). Les recommandations ont été formulées sous forme de déclarations de consensus. Le document final a été analysé et approuvé par le comité exécutif et le Conseil de la SOGC. Résultats : Le présent document offre un résumé des dernières données quant au diagnostic, aux explorations et à la prise en charge médicale et chirurgicale des SUA. Les recommandations qui y sont formulées peuvent être adaptées par les professionnels de la santé qui offrent leurs services aux femmes qui présentent de tels saignements. Conclusions : Les saignements utérins anormaux constituent un trouble courant et parfois débilitant qui affecte les femmes en âge de procréer. La mise en œuvre d'une standardisation de la terminologie connexe, d'une approche systématique en matière de diagnostic et d'exploration, et d'une approche par étapes pour ce qui est de l'intervention s'avère nécessaire. Toutes les interventions thérapeutiques ont pour objectif absolu de débuter le traitement au moyen de modalités thérapeutiques médicales, pour ensuite avoir recours aux modalités chirurgicales les moins effractives possibles, le tout en vue de permettre à la patiente d'obtenir des résultats satisfaisants. Données : Des recherches ont été menées en mars 2011 dans les bases de données MEDLINE et Cochrane afin d'en tirer les articles publiés en anglais, au moyen d'un vocabulaire contrôlé (p. ex. « uterine hemorrhage ¼, « menorrhagia ¼) et de mots clés appropriés (p. ex. « menorrhagia ¼, « heavy menstrual bleeding ¼, « abnormal uterine bleeding ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles publiés en anglais entre janvier 1999 et mars 2011. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en février 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La mise en œuvre des recommandations de la présente directive clinique entraînera l'amélioration de la santé et du bien-être des femmes qui présentent des saignements utérins anormaux, de leur famille et de la société. Les coûts économiques de la mise en œuvre de la présente directive clinique au sein du système de santé canadien n'ont pas été pris en considération. Déclarations sommaires 1. Les SUA constituent un trouble courant qui affecte les femmes en âge de procréer et qui exerce des effets considérables sur les plans social et économique. (II-2) 2. La terminologie contemporaine utilisée pour décrire les SUA chez les femmes en âge de procréer vise à simplifier les définitions et à fournir des descriptions standard en ce qui concerne les symptômes présentés par la patiente. (III) 3. Les conséquences des SUA sur la santé globale d'une femme déterminent le degré d'intervention pouvant s'avérer requis. (II-2) 4. Une anamnèse et un examen physique exhaustifs indiqueront souvent la cause des SUA, et détermineront la nécessité de procéder à d'autres explorations et de mettre en œuvre d'autres traitements. (III) 5. L'imagerie et l'hystéroscopie offrent au clinicien des renseignements additionnels qui contribuent à l'évaluation et au traitement de la patiente, lorsque les circonstances le permettent. (I) 6. Une fois que la présence d'une tumeur maligne ou d'une pathologie pelvienne significative a été écartée, la mise en œuvre d'un traitement médical constitue une option thérapeutique de première intention efficace pour ce qui est des saignements utérins anormaux. (I) 7. La mise en œuvre d'un traitement médical adapté aux objectifs thérapeutiques, aux souhaits en matière de contraception, aux pathologies médicales sous-jacentes et à la tolérance quant aux effets indésirables d'une patiente donnée permettra de favoriser l'observance et de maximiser la probabilité de réussite du traitement. (III) 8. Les techniques d'ablation non hystéroscopiques offrent, en matière de satisfaction de la patiente, des résultats semblables à ceux de l'ablation hystéroscopique traditionnelle, en plus de compter moins de risques de complication et de nécessiter une anesthésie moindre. (I) 9. L'hystérectomie constitue un traitement définitif contre les saignements utérins anormaux. (I) 10. Les saignements utérins anormaux attribuables à des fibromes sous-muqueux peuvent être pris en charge au moyen d'une myomectomie hystéroscopique. (I) 11. Les troubles hémostatiques héréditaires peuvent constituer une cause sous-jacente de saignements utérins anormaux, la maladie de von Willebrand étant présente dans la majorité de ces cas. (II-2) 12. Les saignements menstruels abondants aigus peuvent donner lieu à une anémie significative et nécessiter des soins de première urgence. (III) 13. Chez les adolescentes, les SUA découlent plus souvent qu'autrement d'une dysfonction ovulatoire associée à l'immaturité de l'axe hypothalamo-hypophyso-ovarien. (II-2) Recommandations 1. L'adoption d'une terminologie internationale standardisée devrait être envisagée pour ce qui est des SUA. (III-C) 2. La tenue d'un hémogramme complet est recommandée chez les femmes qui présentent des saignements abondants ou prolongés. (II-2A) 3. En présence de toute possibilité de grossesse, une analyse d'urine sensible ou un test sérique de grossesse devrait être mené. (III-C) 4. Le dépistage des troubles de la coagulation ne devrait être envisagé que chez les femmes qui présentent des antécédents de saignements menstruels abondants remontant à la ménarche ou des antécédents personnels ou familiaux de saignements anormaux. (II-2B) 5. Le tenue de tests de la fonction thyroïdienne n'est pas indiquée, sauf en présence de constatations cliniques laissant entrevoir un possible indice de suspicion de maladie thyroïdienne. (II-2D) 6. Lorsque la tenue d'une imagerie s'avère indiquée, l'échographie transvaginale devrait constituer la modalité de première intention dans le cas des SUA. (I-A) 7. L'échohystérographie avec injection de liquide intra-utérin et l'hystéroscopie diagnostique devraient être utilisées aux fins du diagnostic et de la caractérisation des anomalies intra-utérines discrètes (telles que les fibromes sous-muqueux). (I-A) 8. Le recours à la biopsie endométriale devrait être envisagé chez les femmes de plus de 40 ans qui présentent des saignements ou chez les femmes dont les saignements ne réagissent pas au traitement médical, ainsi que chez les jeunes femmes qui présentent des facteurs de risque de cancer de l'endomètre. (II-2A) 9. La biopsie endométriale menée en cabinet devrait remplacer la dilatation-curetage de l'utérus à titre de modalité initiale d'évaluation de l'endomètre chez ces femmes. (II-2A) 10. Les lésions focales de l'endomètre qui nécessitent une biopsie devraient être prises en charge au moyen d'une évaluation guidée par hystéroscopie. (II-2A) 11. Des options non hormonales, telles que les AINS et les antifibrinolytiques, peuvent être utilisées efficacement pour assurer la prise en charge des saignements menstruels abondants dont la manifestation est principalement cyclique ou prévisible. (I-A) 12. Les contraceptifs oraux combinés, l'acétate de médroxyprogestérone-retard et le système intra-utérin à libération de lévonorgestrel permettent une diminution considérable des saignements menstruels et devraient être utilisés pour traiter les femmes présentant des saignements utérins anormaux qui souhaitent obtenir une contraception efficace. (I-A) 13. Les progestatifs cycliques administrés pendant la phase lutéale ne permettent pas une diminution efficace de la perte sanguine; ainsi, ils ne devraient pas être utilisés à titre de traitement visant particulièrement les saignements menstruels abondants. (I-E) 14. Le danazol et les agonistes de la GnRH permettront une diminution efficace des saignements menstruels, et pourraient être utilisés en présence de scénarios dans le cadre desquels l'utilisation d'autres traitements médicauxou chirurgicaux a échoué ou est contre-indiquée. (I-C) 15. Les patientes qui prennent un agoniste de la GnRH pendant plus de six mois devraient se voir prescrire une hormonothérapie de compensation, lorsque celle-ci n'a pas déjà été mise en œuvre au début du traitement à l'agoniste de la GnRH. (I-A) 16. Le SIU à libération d'un progestatif donne lieu à l'obtention d'issues semblables à celles de l'ablation de l'endomètre chez les femmes qui présentent des saignements menstruels abondants; ainsi, son utilisation pourrait être prise en considération avant d'avoir recours à une intervention chirurgicale. (I-A) 17. Chez des candidates appropriées, les techniques d'ablation non hystéroscopiques devraient être les méthodes d'ablation à privilégier, et ce, en raison de leur efficacité et de leur innocuité supérieures, par comparaison avec les techniques hystéroscopiques. (I-A) 18. À l'exception des AINS, les mêmes agents médicaux qui sont utilisés pour assurer la prise en charge des saignements menstruels abondants chez les femmes présentant une coagulation normale peuvent être efficacement utilisés chez les femmes atteintes de troubles hémostatiques héréditaires. (II-1B) 19. Le recours à une approche multidisciplinaire constitue la meilleure façon d'assurer la prise en charge des femmes atteintes de troubles hémostatiques héréditaires qui connaissent des saignements menstruels considérablement abondants ou chez lesquelles le traitement médical conventionnel a échoué. (III-C) 20. La planification de l'hystérectomie ou la mise en œuvre d'un traitement faisant appel à des produits sanguins devraient être menées en consultation avec un hématologue dans le cas des patientes atteintes de troubles hémostatiques héréditaires. (III-C) 21. Les saignements menstruels abondants aigus devraient faire l'objet d'une prise en charge sans délai et de façon systématique, et ce, afin de minimiser la morbidité chez la patiente et la nécessité d'avoir recours à une transfusion sanguine. (III-C) 22. Les œstrogènes à forte dose et l'acide tranexamique peuvent contribuer à atténuer ou à juguler les saignements menstruels abondants aigus. (III-C) 23. Chez les adolescentes qui connaissent des saignements menstruels abondants à la ménarche ou peu après, l'anamnèse et les explorations devraient comprendre une évaluation visant à déterminer la présence d'un trouble hémostatique sous-jacent. (II-2A).

SOGC clinical practice guidelines: Oral contraceptives and the risk of venous thromboembolism: an update: no. 252, December 2010.

OBJECTIVE: To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism. EVIDENCE: Articles published in English from 2005 were retrieved through searches of PubMed and Medline, using the following terms: venous thromboembolism, VTE, contraception, oral contraceptives, hormonal contraception. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to May 2010. 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 by the Canadian Task Force on Preventive Health Care (Table).

SOGC clinical practice guidelines: Adhesion prevention in gynaecological surgery: no. 243, June 2010.

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.

Asymptomatic endometrial thickening.

OBJECTIVE: To formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding. OUTCOMES: Ensure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately. EVIDENCE: Published literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., "asymptomatic endometrial thickness," "endometrial cancer," "postmenopausal bleeding," "transvaginal ultrasonography," "endometrial biopsy" and "endometrial polyp"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 2010. 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 level of evidence was determined according to the criteria established by the Canadian Task Force on Preventative Health Care (Table). Recommendations are ranked according to this method. BENEFITS, HARMS, AND COSTS: It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions.