Clinical Review
2014 Update on abnormal uterine bleeding
Randomized data shed light on AUB associated with fibroids, adenomyosis, and the use of progestins
They finally propose that women who are symptomatic be treated with oral contraceptives unless immediate fertility is desired, or by expectant management without intervention. While their primary focus was to assess AUB, given the stated shortcomings of the included studies and lack of long-term follow-up, the authors also warn against hysteroscopic, laparoscopic, or vaginal repair for fertility, as the risk to pregnancy or delivery after these therapies is unknown.
CASE RESOLVED
Suspecting a cesarean scar defect, you perform a saline infusion sonography and diagnose a 14 mm x 19 mm anechoic region within the scar, with no other intracavitary abnormalities found. You first reassure the patient that this is a benign finding and inform her why she likely is experiencing this type of bleeding pattern. After an informed discussion with you regarding the risks and benefits of possible surgical or nonsurgical options for management, she chooses to use oral contraceptive pills in a continuous fashion.
CONCLUSION
Consider a history of cesarean section in the evaluation of AUB, and be cognizant of the prevalence of CSD with cesarean delivery and the association of postmenstrual bleeding with CSD.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
• A critical systematic review of available data suggests that there is not enough clinical evidence to support surgical intervention for the treatment of CSD for women symptomatic with AUB.
• Recommended nonhysterectomy treatments for AUB associated with CSD include oral contraceptives or expectant management.
• Surgical treatment should be limited to the research environment in the form of RCT to assess the long-term outcomes of intervention.
• An RCT of the LNG-IUS for the treatment of AUB associated with CSD is needed.
Acknowledgments
The author would like to thank Andrew Brill, MD, Lee Sloan-Garcia, MD, and William Parker, MD, for their thoughtful review of this manuscript.
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