Publications by authors named "Wendy Wolfman"

34 Publications

A core outcome set for genitourinary symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative.

Menopause 2021 May 10. Epub 2021 May 10.

Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University. Melbourne, Australia School of Nursing, Indiana University, Indianapolis, IN Department of Obstetrics and Gynaecology, University of Chicago, Chicago, IL Red Hot Mamas North America, Inc., New York, NY Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY Department of Obstetrics and Gynaecology, University Hospitals Dorset NHS Trust, Poole, Dorset, UK Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University London, UK Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Department of Obstetrics and Gynaecology, Fortis Escort Hospital, Jaipur, India Department of Gynaecology and Obstetrics, University of Muenster, Muenster, Germany Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia Department of Reproductive and Maternal Medicine, School of Medicine, University of Glasgow, Glasgow, UK Departments of Psychiatry, Psychology and Obstetrics and Gynecology, University of Illinois at Chicago, Chicago IL Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, University of Pavia, Pavia, Italy Department of Urology, UIC College of Medicine, Chicago IL Queen Charlotte's and Chelsea and Westminster Hospitals, Imperial College London, London, UK Auckland District Health Board, Auckland, New Zealand Department of Obstetrics and Gynecology, Midlife Women's Health Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA Department of Obstetrics and Gynecology, George Washington University, Washington, DC Department of Obstetrics and Gynecology, University Clinic Inselspital Bern, Bern, Switzerland Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada.

Objective: Genitourinary symptoms, such as vaginal dryness and pain with sex, are commonly experienced by postmenopausal women. Comparing treatments for these genitourinary symptoms are restricted by the use of different outcome measures in clinical trials and the omission of outcomes, which may be relevant to women. The aim of this project was to develop a Core Outcome Set (COS) to be reported in clinical trials of treatments for genitourinary symptoms associated with menopause.

Methods: We performed a systematic review of randomized controlled trials of treatments for genitourinary symptoms associated with menopause and extracted their outcomes. This list was refined and entered into a two-round modified Delphi survey, which was open to clinicians, researchers, and postmenopausal women from November 2019 to March 2020. Outcomes were scored on a nine-point scale from "not important" to "critically important." The final COS was determined following two international consensus meetings.

Results: A total of 26 unique outcomes were included in the Delphi process, which was completed by 227 participants of whom 58% were postmenopausal women, 34% clinicians, and 8% researchers. Predefined thresholds were applied to the Delphi scores to categorize outcomes by importance, which informed the e consensus meetings, attended by 43 participants from 21 countries. The final COS includes eight outcomes: (1) pain with sex, (2) vulvovaginal dryness, (3) vulvovaginal discomfort or irritation, (4) discomfort or pain when urinating, (5) change in most bothersome symptom, (6) distress, bother or interference of genitourinary symptoms, (7) satisfaction with treatment, (8) side effects of treatment.

Conclusion: These eight core outcomes reflect the joint priorities of postmenopausal women, clinicians, and researchers internationally. Standardized collection and reporting of these outcomes in clinical trials will facilitate the comparison of different treatments for genitourinary symptoms, advance clinical practice, and ultimately improve outcomes for symptomatic women.

Video Summary:http://links.lww.com/MENO/A765.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GME.0000000000001788DOI Listing
May 2021

A core outcome set for vasomotor symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative.

Menopause 2021 Apr 26. Epub 2021 Apr 26.

Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia Obstetrics and Gynaecology, Eastern Virginia Medical School, Norfolk, VA Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia School of Nursing, Indiana University, Indianapolis, IN Department of Obstetrics and Gynaecology, University of Chicago, Chicago, IL Red Hot Mamas North America, Inc, Town of Ridgefield, CT Obstetrics and Gynecology, New York University School of Medicine, New York, NY Department of Obstetrics and Gynaecology, University Hospitals Dorset NHS Trust, Poole, Dorset, UK Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University London, London, UK Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Connors Center for Women's Health and Gender Biology and the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA Department of Obstetrics and Gynaecology, Fortis Escort Hospital, Jaipur, India Department of Gynaecology and Obstetrics, University of Muenster, Muenster, Germany Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia Amsterdam Reproduction and Development, Center for Reproductive Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands Department of Reproductive and Maternal medicine, School of Medicine, University of Glasgow, Glasgow, UK University of Illinois at Chicago, Departments of Psychiatry, Psychology and Obstetrics and Gynecology, Chicago, IL Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy Queen Charlotte's and Chelsea and Chelsea and Westminster Hospitals, Imperial College London, London, UK Auckland District Health Board, Auckland, New Zealand Midlife Women's Health Center, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Department of Obstetrics and Gynecology, George Washington University, Washington, DC Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada.

Objective: Vasomotor symptoms (VMS) (hot flashes and night sweats) affect most women over the menopause transition. Comparing the safety and effectiveness of treatments for vasomotor symptoms is limited by the use of inconsistent outcome measures, and uncertainty as to which outcomes are most important to symptomatic women. To address this, we have developed a Core Outcome Set (COS) for use in clinical trials of treatments for VMS.

Methods: We systematically reviewed the primary outcomes measured in randomized controlled trials of treatments for VMS. These were refined and entered into a two-round modified Delphi survey completed by clinicians, researchers, and postmenopausal women between November 2019 and March 2020. Outcomes were scored on a nine-point scale from "not important" to "critically important." Two international consensus meetings were held to finalize the COS.

Results: Based on the systematic review, 13 separate outcomes were included in the Delphi process. This was completed by 227 participants of whom 58% were postmenopausal women, 34% clinicians, and 8% researchers. Predefined thresholds were applied to categorize importance scores obtained during Round 2 of the Delphi survey. These informed discussions at the consensus meetings which were attended by 56 participants from 28 countries. The final COS includes six outcomes: 1) frequency of VMS, 2) severity of VMS, 3) distress, bother or interference caused by VMS, 4) impact on sleep, 5) satisfaction with treatment, and 6) side-effects of treatment.

Conclusion: Implementation of this COS will: better enable research studies to accurately reflect the joint priorities of postmenopausal women, clinicians and researchers, standardize outcome reporting, and facilitate combining and comparing results from different studies, and ultimately improve outcomes for women with bothersome VMS.

Video Summary:http://links.lww.com/MENO/A763.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GME.0000000000001787DOI Listing
April 2021

Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation.

Menopause 2020 09 4;28(1):8-11. Epub 2020 Sep 4.

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.

Objective: To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy.

Methods: Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions.

Results: Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749).

Conclusions: Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GME.0000000000001652DOI Listing
September 2020

Factors associated with use of hormone therapy after preventive oophorectomy in BRCA mutation carriers.

Menopause 2020 12;27(12):1396-1402

Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.

Objective: Bilateral salpingo-oophorectomy (oophorectomy) is recommended to women with a germline BRCA1 or BRCA2 mutation before natural menopause to prevent ovarian and fallopian tube cancer. The adverse effects of early surgical menopause are well established. Although many of the side effects can be ameliorated by the use of hormone therapy (HT); use of HT in this group of predominantly young patients remains suboptimal. The goal of this study was to identify the frequency of HT use, as well as predictors of HT uptake in BRCA mutation carriers who underwent preventive oophorectomy before natural menopause.

Methods: Eligible participants were identified from a longitudinal study of BRCA mutation carriers. We included premenopausal women with no personal history of cancer who underwent oophorectomy before age 50 and who had a minimum of 2 years of follow-up. Detailed information on HT use and other important variables was collected by a research questionnaire every 2 years. Descriptive statistics were used to evaluate the use of HT in various subgroups.

Results: A total of 793 women with a BRCA1 or BRCA2 mutation were included in this analysis. The mean age at oophorectomy was 42 years (range 28-49). Sixty-one percent of the women reported using HT after oophorectomy. Factors associated with HT use included young age at surgery, a high level of education and preventive mastectomy.

Conclusions: The uptake of HT after oophorectomy in women with a BRCA1 or BRCA2 mutation varies by age, education, and surgical history. Clinician and patient awareness may lead to better utilization of HT in women who undergo oophorectomy at an early age to help mitigate the adverse effects associated with surgical menopause.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GME.0000000000001629DOI Listing
December 2020

Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses.

J Obstet Gynaecol Can 2020 08;42(8):1040-1050.e1

Toronto, ON.

Objective: To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management.

Intended Users: Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers.

Target Population: Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer.

Outcomes: This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist.

Evidence: Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary.

Validation Methods: The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework.

Benefits, Harms, Costs: Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications.

Summary Statements (grade Ratings In Parentheses): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2020.01.014DOI Listing
August 2020

O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee.

Radiology 2020 01 5;294(1):168-185. Epub 2019 Nov 5.

From the Department of Radiology and Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt University College of Medicine, 1161 21st Ave S, #D3300, Nashville, Tenn 37232 (R.F.A.); Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium (D.T.); Department of Radiology, University of California, San Francisco, San Francisco, Calif (L.M.S.); Department of Development and Regeneration, KU Leuven, Leuven, Belgium (W.F.); Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium (W.F.); Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Brookline, Mass (B.R.B.); Department of Radiology, NYU Langone Health, New York, NY (G.L.B.); Department of Obstetrics and Gynecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, England (T.B.); Department of Radiology, Mayo Clinic, Rochester, Minn (D.L.B.); Department of Radiology, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pa (B.G.C.); Department of Radiology, Brigham and Women's Hospital, Boston, Mass (M.C.F.); Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY (S.R.G.); Department of Radiology, Johns Hopkins University, School of Medicine, Baltimore, Md (U.M.H.); Department of Radiology, Einstein Medical Center, Philadelphia, Pa (M.M.H.); Department of Radiology and Radiological Sciences, Carell Children's Hospital at Vanderbilt, Nashville, Tenn (M.H.S.); Department of Radiology, McGill University Health Centre, Montreal, Canada (C.R.); Department of Obstetrics and Gynecology, University of Wisconsin, Madison, Wis (S.L.R.); Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Conn (B.P.W.); Department of Obstetrics and Gynecology, Mt. Sinai Hospital, University of Toronto, Toronto, Canada (W.L.W.); and Department of Medical Imaging and Department of Obstetrics and Gynecology, University of Toronto, Sunnybrook Research Institute, Toronto, Canada (P.G.).

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1148/radiol.2019191150DOI Listing
January 2020

N° 311 - Prise en charge de la ménopause (Résumé/Déclarations Sommaires et Recommandations).

J Obstet Gynaecol Can 2019 Jun;41 Suppl 1:S29-S35

Toronto (Ont.).

Objectif: Offrir, aux fournisseurs de soins de santé, une mise à jour de la directive clinique quant à la prise en charge de la ménopause chez les femmes asymptomatiques en santé, ainsi que chez les femmes qui présentent des symptômes vasomoteurs ou urogénitaux; cette mise à jour se penche également sur les facteurs associés à la maladie cardiovasculaire, au cancer du sein, à l'urogynécologie et à la sexualité.

Issues: Les interventions quant au mode de vie, les médicaments d'ordonnance et les traitements de médecine complémentaire et parallèle sont présentés en fonction de leur efficacité dans la prise en charge des symptômes ménopausiques. Des stratégies de counseling et thérapeutiques en ce qui concerne les préoccupations en matière de sexualité au cours de la périménopause et de la postménopause sont passées en revue. Des approches quant à l'identification et à l'évaluation des femmes exposées à un risque élevé d'ostéoporose (ainsi que des options en matière de prévention et de traitement) sont présentées dans la directive clinique sur l'ostéoporose qui accompagne les présentes. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library, en août et en septembre 2012, au moyen d'un vocabulaire contrôlé (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots clés (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les résultats ont été restreints aux directives cliniques, aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Les résultats ont également été restreints aux documents publiés, en anglais ou en français, à partir de 2009. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'au 5 janvier 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, auprès de sociétés de spécialité médicale nationales et internationales, et dans des collections de directives cliniques.

Valeurs: La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2019.02.139DOI Listing
June 2019

N 377- Indications gynécologiques bénignes de l'hystérectomie.

J Obstet Gynaecol Can 2019 Apr;41(4):558-574

Hamilton (Ont.).

Objectif: Aider les médecins qui pratiquent la chirurgie gynécologique dans leur processus décisionnel relatif aux indications bénignes de l'hystérectomie.

Public Cible: Médecins, y compris gynécologues, obstétriciens, médecins de famille, chirurgiens généralistes, urgentologues; infirmières, y compris les infirmières autorisées et les infirmières praticiennes; apprentis en médecine, y compris étudiants de médecine, résidents, stagiaires (fellows); et autres fournisseurs de soins de santé.

Population Cible: Femmes adultes (18 ans et plus) qui devront subir une hystérectomie pour une indication gynécologie bénigne.

Options: La présente directive clinique examine les différentes voies d'abord de l'hystérectomie et l'utilité des interventions chirurgicales concomitantes. DONNéES PROBANTES: Pour la présente directive clinique, des recherches ont été effectuées dans les bases de données PubMed, Medline et Cochrane Library pour trouver des études pertinentes. Les recherches ont été effectuées parmi les publications des cinq dernières années (2012-2017) au moyen des termes de recherche MeSH suivants ainsi que leurs variations : vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy et total vaginal hysterectomy. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux et membres du comité de pratique clinique - gynécologie. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes utilisées dans le présent document a été évaluée au moyen des critères du cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) (tableau 1, tableau 2). Le résumé des conclusions est disponible sur demande. AVANTAGES, PRéJUDICES ET COûTS: Bien que l'hystérectomie soit commune, la pratique chirurgicale varie grandement chez les médecins spécialisés en gynécologie. La présente directive expose les facteurs pré- et périopératoires à prendre en compte pour améliorer la qualité des soins prodigués aux femmes qui doivent subir une chirurgie pour une affection gynécologique bénigne. MISE à JOUR DE LA DIRECTIVE CLINIQUE: La présente directive clinique de la Société des obstétriciens et gynécologues du Canada sera automatiquement passée en revue cinq ans après sa publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de cinq ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

Promoteurs: La présente directive clinique a été élaborée au moyen de ressources financées par la Société des obstétriciens et gynécologues du Canada. DéCLARATIONS CONDENSéES: RECOMMANDATIONS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2019.02.002DOI Listing
April 2019

No. 377-Hysterectomy for Benign Gynaecologic Indications.

J Obstet Gynaecol Can 2019 Apr;41(4):543-557

Hamilton, ON.

Objective: To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications.

Intended Users: Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers.

Target Population: Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications.

Options: The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline.

Evidence: For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy.

Validation Methods: The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request.

Benefits, Harms, And Costs: Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery.

Guideline Update: This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

Sponsors: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada.

Summary Statements: RECOMMENDATIONS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2018.12.006DOI Listing
April 2019

Survey of Canadian PGY-4 and PGY-5 Obstetrics and Gynaecology Residents on Knowledge of and Exposure to Premature Ovarian Insufficiency.

J Obstet Gynaecol Can 2018 10 17;40(10):1324-1328. Epub 2018 Jul 17.

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON.

Objectives: (1) To determine exposure to and general knowledge on premature ovarian insufficiency (POI) among Canadian senior obstetrics and gynaecology residents. (2) To identify opportunity to improve trainee exposure to POI.

Methods: Canadian PGY-4 and PGY-5 obstetrics and gynaecology residents were approached to complete an electronic survey. The questions in the survey included the basic POI knowledge, previous exposure to POI, and comfort level in managing POI patients. Data from the survey was summarized descriptively and compared between two trainee groups (PGY-4 and PGY-5) using chi-square or Fisher exact tests.

Results: Responses were received from trainees in all Canadian residency programs with an overall response rate of 45% (95/210 residents). Most respondents (79%, 75/95 residents) identified correct age for POI diagnosis, and 65% (62/95 residents) recognized the most common aetiology. A majority (99%, 92/93 residents) would prescribe hormone therapy for POI patients. Most trainees (62%, 59/95 residents) lack access to a POI clinic at their centre and 63% (59/94 residents) have seen less than six POI patients during residency training. Most feel somewhat comfortable managing POI patients (67%, 64/95 residents), but 22% (21/95 residents) feel totally uncomfortable with a majority of respondents (83%, 78/94 residents), indicating they would benefit from additional training. Compared with PGY-4 residents, the proportion of trainees who could identify the correct age for diagnosis of POI was significantly higher in PGY-5 residents (89% vs. 70%, P = 0.024).

Conclusion: Many senior obstetrics and gynaecology residents in Canada lack knowledge around POI, and most indicate need for further exposure to POI during residency training. We identified an opportunity for improved POI curricula.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2018.01.005DOI Listing
October 2018

No. 292-Abnormal Uterine Bleeding in Pre-Menopausal Women.

J Obstet Gynaecol Can 2018 05;40(5):e391-e415

Toronto, ON.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2018.03.007DOI Listing
May 2018

N 249-Épaississement endométrial asymptomatique.

Authors:
Wendy Wolfman

J Obstet Gynaecol Can 2018 05;40(5):e378-e390

Toronto, ON.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2018.03.006DOI Listing
May 2018

No. 249-Asymptomatic Endometrial Thickening.

Authors:
Wendy Wolfman

J Obstet Gynaecol Can 2018 05;40(5):e367-e377

Toronto, ON.

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 Preventive Health Care (Table 1). 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.

Recommendations:
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2018.03.005DOI Listing
May 2018

Letter to the Editor.

Authors:
Wendy L Wolfman

J Obstet Gynaecol Can 2017 11;39(11):976

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2017.07.015DOI Listing
November 2017

Letter to the Editor.

Authors:
Wendy L Wolfman

J Obstet Gynaecol Can 2017 11;39(11):976

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2017.07.015DOI Listing
November 2017

First International Consensus Report on Adnexal Masses: Management Recommendations.

J Ultrasound Med 2017 May 7;36(5):849-863. Epub 2017 Mar 7.

Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA.

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jum.14197DOI Listing
May 2017

Saignements utérins anormaux chez les femmes préménopausées.

J Obstet Gynaecol Can 2016 Dec 4;38(12S):S231-S263. Epub 2017 Jan 4.

Toronto (Ont.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jogc.2016.09.035DOI Listing
December 2016

Endometrial ablation in the management of abnormal uterine bleeding.

J Obstet Gynaecol Can 2015 Apr;37(4):362-79

London ON.

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).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s1701-2163(15)30288-7DOI Listing
April 2015

Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy.

J Obstet Gynaecol Can 2015 Jan;37(1):68-81

Ottawa ON.

Objective: To review the use of tissue morcellation in minimally invasive gynaecological surgery.

Outcomes: Morcellation may be used in gynaecological surgery to allow removal of large uterine specimens, providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

Evidence: Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyomsarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, morcellation, and MRI). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to August 2014. 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 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: Gynaecologists may offer women minimally invasive surgery and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine sarcoma or endometrial cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Appropriate training and safe practices should be in place before offering tissue morcellation. SUMMARY STATEMENTS: 1. Uterine sarcomas may be difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for presumed benign uterine leiomyoma is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500. (II-2) This risk increases with age. (II-2) 2. An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour-spread and a worse prognosis. (II-2) 3. Uterus-sparing surgery remains a safe option for patients with symptomatic leiomyomas who desire future fertility. (II-1) RECOMMENDATIONS: 1. Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread. (III-C) 2. Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the value of these is limited. (III-C) 3. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended. (II-2A) 4. Hereditary cancer syndromes that increase the risk of uterine malignancy should be considered a contraindication to uncontained uterine morcellation. (III-C) 5. Uterine morcellation is contraindicated in women with established or suspected cancer. (II-2A) If there is a high index of suspicion of a uterine sarcoma prior to surgery, patients should be advised to proceed with a total abdominal hysterectomy, bilateral salpingectomy, and possible oophorectomy. (II-2C) A gynaecologic oncology consultation should be obtained. 6. Tissue morcellation techniques require appropriate training and experience. Safe practice initiatives surrounding morcellation technique and the use of equipment should be implemented at the local level. (II-3B) 7. Morcellation is an acceptable option for retrieval of benign uterine specimens and may facilitate a minimally invasive surgical approach, which is associated with decreased perioperative risks. Each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. (III-C).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s1701-2163(15)30366-2DOI Listing
January 2015

Managing menopause.

J Obstet Gynaecol Can 2014 Sep;36(9):830-833

Toronto ON.

Objective: To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality.

Outcomes: Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline.

Evidence: Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1701-2163(15)30487-4DOI Listing
September 2014

Abnormal uterine bleeding in pre-menopausal women.

J Obstet Gynaecol Can 2013 May;35(5):473-475

Toronto ON.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1701-2163(15)30939-7DOI Listing
May 2013

Endometrial thickness in 1,500 asymptomatic postmenopausal women not on hormone replacement therapy.

Gynecol Obstet Invest 2013 6;75(3):191-5. Epub 2013 Mar 6.

True North Imaging, Thornhill, Ont., Canada.

Objective: To determine the normal endometrial thickness (ET) on transvaginal ultrasound (TVUS) of asymptomatic postmenopausal women not on hormone replacement therapy. A subgroup that was determined to be suspicious for having an endometrial polyp was compared with the remainder.

Methods: This prospective study selected 1,500 consecutive asymptomatic postmenopausal women receiving TVUS assessment from January to August 2010. ET was recorded. Results were divided into those with a normal-appearing lining (n = 1,399) and those suspicious for polyp (n = 101). Results for the entire sample were obtained and the groups were compared using independent samples t tests.

Results: Of 1,500 women aged 45-95 years, 77.1% had an ET of ≤4 mm and 92% were ≤5 mm. Independent samples t tests were performed to compare the mean age and mean ET based on polyp status (i.e. with or without a possible polyp). There was a significant difference in mean age, 67.71 vs. 62.36 years (p < 0.01) and mean ET 8.02 vs. 3.40 mm (p < 0.01) between groups.

Conclusions: 92% of asymptomatic postmenopausal women not on hormone replacement therapy had an ET of ≤5 mm. The mean ET was 3.71 ± 1.9 mm. However, a significant group, 6.7%, had an endometrial lining suspicious for polyp. These women had a significant increase in mean age and ET.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000347064DOI Listing
November 2013

The safety of testosterone therapy in women.

J Obstet Gynaecol Can 2012 Sep;34(9):859-865

Department of Obstetrics and Gynecology, University of Toronto, Toronto ON.

Hypoactive sexual desire disorder (HSDD), a subset of female sexual dysfunction, causes personal distress for surgically and naturally postmenopausal and premenopausal women. HSDD has a multi-factorial etiology, including psychosocial factors such as relationship issues and medical factors such as medications, chronic illnesses, and hormonal effects. Although no androgen therapies for female sexual dysfunction are currently approved for use in Canada, clinical trials support the efficacy and short-term safety of testosterone therapy for HSDD. We review the scientific evidence for the safety of testosterone therapy for HSDD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1701-2163(16)35385-3DOI Listing
September 2012

Significance of abnormal sonographic findings in postmenopausal women with and without bleeding.

J Obstet Gynaecol Can 2011 Sep;33(9):944-51

Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON.

Objective: We sought to determine the incidence of cancer and to compare pathologic outcomes in bleeding and non-bleeding postmenopausal patients who underwent hysteroscopy.

Methods: We conducted a retrospective chart review of 294 postmenopausal women with abnormal uterine bleeding and 142 postmenopausal women without symptoms who underwent hysteroscopy. An 11 mm cut-off for asymptomatic women was applied to determine whether this endometrial thickness threshold would differentiate women with and without endometrial cancer in the asymptomatic group.

Results: In symptomatic patients, 14 were found to have endometrial cancer and 10 were found to have endometrial hyperplasia. In the asymptomatic group, two women (1.4%) were found to have endometrial cancer with average thickness 17.5 mm, and one (0.71%) was found to have endometrial hyperplasia. Logistic regression models showed the risk of a bleeding patient developing endometrial cancer at an endometrial thickness of 4 mm was the same as the risk in a non-bleeding patient at a thickness of 15 mm.

Conclusion: Asymptomatic postmenopausal women have a low risk of having significant endometrial pathology. Cancer was approximately four times more prevalent in women with bleeding than in women with no bleeding.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s1701-2163(16)35020-4DOI Listing
September 2011

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

Int J Gynaecol Obstet 2011 Mar;112(3):252-6

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).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijgo.2010.12.003DOI Listing
March 2011

Asymptomatic endometrial thickening.

J Obstet Gynaecol Can 2010 Oct;32(10):990-9

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s1701-2163(16)34690-4DOI Listing
October 2010

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

Int J Gynaecol Obstet 2010 Nov;111(2):193-7

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijgo.2010.07.002DOI Listing
November 2010

A novel regimen of combination transdermal estrogen and intermittent vaginally administered progesterone for relief of menopausal symptoms.

Gynecol Endocrinol 2010 Dec 21;26(12):902-8. Epub 2010 May 21.

Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.

Objectives: To determine the safety and efficacy of a novel regimen of transdermal estrogen and vaginally administered progesterone for treatment of menopausal symptoms.

Study Methods: A retrospective chart review was conducted of menopausal patients aged 46-65, using an oestradiol patch and vaginally administered prometrium for at least 1 year. Available transvaginal ultrasound (TVUS) measurements of endometrial thickness and endometrial biopsy results after at least 1 year of treatment were collated. Symptom relief, bleeding and side effects were reviewed.

Results: Forty-one patients were identified, using an estrogen patch ranging from 25 to 100 μg twice weekly and vaginal prometrium either continuously 3-5 days weekly (36 patients), or sequentially 12 days/month (5 patients). Seventeen patients were lost to follow-up or discontinued therapy within 1 year. Only 23.5% (4/17 patients) of patients who had a TVUS after 1 year (or sooner if bleeding occurred) had a thickened endometrial lining on ultrasound (>5 mm), and all of these had normal endometrial biopsies. By 1 year of follow-up, 91.7% of patients were amenorrhoeic. All patients had relief of menopausal symptoms.

Conclusions: Vaginal administration of progesterone as part of combined estrogen plus progestin therapy has the potential for decreasing side effects while maintaining endometrial safety and amenorrhoea. Larger prospective trials are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3109/09513590.2010.487602DOI Listing
December 2010