IJG-08385; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
1
CLINICAL ARTICLE
4Q2
Ji Young Lee a,1, Dong-Yun Lee b,1, Jae Yen Song c, Eun Sil Lee d, Kyungah Jeong e, DooSeok Choi b,⁎
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A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea
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a
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a r t i c l e
11 12 13 14
Article history: Received 27 November 2014 Received in revised form 1 April 2015 Accepted 8 June 2015
15 16 17 18
Keywords: Abnormal uterine bleeding Clinician survey Management
Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea Department of Obstetrics and Gynecology, Uijeongbu St. Mary’s Hospital, Catholic University of Korea, Uijeongbu-si, South Korea d Department of Obstetrics and Gynecology, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, South Korea e Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, South Korea b
a b s t r a c t
P
i n f o
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c
Objective: To evaluate practice patterns of gynecologists in the management of abnormal uterine bleeding (AUB) in South Korea. Methods: Between February 24 and March 12, 2014, a cross-sectional survey was performed through face-to-face interviews with 100 gynecologists selected through quota sampling reflecting regions and hospital types. Through the use of a questionnaire, the level of awareness and practice patterns regarding diagnosis and management of AUB were evaluated. Results: Among 100 respondents, 60 reported that they had not previously heard of the International Federation of Gynecology and Obstetrics (FIGO) classification system. The standardization of AUB terminology was reported to be necessary or very necessary by 70 respondents. Pelvic ultrasonography would be used for diagnosis by 99 physicians. The most common first-line AUB treatment was combined oral contraceptives: 55 respondents would use them for heavy menstrual bleeding, 56 for intermenstrual bleeding, and 56 for polycystic ovary syndrome. Combined oral contraceptives were the preferred follow-up medication: 30 would use them for heavy menstrual bleeding, 24 for intermenstrual bleeding, and 52 for polycystic ovary syndrome. Conclusion: Despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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2Q1
36 34
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1. Introduction
38
Abnormal uterine bleeding (AUB), which covers a wide range of bleeding symptoms [1], is one of the most common gynecologic problems in women of reproductive age [2]. Despite its high prevalence, socioeconomic burden, and influence on patient quality of life, research addressing this problem remains scarce. Additionally, there is substantial variation with regard to the terms used to describe AUB, including symptoms, signs, and causes [3], leading to difficulties in the interpretation of clinical studies, as well as to miscommunication among clinicians and between clinicians and patients [4]. A classification system for causes of AUB according to the pattern of bleeding and etiology in non-gravid women of reproductive age was proposed in 2011 by the International Federation of Gynecology and Obstetrics (FIGO) [5] and recommended for clinical use in 2012 [6]. Despite the time elapsed since its implementation, clinician awareness of this classification system is yet to be addressed in the literature.
43 44 45 46 47 48 49 50 51 52
N C O
41 42
U
39 40
R
37
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135–710, South Korea. Tel.: +82 2 3410 3519; fax: +82 2 3410 0630. E-mail address: [email protected] (D. Choi). 1 These authors contributed equally.
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Guidelines for the management of AUB are available in some countries [7]. Further, surveys have documented treatment patterns for menorrhagia (heavy menstrual bleeding in FIGO terminology) in the USA [8] and New Zealand [9]. Nevertheless, these surveys did not evaluate clinician awareness of FIGO terminology or the FIGO classification system. The present survey was conducted to evaluate gynecologists’ level of awareness of AUB and to assess current AUB management patterns in South Korea.
53
2. Materials and methods
61
A cross-sectional survey of gynecologists was conducted through face-to-face interviews held between February 24 and March 12, 2014. On the basis of a report from medical/healthcare institutions in accordance with Korean national health insurance policy in 2013, the target group was defined as gynecologic specialists who practiced in general hospitals (≥100 admission beds), hospitals (30–100 admission beds), or clinics (b 30 admission beds). According to this classification, 4669 practitioners listed in the national society database formed the target population. Quota sampling was applied to reflect region and each target hospital type (general hospital, hospital, or clinic); finally, a nationwide target sample size of 100 gynecologists was selected. The sample size of 100 in a target population of 4669 incurred a 9.69%
62 63
http://dx.doi.org/10.1016/j.ijgo.2015.04.034 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
54 55 56 57 58 59 60
64 65 66 67 68 69 70 71 72 73
t1:1 t1:2
Table 1 Presented cases of abnormal uterine bleeding.
97 98 99 100 101 102 103 104 105 106
110 111 112 113
C
95 96
E
93 94
R
91 92
R
89 90
t1:3
Case 1: heavy menstrual bleeding
56 (56) 44 (44) 24 (24) 76 (76) 38 (38) 62 (62)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22
the classification, most had first heard of it at medical society meetings and seminars (Table 3). Among all respondents, 68% thought it was necessary or very necessary for AUB terms to be standardized (Table 3). Overall, 37 (37%) respondents were willing and 29 (29%) were very willing to attend lectures on the FIGO classification system. Overall, 99% of physicians stated that they would perform pelvic ultrasonography (Table 4). The most common reasons given for such an approach were to confirm underlying disease (98/99 [99%]) and to measure endometrial thickness (97/99 [98%]); it was also used to identify any pregnancy by 75/99 (76%) of respondents. The preferred first-line drug of choice for treatment of regular HMB (case 1) was combined oral contraceptives (COCs), followed by oral progestin and oral estrogen (Table 5). Among the demographic and clinical practice factors, only the number of years in practice affected the likelihood of choosing COCs as a first-line treatment: 26 (68%) of the 38 practitioners with less than 15 years of experience would choose COCs compared with 29 (47%) of the 62 with at least 15 years of experience (P = 0.0347). Few respondents chose a levonorgestrel-releasing intrauterine system (LNG-IUS) as a first-line treatment for HMB (Table 5). Most respondents stated that they would follow up patients after HMB was controlled, with half choosing to follow without any medication (Table 6).
Age, y Paritya Reason for visit Menstrual cycle and length of menstrual flow
t1:9
Amount of bleeding
t1:10
Menstrual history
t1:11
Ultrasonography findings
t1:12
Other information
Case 2: intermenstrual bleeding
Case 3: Polycystic ovary syndrome
33 1-0-0-1 Heavy menstrual bleeding Regular menstrual cycle of 30 days, lasting for 7 days
22 0-0-0-0 Irregular bleeding Irregular menstrual cycle for the past 2 months, with bleeding between periods
Bleeding was heavy from menarche and gradually increased; it is now difficult to perform daily activities when it is heavy Menarche at age 13 years Menstrual cycle used to be regular (30 days) Endometrial thickness of 6 mm No abnormalities in the uterus or ovaries The patient complains of light dizziness due to menstruation No other history of diseases
A small amount of bleeding that lasts for 10 days
28 0-0-1-0 Irregular bleeding Most recent menstruation was 3 months ago Menstrual cycle of 24–50 days; irregular and unpredictable Hard to predict
Menarche at age 13 years Menstrual cycle used to be regular (30 days) Endometrial thickness of 5 mm No abnormalities found in the uterus or ovaries Except for slight menstrual pain, there are no other symptoms The patient has a boyfriend and no particular method of contraception is being used No unusual medical diseases or history of surgery
Menarche at age 13 years Menstrual cycle has typically been irregular Endometrial thickness of 8 mm Ovaries appear polycystic Her mother has type 2 diabetes BMI of 28 Physical examination reveals extensive facial hair accompanied with acne No other particular disease history
U
t1:4 t1:5 t1:6 t1:7 t1:8
t1:13 t1:14
36 (36) 64 (64)
t2:3
O
87 88
C
85 86
N
83 84
13 (13) 40 (40) 47 (47)
F
114
Most of the 100 respondents were aged 40 years or older and had more than 15 years of clinical experience (Table 2). Almost two-thirds were based in a clinic (Table 2). Overall, 60% of respondents were unfamiliar with the FIGO classification; only 2% were actively applying the classification system in practice (Table 3). Among the 40 respondents who were aware of
81 82
58 (58) 42 (42)
O
109
80
No. (%)
Sex Male Female Age, y b40 40–49 ≥50 Type of practice General hospital or hospital Clinic Area Seoul (metropolitan) Other Subspecialty Yes No Time in practice, y b15 ≥15
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3. Results
78 79
Demographic characteristic
P
108
76 77
t2:1 t2:2
Table 2 Demographic characteristics of respondents (n = 100).
T
107
sampling error in a 95% confidence interval and an 8.13% sampling error in a 90% confidence interval. The study was approved by the Institutional Review Board for Clinical Research at Samsung Medical Center, Seoul, South Korea. Informed consent was obtained from study participants. To develop the questionnaire for the survey, an expert group of eight specialists was organized, consisting of faculty members of a tertiary general hospital who were selected on the basis of their experience in treating patients with AUB. Experts were interviewed by a professional interviewer to identify the overall AUB course management, from diagnosis to treatment and follow-up, and to understand the variation in treatment course among AUB types. On the basis of the results of this qualitative study, members of the expert group developed the questionnaire to be used for quantitative research. A synopsis of three typical AUB cases was established: heavy menstrual bleeding (HMB, case 1), intermenstrual bleeding (IMB, case 2), and polycystic ovary syndrome (PCOS, case 3) (Table 1). Once the draft questionnaire was developed, pilot interviews were performed with two specialists to verify the logic of the questionnaire and its contents. Feedback from the pilot interviews was reflected in the final version of the questionnaire. Practical patterns for AUB management were assessed using the case synopsis questionnaire. Clinicians were asked to choose their top three preferred treatment options for each clinical case. An interviewer was physically present to administer the survey and to assist the respondent in completing the survey. The face-to-face interview followed a standardized script without deviation. Each respondent was asked identical questions following the same logic and order. Interviewers were not allowed to change the order of the questions or revise the questions according to their own judgment. All statistical analyses were performed using R i386 version 2.15.3 (http://www.r-project.org/). P b 0.05 was deemed statistically significant. For statistical verification of the differences between variables, the χ2 test was used to analyze differences in the response rate among the groups and the t test or analysis of variance were used to evaluate differences in the mean of numeric answers among variables/groups.
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J.Y. Lee et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
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Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters). a Values are shown as number of full-term deliveries, number of preterm deliveries, number of spontaneous/induced abortions, and number of live children.
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136
J.Y. Lee et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 3 Level of awareness of the FIGO classification system for abnormal uterine bleeding (n =
t3:3
100).
t3:4
Variables
t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18
Awareness of the FIGO classification system First time hearing of it Don’t know any details, but aware that it exists Aware of the specifications, but have not applied it in practice Currently applying it in practice Information source for FIGO classification (n = 40) Medical society meetings and seminars Medical journals Colleagues Importance of standardizing abnormal uterine bleeding terminology Very necessary Necessary Neutral Unnecessary
t3:19
Abbreviation: FIGO, International Federation of Gynecology and Obstetrics.
137 138
151
Similar preferences in the treatment of irregular IMB (case 2) were observed. The top three first-line drug choices were COCs, oral estrogen, and oral progestin (Table 5). The likelihood of choosing COCs as a firstline treatment for IMB varied by type of practice: 27 (75%) of the 36 respondents from general hospitals reported they would select COCs compared with 29 (45%) of 64 physicians from clinics (P = 0.0041). Follow-up was similar to that for HMB (Table 6). The most common first-line treatments chosen for irregular bleeding associated with PCOS (case 3) were COCs, progestin injection, and oral progestin (Table 5). The preferred treatment for bleeding due to PCOS did not differ by type of practice or years in practice (data not shown). Regular prescription of COCs was the preferred follow-up treatment in the PCOS case (Table 6). The proportion of respondents who would track the patient’s bleeding pattern without any use of medication was lower than that for HMB and IMB (Table 6).
152
4. Discussion
153
Despite the need for a universal system of AUB classification to prevent the misinterpretation of clinical studies or miscommunication among clinicians and between clinicians and patients, many physicians in the present study (60%) were unaware of the recent release of the new FIGO classification system and its potential usefulness, with only 2% of respondents applying the FIGO system in current clinical practice. Most clinicians agreed that there was a distinct need for standardization of AUB terminology as well as for widespread education on the matter. Considering that 85% of the respondents who were aware of the AUB system first received this information at society meetings or seminars, efforts should be made to introduce the new classification system through various continuing education programs. Further, national
154 155 156 157 158 159 160 161 162 163 164
t4:1 t4:2
Heavy menstrual bleeding
Intermenstrual bleeding
Polycystic ovary syndrome
t5:3
Combined oral contraceptives Oral progestin Oral estrogen Progestin injection Non-steroidal anti-inflammatory drugs Levonorgestrel intrauterine system Estrogen injection Surgical methods (e.g. dilation and curettage, endometrial ablation) Tranexamic acid Other
55 (55) 13 (13) 11 (11) 7 (7) 5 (5) 3 (3) 2 (2) 2 (2)
56 (56) 13 (13) 14 (14) 7 (7) 5 (5) 0 2 (2) 0
56 (56) 14 (14) 4 (4) 16 (16) 1 (1) 0 0 4 (4)
0 3 (3)
0 5 (5)
t5:4 t5:5 t5:6 t5:7 t5:8 t5:9 t5:10 t5:11 t5:12 t5:13 t5:14
1 (1) 1 (1)
t5:15
Values are given as number (percentage).
O
a
165 166
Table 6 Follow-up (n = 100).a
t6:1 t6:2
D
P
R O
societies should play a greater part in disseminating new information and providing continuous medical education to ensure reinforcement. Laboratory assessment for AUB usually includes a pregnancy test, complete blood count, thyroid-stimulating hormone, and/or cervical cancer screening, but decisions regarding specific tests should be based on clinical findings [6]. According to various guidelines, pelvic ultrasonography is not a first-line diagnostic tool [5]. However, nearly all respondents stated that they would perform pelvic ultrasonography when investigating AUB for various reasons, whereas endometrial biopsy was infrequently selected. This finding could be associated with the high accessibility of specialist medical services and their relatively low cost in South Korea. COCs were the preferred first-line treatment for HMB, IMB, and PCOS among the respondents. Although South Korea has one of the lowest preferences for COCs as a form of contraception [10], their use for treatment purposes is as widely accepted as it is in other countries. LNG-IUS was not included in the top three first-line treatment modalities in any of the cases, despite it being highly effective in the treatment of HMB. LNG-IUS is an attractive option, particularly for younger women, since it is cost-effective, reversible, and fertility preserving [11]; further, it can be considered for all age groups [7]. Despite evidence that LNG-IUS is an important and cost-effective alternative to surgical management for HMB [12], it is likely that the respondents preferred less invasive oral or injectable progestin treatments over LNG-IUS because the cases described young women who were likely to desire a pregnancy in the near future. Tranexamic acid is also effective in the treatment of HMB and, along with COCs, is recommended if LNG-IUS is not used. However, only 1% of respondents reported the use of tranexamic acid, indicating their possible unfamiliarity with recent guidelines. Treatment continuation is recommended for AUB because it tends to be persistent and recurrent. Indeed, the main objectives of AUB management are the reduction of recurrence in subsequent cycles and control of the current bleeding episode [13]. Nevertheless, many physicians in the present survey did not choose to prescribe medication
E
T
C
149 150
E
147 148
32 (32) 36 (36) 11 (11) 21 (21)
R
145 146
34 (85) 3 (8) 3 (8)
R
143 144
60 (60) 31 (31) 7 (9) 2 (2)
N C O
141 142
Treatment No. (%)
U
139 140
t5:1 t5:2
Table 5 Initial treatment (n = 100).a
F
t3:1 t3:2
3
167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199
Table 4 Diagnostic tests (n = 100).
t4:3
Test
No. (%)
t4:4 t4:5 t4:6 t4:7 t4:8 t4:9 t4:10 t4:11 t4:12 t4:13 t4:14 t4:15
Ultrasonography Pregnancy test Cervical smear Complete blood count Coagulation test Prolactin Levels of thyroid-stimulating hormone Endometrial biopsy Hormone tests, including levels of luteinizing hormone, follicle-stimulating hormone, and estradiol Liver function test Test for sexually transmitted infections
99 (99) 59 (59) 49 (49) 17 (17) 5 (5) 5 (5) 5 (5) 3 (3) 3 (3) 2 (2) 1 (1)
Follow-up No medication Combined oral contraceptives Progestin Levonorgestrel intrauterine system Other No follow-up a
Heavy menstrual bleeding
Intermenstrual bleeding
Polycystic ovary syndrome
t6:3
72 (72) 38 (53) 30 (42) 3 (4) 1 (1) 0 28 (28)
65 (65) 39 (60) 24 (37) 1 (2) 1 (2) 0 35 (35)
82 (82) 24 (29) 51 (62) 5 (6) 0 2 (2) 18 (18)
t6:4 t6:5 t6:6 t6:7 t6:8 t6:9 t6:10
Values are given as number (percentage).
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
t6:11
231
References
232 233 234 235 236 237 276
C
223 224
[1] Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med 2011;29(5):383–90. [2] Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health 1996;86(2):195–9.
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This article was written on the basis of the results of an advisory board meeting by Bayer HealthCare. All authors have been symposium speakers and advisory board members of, and received honoraria and consulting fees from, Bayer HealthCare.
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Conflict of interest
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[3] Fraser IS, Critchley HO, Munro MG, Broder M, Writing Group for this Menstrual Agreement Process. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril 2007;87(3):466–76. [4] Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol 2012;207(4):259–65. [5] Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011; 113(1):3–13. [6] Committee on Practice Bulletins–Gynecology. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012; 120(1):197–206. [7] Committee on Practice Bulletins–Gynecology. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122(1):176–85. [8] Matteson KA, Anderson BL, Pinto SB, Lopes V, Schulkin J, Clark MA. Practice patterns and attitudes about treating abnormal uterine bleeding: a national survey of obstetricians and gynecologists. Am J Obstet Gynecol 2011;205(4):321.e1–8. [9] Park S, Farquhar CM. A survey of practice preferences and attitudes to the New Zealand Guidelines for the Management of Heavy Menstrual Bleeding. Aust N Z J Obstet Gynaecol 2002;42(4):374–8. [10] Lee DY, Koo YA, Yoon BK, Choi D. Reproductive health characteristics of urban South Korean women. Gynecol Obstet Invest 2010;70(3):154–9. [11] de Souza SS, Camargos AF, de Rezende CP, Pereira FA, Araujo CA, Silva Filho AL. A randomized prospective trial comparing the levonorgestrel-releasing intrauterine system with thermal balloon ablation for the treatment of heavy menstrual bleeding. Contraception 2010;81(3):226–31. [12] Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005;4: CD002126. [13] American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013;121(4):891–6. [14] Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, Petraglia F. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynecol Obstet 2015;128(3):196–200.
T
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to prevent recurrence of AUB, and some did not recommend follow-up after the cessation of bleeding. Thus, a greater level of focus on the longterm treatment of AUB patients is needed. In a recent European survey [14], nearly two-thirds of women with confirmed HMB were diagnosed with iron deficiency, but only half received appropriate medication. Although questions about specific tests and use of iron supplementation in women with HMB were not included in the current survey, it is likely that many women with HMB have iron deficiency in South Korea. In this context, greater attention should be focused on the management of HMB. The performance of face-to-face interviews using a structured questionnaire represents a major strength of the present study. To minimize deviation among interviewers, each interview was strictly conducted following the structured questionnaire. Because the interviewer elicited and recorded the data, issues regarding missing data, unclear markings, and illegible handwriting were eliminated. Thus, errors associated with misunderstandings were minimized. Although face-to-face interviews are time-consuming and cost-prohibitive, they have great advantages in terms of data quality and response rates. The small number of respondents is a limitation of the present study, and selection bias could have affected the choice of candidates for interviews. In conclusion, the present survey provides insight regarding awareness of the new FIGO classification system and AUB management patterns in South Korea. The study indicated that, despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low.
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J.Y. Lee et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
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Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
1
CLINICAL ARTICLE
4Q2
Ji Young Lee a,1, Dong-Yun Lee b,1, Jae Yen Song c, Eun Sil Lee d, Kyungah Jeong e, DooSeok Choi b,⁎
O
F
3
A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea
5 6 7 8 9
a
1 0
a r t i c l e
11 12 13 14
Article history: Received 27 November 2014 Received in revised form 1 April 2015 Accepted 8 June 2015
15 16 17 18
Keywords: Abnormal uterine bleeding Clinician survey Management
Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea Department of Obstetrics and Gynecology, Uijeongbu St. Mary’s Hospital, Catholic University of Korea, Uijeongbu-si, South Korea d Department of Obstetrics and Gynecology, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, South Korea e Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, South Korea b
a b s t r a c t
P
i n f o
R O
c
Objective: To evaluate practice patterns of gynecologists in the management of abnormal uterine bleeding (AUB) in South Korea. Methods: Between February 24 and March 12, 2014, a cross-sectional survey was performed through face-to-face interviews with 100 gynecologists selected through quota sampling reflecting regions and hospital types. Through the use of a questionnaire, the level of awareness and practice patterns regarding diagnosis and management of AUB were evaluated. Results: Among 100 respondents, 60 reported that they had not previously heard of the International Federation of Gynecology and Obstetrics (FIGO) classification system. The standardization of AUB terminology was reported to be necessary or very necessary by 70 respondents. Pelvic ultrasonography would be used for diagnosis by 99 physicians. The most common first-line AUB treatment was combined oral contraceptives: 55 respondents would use them for heavy menstrual bleeding, 56 for intermenstrual bleeding, and 56 for polycystic ovary syndrome. Combined oral contraceptives were the preferred follow-up medication: 30 would use them for heavy menstrual bleeding, 24 for intermenstrual bleeding, and 52 for polycystic ovary syndrome. Conclusion: Despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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1. Introduction
38
Abnormal uterine bleeding (AUB), which covers a wide range of bleeding symptoms [1], is one of the most common gynecologic problems in women of reproductive age [2]. Despite its high prevalence, socioeconomic burden, and influence on patient quality of life, research addressing this problem remains scarce. Additionally, there is substantial variation with regard to the terms used to describe AUB, including symptoms, signs, and causes [3], leading to difficulties in the interpretation of clinical studies, as well as to miscommunication among clinicians and between clinicians and patients [4]. A classification system for causes of AUB according to the pattern of bleeding and etiology in non-gravid women of reproductive age was proposed in 2011 by the International Federation of Gynecology and Obstetrics (FIGO) [5] and recommended for clinical use in 2012 [6]. Despite the time elapsed since its implementation, clinician awareness of this classification system is yet to be addressed in the literature.
43 44 45 46 47 48 49 50 51 52
N C O
41 42
U
39 40
R
37
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135–710, South Korea. Tel.: +82 2 3410 3519; fax: +82 2 3410 0630. E-mail address: [email protected] (D. Choi). 1 These authors contributed equally.
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Guidelines for the management of AUB are available in some countries [7]. Further, surveys have documented treatment patterns for menorrhagia (heavy menstrual bleeding in FIGO terminology) in the USA [8] and New Zealand [9]. Nevertheless, these surveys did not evaluate clinician awareness of FIGO terminology or the FIGO classification system. The present survey was conducted to evaluate gynecologists’ level of awareness of AUB and to assess current AUB management patterns in South Korea.
53
2. Materials and methods
61
A cross-sectional survey of gynecologists was conducted through face-to-face interviews held between February 24 and March 12, 2014. On the basis of a report from medical/healthcare institutions in accordance with Korean national health insurance policy in 2013, the target group was defined as gynecologic specialists who practiced in general hospitals (≥100 admission beds), hospitals (30–100 admission beds), or clinics (b 30 admission beds). According to this classification, 4669 practitioners listed in the national society database formed the target population. Quota sampling was applied to reflect region and each target hospital type (general hospital, hospital, or clinic); finally, a nationwide target sample size of 100 gynecologists was selected. The sample size of 100 in a target population of 4669 incurred a 9.69%
62 63
http://dx.doi.org/10.1016/j.ijgo.2015.04.034 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
54 55 56 57 58 59 60
64 65 66 67 68 69 70 71 72 73
t1:1 t1:2
Table 1 Presented cases of abnormal uterine bleeding.
97 98 99 100 101 102 103 104 105 106
110 111 112 113
C
95 96
E
93 94
R
91 92
R
89 90
t1:3
Case 1: heavy menstrual bleeding
56 (56) 44 (44) 24 (24) 76 (76) 38 (38) 62 (62)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22
the classification, most had first heard of it at medical society meetings and seminars (Table 3). Among all respondents, 68% thought it was necessary or very necessary for AUB terms to be standardized (Table 3). Overall, 37 (37%) respondents were willing and 29 (29%) were very willing to attend lectures on the FIGO classification system. Overall, 99% of physicians stated that they would perform pelvic ultrasonography (Table 4). The most common reasons given for such an approach were to confirm underlying disease (98/99 [99%]) and to measure endometrial thickness (97/99 [98%]); it was also used to identify any pregnancy by 75/99 (76%) of respondents. The preferred first-line drug of choice for treatment of regular HMB (case 1) was combined oral contraceptives (COCs), followed by oral progestin and oral estrogen (Table 5). Among the demographic and clinical practice factors, only the number of years in practice affected the likelihood of choosing COCs as a first-line treatment: 26 (68%) of the 38 practitioners with less than 15 years of experience would choose COCs compared with 29 (47%) of the 62 with at least 15 years of experience (P = 0.0347). Few respondents chose a levonorgestrel-releasing intrauterine system (LNG-IUS) as a first-line treatment for HMB (Table 5). Most respondents stated that they would follow up patients after HMB was controlled, with half choosing to follow without any medication (Table 6).
Age, y Paritya Reason for visit Menstrual cycle and length of menstrual flow
t1:9
Amount of bleeding
t1:10
Menstrual history
t1:11
Ultrasonography findings
t1:12
Other information
Case 2: intermenstrual bleeding
Case 3: Polycystic ovary syndrome
33 1-0-0-1 Heavy menstrual bleeding Regular menstrual cycle of 30 days, lasting for 7 days
22 0-0-0-0 Irregular bleeding Irregular menstrual cycle for the past 2 months, with bleeding between periods
Bleeding was heavy from menarche and gradually increased; it is now difficult to perform daily activities when it is heavy Menarche at age 13 years Menstrual cycle used to be regular (30 days) Endometrial thickness of 6 mm No abnormalities in the uterus or ovaries The patient complains of light dizziness due to menstruation No other history of diseases
A small amount of bleeding that lasts for 10 days
28 0-0-1-0 Irregular bleeding Most recent menstruation was 3 months ago Menstrual cycle of 24–50 days; irregular and unpredictable Hard to predict
Menarche at age 13 years Menstrual cycle used to be regular (30 days) Endometrial thickness of 5 mm No abnormalities found in the uterus or ovaries Except for slight menstrual pain, there are no other symptoms The patient has a boyfriend and no particular method of contraception is being used No unusual medical diseases or history of surgery
Menarche at age 13 years Menstrual cycle has typically been irregular Endometrial thickness of 8 mm Ovaries appear polycystic Her mother has type 2 diabetes BMI of 28 Physical examination reveals extensive facial hair accompanied with acne No other particular disease history
U
t1:4 t1:5 t1:6 t1:7 t1:8
t1:13 t1:14
36 (36) 64 (64)
t2:3
O
87 88
C
85 86
N
83 84
13 (13) 40 (40) 47 (47)
F
114
Most of the 100 respondents were aged 40 years or older and had more than 15 years of clinical experience (Table 2). Almost two-thirds were based in a clinic (Table 2). Overall, 60% of respondents were unfamiliar with the FIGO classification; only 2% were actively applying the classification system in practice (Table 3). Among the 40 respondents who were aware of
81 82
58 (58) 42 (42)
O
109
80
No. (%)
Sex Male Female Age, y b40 40–49 ≥50 Type of practice General hospital or hospital Clinic Area Seoul (metropolitan) Other Subspecialty Yes No Time in practice, y b15 ≥15
R O
3. Results
78 79
Demographic characteristic
P
108
76 77
t2:1 t2:2
Table 2 Demographic characteristics of respondents (n = 100).
T
107
sampling error in a 95% confidence interval and an 8.13% sampling error in a 90% confidence interval. The study was approved by the Institutional Review Board for Clinical Research at Samsung Medical Center, Seoul, South Korea. Informed consent was obtained from study participants. To develop the questionnaire for the survey, an expert group of eight specialists was organized, consisting of faculty members of a tertiary general hospital who were selected on the basis of their experience in treating patients with AUB. Experts were interviewed by a professional interviewer to identify the overall AUB course management, from diagnosis to treatment and follow-up, and to understand the variation in treatment course among AUB types. On the basis of the results of this qualitative study, members of the expert group developed the questionnaire to be used for quantitative research. A synopsis of three typical AUB cases was established: heavy menstrual bleeding (HMB, case 1), intermenstrual bleeding (IMB, case 2), and polycystic ovary syndrome (PCOS, case 3) (Table 1). Once the draft questionnaire was developed, pilot interviews were performed with two specialists to verify the logic of the questionnaire and its contents. Feedback from the pilot interviews was reflected in the final version of the questionnaire. Practical patterns for AUB management were assessed using the case synopsis questionnaire. Clinicians were asked to choose their top three preferred treatment options for each clinical case. An interviewer was physically present to administer the survey and to assist the respondent in completing the survey. The face-to-face interview followed a standardized script without deviation. Each respondent was asked identical questions following the same logic and order. Interviewers were not allowed to change the order of the questions or revise the questions according to their own judgment. All statistical analyses were performed using R i386 version 2.15.3 (http://www.r-project.org/). P b 0.05 was deemed statistically significant. For statistical verification of the differences between variables, the χ2 test was used to analyze differences in the response rate among the groups and the t test or analysis of variance were used to evaluate differences in the mean of numeric answers among variables/groups.
D
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J.Y. Lee et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
E
2
Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters). a Values are shown as number of full-term deliveries, number of preterm deliveries, number of spontaneous/induced abortions, and number of live children.
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136
J.Y. Lee et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 3 Level of awareness of the FIGO classification system for abnormal uterine bleeding (n =
t3:3
100).
t3:4
Variables
t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18
Awareness of the FIGO classification system First time hearing of it Don’t know any details, but aware that it exists Aware of the specifications, but have not applied it in practice Currently applying it in practice Information source for FIGO classification (n = 40) Medical society meetings and seminars Medical journals Colleagues Importance of standardizing abnormal uterine bleeding terminology Very necessary Necessary Neutral Unnecessary
t3:19
Abbreviation: FIGO, International Federation of Gynecology and Obstetrics.
137 138
151
Similar preferences in the treatment of irregular IMB (case 2) were observed. The top three first-line drug choices were COCs, oral estrogen, and oral progestin (Table 5). The likelihood of choosing COCs as a firstline treatment for IMB varied by type of practice: 27 (75%) of the 36 respondents from general hospitals reported they would select COCs compared with 29 (45%) of 64 physicians from clinics (P = 0.0041). Follow-up was similar to that for HMB (Table 6). The most common first-line treatments chosen for irregular bleeding associated with PCOS (case 3) were COCs, progestin injection, and oral progestin (Table 5). The preferred treatment for bleeding due to PCOS did not differ by type of practice or years in practice (data not shown). Regular prescription of COCs was the preferred follow-up treatment in the PCOS case (Table 6). The proportion of respondents who would track the patient’s bleeding pattern without any use of medication was lower than that for HMB and IMB (Table 6).
152
4. Discussion
153
Despite the need for a universal system of AUB classification to prevent the misinterpretation of clinical studies or miscommunication among clinicians and between clinicians and patients, many physicians in the present study (60%) were unaware of the recent release of the new FIGO classification system and its potential usefulness, with only 2% of respondents applying the FIGO system in current clinical practice. Most clinicians agreed that there was a distinct need for standardization of AUB terminology as well as for widespread education on the matter. Considering that 85% of the respondents who were aware of the AUB system first received this information at society meetings or seminars, efforts should be made to introduce the new classification system through various continuing education programs. Further, national
154 155 156 157 158 159 160 161 162 163 164
t4:1 t4:2
Heavy menstrual bleeding
Intermenstrual bleeding
Polycystic ovary syndrome
t5:3
Combined oral contraceptives Oral progestin Oral estrogen Progestin injection Non-steroidal anti-inflammatory drugs Levonorgestrel intrauterine system Estrogen injection Surgical methods (e.g. dilation and curettage, endometrial ablation) Tranexamic acid Other
55 (55) 13 (13) 11 (11) 7 (7) 5 (5) 3 (3) 2 (2) 2 (2)
56 (56) 13 (13) 14 (14) 7 (7) 5 (5) 0 2 (2) 0
56 (56) 14 (14) 4 (4) 16 (16) 1 (1) 0 0 4 (4)
0 3 (3)
0 5 (5)
t5:4 t5:5 t5:6 t5:7 t5:8 t5:9 t5:10 t5:11 t5:12 t5:13 t5:14
1 (1) 1 (1)
t5:15
Values are given as number (percentage).
O
a
165 166
Table 6 Follow-up (n = 100).a
t6:1 t6:2
D
P
R O
societies should play a greater part in disseminating new information and providing continuous medical education to ensure reinforcement. Laboratory assessment for AUB usually includes a pregnancy test, complete blood count, thyroid-stimulating hormone, and/or cervical cancer screening, but decisions regarding specific tests should be based on clinical findings [6]. According to various guidelines, pelvic ultrasonography is not a first-line diagnostic tool [5]. However, nearly all respondents stated that they would perform pelvic ultrasonography when investigating AUB for various reasons, whereas endometrial biopsy was infrequently selected. This finding could be associated with the high accessibility of specialist medical services and their relatively low cost in South Korea. COCs were the preferred first-line treatment for HMB, IMB, and PCOS among the respondents. Although South Korea has one of the lowest preferences for COCs as a form of contraception [10], their use for treatment purposes is as widely accepted as it is in other countries. LNG-IUS was not included in the top three first-line treatment modalities in any of the cases, despite it being highly effective in the treatment of HMB. LNG-IUS is an attractive option, particularly for younger women, since it is cost-effective, reversible, and fertility preserving [11]; further, it can be considered for all age groups [7]. Despite evidence that LNG-IUS is an important and cost-effective alternative to surgical management for HMB [12], it is likely that the respondents preferred less invasive oral or injectable progestin treatments over LNG-IUS because the cases described young women who were likely to desire a pregnancy in the near future. Tranexamic acid is also effective in the treatment of HMB and, along with COCs, is recommended if LNG-IUS is not used. However, only 1% of respondents reported the use of tranexamic acid, indicating their possible unfamiliarity with recent guidelines. Treatment continuation is recommended for AUB because it tends to be persistent and recurrent. Indeed, the main objectives of AUB management are the reduction of recurrence in subsequent cycles and control of the current bleeding episode [13]. Nevertheless, many physicians in the present survey did not choose to prescribe medication
E
T
C
149 150
E
147 148
32 (32) 36 (36) 11 (11) 21 (21)
R
145 146
34 (85) 3 (8) 3 (8)
R
143 144
60 (60) 31 (31) 7 (9) 2 (2)
N C O
141 142
Treatment No. (%)
U
139 140
t5:1 t5:2
Table 5 Initial treatment (n = 100).a
F
t3:1 t3:2
3
167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199
Table 4 Diagnostic tests (n = 100).
t4:3
Test
No. (%)
t4:4 t4:5 t4:6 t4:7 t4:8 t4:9 t4:10 t4:11 t4:12 t4:13 t4:14 t4:15
Ultrasonography Pregnancy test Cervical smear Complete blood count Coagulation test Prolactin Levels of thyroid-stimulating hormone Endometrial biopsy Hormone tests, including levels of luteinizing hormone, follicle-stimulating hormone, and estradiol Liver function test Test for sexually transmitted infections
99 (99) 59 (59) 49 (49) 17 (17) 5 (5) 5 (5) 5 (5) 3 (3) 3 (3) 2 (2) 1 (1)
Follow-up No medication Combined oral contraceptives Progestin Levonorgestrel intrauterine system Other No follow-up a
Heavy menstrual bleeding
Intermenstrual bleeding
Polycystic ovary syndrome
t6:3
72 (72) 38 (53) 30 (42) 3 (4) 1 (1) 0 28 (28)
65 (65) 39 (60) 24 (37) 1 (2) 1 (2) 0 35 (35)
82 (82) 24 (29) 51 (62) 5 (6) 0 2 (2) 18 (18)
t6:4 t6:5 t6:6 t6:7 t6:8 t6:9 t6:10
Values are given as number (percentage).
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
t6:11
231
References
232 233 234 235 236 237 276
C
223 224
[1] Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med 2011;29(5):383–90. [2] Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health 1996;86(2):195–9.
E
221 222
R
219 220
R
217 218
O
215 216
C
213 214
N
211 212
U
209 210
F
229 230
This article was written on the basis of the results of an advisory board meeting by Bayer HealthCare. All authors have been symposium speakers and advisory board members of, and received honoraria and consulting fees from, Bayer HealthCare.
207 208
O
227 228
206
R O
Conflict of interest
204 205
P
226
202 203
[3] Fraser IS, Critchley HO, Munro MG, Broder M, Writing Group for this Menstrual Agreement Process. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril 2007;87(3):466–76. [4] Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol 2012;207(4):259–65. [5] Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011; 113(1):3–13. [6] Committee on Practice Bulletins–Gynecology. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012; 120(1):197–206. [7] Committee on Practice Bulletins–Gynecology. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013;122(1):176–85. [8] Matteson KA, Anderson BL, Pinto SB, Lopes V, Schulkin J, Clark MA. Practice patterns and attitudes about treating abnormal uterine bleeding: a national survey of obstetricians and gynecologists. Am J Obstet Gynecol 2011;205(4):321.e1–8. [9] Park S, Farquhar CM. A survey of practice preferences and attitudes to the New Zealand Guidelines for the Management of Heavy Menstrual Bleeding. Aust N Z J Obstet Gynaecol 2002;42(4):374–8. [10] Lee DY, Koo YA, Yoon BK, Choi D. Reproductive health characteristics of urban South Korean women. Gynecol Obstet Invest 2010;70(3):154–9. [11] de Souza SS, Camargos AF, de Rezende CP, Pereira FA, Araujo CA, Silva Filho AL. A randomized prospective trial comparing the levonorgestrel-releasing intrauterine system with thermal balloon ablation for the treatment of heavy menstrual bleeding. Contraception 2010;81(3):226–31. [12] Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005;4: CD002126. [13] American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013;121(4):891–6. [14] Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, Petraglia F. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynecol Obstet 2015;128(3):196–200.
T
225
to prevent recurrence of AUB, and some did not recommend follow-up after the cessation of bleeding. Thus, a greater level of focus on the longterm treatment of AUB patients is needed. In a recent European survey [14], nearly two-thirds of women with confirmed HMB were diagnosed with iron deficiency, but only half received appropriate medication. Although questions about specific tests and use of iron supplementation in women with HMB were not included in the current survey, it is likely that many women with HMB have iron deficiency in South Korea. In this context, greater attention should be focused on the management of HMB. The performance of face-to-face interviews using a structured questionnaire represents a major strength of the present study. To minimize deviation among interviewers, each interview was strictly conducted following the structured questionnaire. Because the interviewer elicited and recorded the data, issues regarding missing data, unclear markings, and illegible handwriting were eliminated. Thus, errors associated with misunderstandings were minimized. Although face-to-face interviews are time-consuming and cost-prohibitive, they have great advantages in terms of data quality and response rates. The small number of respondents is a limitation of the present study, and selection bias could have affected the choice of candidates for interviews. In conclusion, the present survey provides insight regarding awareness of the new FIGO classification system and AUB management patterns in South Korea. The study indicated that, despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low.
D
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E
4
Please cite this article as: Lee JY, et al, A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.034
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