Question: What is the evidence/ recommendation for a 35 year old with regular heavy periods with regards to having an ultrasound scan for investigating the bleeding?
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Answer: The National Institute for Health and Clinical Excellence (NICE) guideline on heavy menstrual bleeding published in 2007 notes that “Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.”
“Evidence shows that MRI has no advantage over ultrasound as a first-line investigation for HMB, but may be reserved for problem solving where ultrasound provides indeterminate results.
Evidence from two reviews shows that ultrasound is an accurate method for identifying pathology (sensitivity 48–100% and specificity 12–100%). Furthermore, studies show that ultrasound is better at identifying fibroids than hysteroscopy, but is less accurate for identifying polyps or endometrial disease when compared with hysteroscopy. However, it is associated with higher completion rates (88%) and greater acceptability (11% finding it ‘unpleasant’) with women than hysteroscopy (77% and 27%, respectively). Saline infusion sonography is an accurate method for identification of pathology, with a sensitivity of 85–100% and a specificity of 50–100%. One review found that for hysteroscopy the sensitivity was 90–97%, and the specificity was 62–93%.
Economic modelling for this guideline (Appendix A) showed that ultrasound is more accurate and less costly than the other imaging methods examined (hysteroscopy and saline infusion sonography).“
(Evidence level 1a)
The NHS Evidence Annual Evidence Update on Heavy Menstrual Bleeding - Examination and investigations for 2009 advises:
“A woman should be sent for an ultrasound investigation if:
- the uterus is palpable abdominally
- pelvic examination reveals a mass of uncertain origin
- medical treatment has failed.
It is very important that the person performing the scan is appropriately trained or misleading results may be obtained.”
References:
- Heavy menstrual bleeding. National Institute for Health and Clinical Excellence 2007
- The NHS Evidence Annual Evidence Update on Heavy Menstrual Bleeding
Search date: November 2009
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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