Objective
We sought to examine the practice patterns and attitudes of obstetricians and gynecologists surrounding treatment of abnormal uterine bleeding (AUB).
Study Design
We conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys, which were distributed using a sequential mixed method (both web- and mail-based) approach, included questions about practice characteristics, practice patterns, and knowledge about treatment options for AUB.
Results
Of 802 questionnaires, 417 were returned (52%). The most commonly selected first-line choice for AUB treatment was combined oral contraceptives (97% anovulatory, 98% ovulatory). The levonorgestrel intrauterine system was the next most frequently selected option (63% anovulatory, 53% ovulatory). Respondents did not score high on questions about the effectiveness of treatments for AUB. Only 25% (n = 86) answered at least 2 of the 3 questions correctly.
Conclusion
Continued education is necessary to increase the utilization of the most effective treatment options for AUB.
Menstrual disorders are the most common gynecologic conditions in the general population. Abnormal uterine bleeding (AUB) can mean both heavy and irregular menstrual bleeding, and many patients experience the combination of these symptoms. The substantial impact of AUB lies not only in its prevalence, but its affect on quality of life, associated loss of productivity, and major health care costs.
AUB contributes to approximately 400,000 hospitalizations and several times that number of ambulatory visits in the United States each year, and physicians encounter many challenges when delivering medical care to these women. The multiple etiologies of AUB, numerous available medical and surgical treatment options, and inconsistent measurement and reporting of treatment outcomes in studies contribute to the confusing nature of the body of literature on AUB. This has resulted in a body of literature that can be difficult to interpret and translate to clinical decision-making. Adding to those challenges, recent studies have highlighted major variations in how clinicians and researchers define the commonly accepted terminologies used to describe the clinical signs and causes of menstrual disorders. Clinical practice guidelines for the medical management of AUB have not been published in the United States, though guidelines from the United Kingdom and New Zealand are available.
Despite the prevalence of AUB and its significant impact on the quality of life of women, in the United States there is no standardized way of evaluating or treating women with this problem. The clinical guidelines published in other countries, which suggest a standardized way of treating women with AUB, are based on a comprehensive systematic review of the evidence on the relative effectiveness of each treatment option. This study was performed to examine the practice patterns and attitudes of obstetricians and gynecologists in the United States about medical treatment of women with AUB. We aimed to evaluate whether physicians were choosing the most effective treatment options for patients with AUB and their attitudes about the effectiveness of commonly used treatment options.
Materials and Methods
We conducted a cross-sectional survey of members of the American College of Obstetricians and Gynecologists (ACOG) from October 2008 through May 2009. The study was approved by the Women and Infants Hospital Institutional Review Board (no. 08-0093).
Questionnaires were sent to 802 ACOG members. In all, 602 recipients were members of the Collaborative Ambulatory Research Network (CARN), which is a group of practicing obstetrician-gynecologists who volunteer to participate in survey research. The other 200 recipients were randomly selected ACOG members who had not received a survey from ACOG in the previous 2 years. Other ACOG studies that surveyed both CARN members and a random sample of ACOG members have found that CARN members had been in practice longer than non-CARN members, but that there were no differences between groups in terms of distribution of responses to the survey questions. ACOG surveys typically achieve a 30-50% response rate; With at least 350 eligible responses, we would have the ability to detect at least a 15% difference in physician demographic characteristics with alpha 0.05 and power of 80%.
We distributed the surveys using a sequential mixed method approach; all potential participants with email addresses received a web-based version and then all potential participants without an email address or who did not respond to the web-based version received a mailed version. This approach has been described as a way to reduce nonresponse error, especially among web-based surveys. We showed in a previous analysis of this web-based survey that this sequential mixed method approach provided adequate representation and that web-based data collection was an appropriate approach for surveying obstetricians and gynecologists.
For the web-based version of the survey, we used DatStat Illume (DatStat Inc, Seattle, WA) and designed the web-based survey using standards suggested by Crawford et al. DatStat Illume, a sophisticated computer software package with excellent data security, allows for complex skip patterns. The content of the survey was the same for the web- and paper-based surveys and included multiple-choice questions about the physician and his/her practice, practice patterns for the evaluation and treatment of AUB, inquiries about the concepts that should be included in a comprehensive AUB questionnaire, and awareness of the evidence (as of the time of the survey) on medical treatment options for AUB. Practice patterns for the treatment of AUB were assessed using case scenarios ( Table 1 ). Respondents were asked to choose the top 3 treatment options they preferred for each clinical scenario. Questions evaluating awareness of the evidence on treatment options for AUB were based on Cochrane Collaboration reviews ( Table 1 ). Both the web- and the paper-based survey were reviewed by experts and critiqued by colleagues of the principal investigator. Initially, we conducted a pilot survey with 25 physicians at Women & Infants Hospital, Providence, RI. The questionnaire and protocol for participant contact were revised based on feedback from the pilot participants.
| CASE SCENARIOS a |
| The following 2 items refer to patients who DO NOT require emergency treatment of heavy menstrual bleeding. b Assume that the patient has no contraindications for any of the listed therapeutic options. c |
| (A) For a 30 year old patient who has heavy and REGULAR menstrual bleeding and who has tried no therapy yet, please select up to 3 of the following that you would most likely prescribe as your first line of treatment. |
| (B) For a 30 year old patient who has heavy and IRREGULAR menstrual bleeding and who has tried no therapy yet, please select up to 3 of the following that you would most likely prescribe as your first line of treatment. |
| The following item refers to patients who DO require emergency treatment of heavy menstrual bleeding. d |
| (C) Consider the following: a 38 year old cigarette smoker who has an episode of acute uterine bleeding and who has tried no therapy yet. Please select the top 3 treatments which you would consider giving to this patient. |
| ASSESSMENT OF AWARENESS OF THE EVIDENCE ON AUB TREATMENT OPTIONS |
| (1) A Cochrane review made what conclusion about treating ovulatory heavy menstrual bleeding with combined oral contraceptives. e |
| (2) A Cochrane review made what conclusion about treating ovulatory heavy menstrual bleeding with cyclic (14 days) of oral progestin. e |
| (3) The levonorgestrel intrauterine system is effective for the treatment of menorrhagia. f |
a For all case scenarios, respondents were asked to assume that the patient did not have endometrial hyperplasia or cancer;
b Respondents were instructed that emergency treatment of heavy menstrual bleeding is defined as a situation in which you feel a patient with acute heavy bleeding necessitates an emergency room evaluation, and/or hospital admission, and/or blood transfusion, and/or immediate medical or surgical intervention;
c Response options included combination estrogen-progestin therapy (pills, patch, ring) equivalent of once per day, danazol, estrogen (single agent), gonadotropin releasing hormone agonist, nonsteroidal antiinflammatory drugs, oral progestin once daily for 14 days/month, oral progestin once daily for 21 days/month, intramuscular progestin (depo-medroxyprogesterone acetate), levonorgestrel intrauterine system, dilation and curettage, endometrial ablation, hysterectomy;
d Response options for “emergency treatment” included all of the options listed above in “c” plus combination estrogen-progestin therapy equivalent to more than 1 pill per day, intrauterine balloon, and oral progestin equivalent to multiple doses daily;
e Response options included effective, NOT effective, there is not enough evidence to make a conclusion, unsure;
f Response options included true, false, there is not enough evidence to make a conclusion, unsure.
We followed principles of data collection recommended by Dillman to maximize response rate. First, prenotification letters of the survey were mailed (n = 802) ( Figure ). Ten days after the prenotification letter, all study participants with a valid email address were sent an email invitation to participate in the web-based survey, which included an embedded link to a page that explained informed consent and included an embedded link to the secure and confidential website for survey completion. Four email reminders were sent to nonresponders. For nonresponders to the web-based survey as well as physicians with an unavailable email address, a paper-based version of the survey was sent by mail 6 weeks after the prenotification letters.
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