Strength of Evidence for Major Management Recommendations
| Recommendation | Strength of Recommendation* |
|---|---|
| TSH. Obtain a thyroid-stimulating hormone (TSH) serum level in women with irregular bleeding or menorrhagia.69–73 | B |
| Age 35. Obtain an endometrial biopsy in women over age 35 with irregular bleeding.2,74 | B |
| Unopposed estrogen. Obtain an endometrial biopsy in women with prolonged unopposed estrogen regardless of age (most commonly, a woman with polycystic ovary syndrome (PCOS) with few or no periods for more than 2 years).2,75 | C |
| Transvaginal ultrasound. Consider transvaginal ultrasound or saline-infused sonohysterogram for perimenopausal women with irregular bleeding.4,54,76 | C |
| Hormonal therapy for irregular bleeding. Offer oral contraceptives or a progestin for cycle regulation in women with irregular bleeding, after ruling out structural causes, systemic causes, and contraindications to the oral contraceptive.2,8,77 | B |
| Hormonal therapy for menorrhagia. Offer oral contraceptives or a progestin to decrease bleeding in women with menorrhagia after ruling out structural causes, systemic causes, and contraindications to the oral contraceptive.8,10,13,77–79 | B |
| Nonsteroidal anti-inflammatory drugs for menorrhagia. Offer nonsteroidal anti-inflammatory drugs for women with menorrhagia, after ruling out structural causes and systemic causes.60,61 | B |
* Strength of recommendation classified according to the 3-component SORT system80: A, recommendation based on consistent and good-quality patient-oriented evidence80; B, recommendation based on inconsistent or limited quality patient-oriented evidence80; C, recommendation based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.80