2. دکتر مریم هاشمی
15 دی ماه 1392 – تالار زیتون

3. vaginitis

4.  Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Symptoms include vaginal discharge, odor, .pruritus, and/or discomfort
The most common causes of vaginal discharge, odor, pruritus, and/or discomfort are bacterial vaginosis, candida vulvovaginitis, and trichomoniasis. These disorders account for over 90 percent of cases.
Less common causes of these symptoms include vaginal atrophy/atrophic vaginitis, cervicitis, foreign body, irritants and allergens, and several rarer entities, including some .systemic medical disorders

5. PATHOGENESIS  
The nonkeratinized stratified squamous epithelium of the vagina in premenopausal women is rich in glycogen. Glycogen from sloughed cells is the substrate for Döderlein's lactobacilli, which convert glucose into lactic acid, thereby creating an acidic vaginal environment (pH 4.0 to 4.5). This acidity helps maintain the normal vaginal flora and inhibits growth of pathogenic organisms. Disruption of the normal ecosystem can lead to conditions favorable for development of vaginitis. Some of these potentially disruptive factors include phase of the menstrual cycle, sexual activity, contraceptive choice, pregnancy, foreign bodies, estrogen level, sexually transmitted diseases, and use of hygienic products or antibiotics

6. PATIENT PRESENTATION 
Women with vaginitis typically present with one or more of the following vulvovaginal symptoms:
●Change in the volume, color, or odor of vaginal discharge
●Pruritus
●Burning
●Irritation
●Erythema
●Dyspareunia
●Spotting
●Dysuria

7. Vaginal discharge is a prominent symptom of vaginitis, but may be difficult to distinguish from normal vaginal discharge.
In reproductive aged women, normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent, thick or thin, and mostly odorless.
This physiologic discharge is formed by mucoid endocervical secretions in combination with sloughing epithelial cells, normal vaginal flora, and vaginal transudate

8. GENERAL PRINCIPLES
 Empiric therapy based on history and physical examination alone should be avoided because of frequent misdiagnosis and inappropriate therapy.
However, 25 to 40 percent of patients with genital symptoms do not have a specific cause identified after initial diagnostic testing.
The three main steps in the evaluation of women with symptoms of vaginitis are:
●Obtain a history and perform a physical examination
●Test for bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis since these disorders account for over 90 percent of vaginitis in premenopausal women and can be diagnosed by pH testing, microscopy, and/or culture (or rapid antigen and nucleic acid amplification test].
●If this evaluation does not lead to a diagnosis, then evaluate for less common and rare causes of vaginitis.
Patients who continue to exhibit symptoms and/or have positive tests for sexually transmitted infections after treatment are most likely to have been re-infected by their sexual partner

9. Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age, accounting for 40 to 50 percent of cases.
The absence of inflammation is the basis for the term "vaginosis" rather than "vaginitis."
Bacterial vaginosis (BV) represents a complex change in the vaginal flora characterized by a reduction in concentration of the normally dominant hydrogen-peroxide producing lactobacilli and an increase in concentration of other organisms, especially anaerobic gram negative rods .The major bacteria detected are Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, and Mobiluncus species. Fusobacterium species and Atopobium vaginae are also common

10. RISK FACTORS BV is highly prevalent (25 to 50 percent) in women who
 Sexual activity is a risk factor for bacterial vaginosis (BV)
BV is highly prevalent (25 to 50 percent) in women who
have sex with women (WSW)
Douching and cigarette smoking
Use of condoms and estrogen-containing contraceptives may be protective factors

11. CLINICAL FEATURES 
Fifty to 75 percent of women with bacterial vaginosis (BV) are asymptomatic .
Symptomatic women typically present with vaginal discharge and/or vaginal odor .The discharge is off-white, thin, and homogeneous; the odor is an unpleasant "fishy smell" that may be more noticeable after sexual intercourse and during menses .
BV alone does not cause dysuria, dyspareunia, pruritus, burning, or vaginal inflammation (erythema, edema) .The presence of these symptoms suggests mixed vaginitis (symptoms due to two pathogens)
Although BV does not involve the cervix, the disorder may be associated with acute cervicitis (endocervical mucopurulent discharge or easily induced cervical bleeding)

12. DIAGNOSIS 
Amsel criteria 
 The diagnosis of BV is usually based on Amsel criteria, which are simple and useful in an office practice where microscopy is available .
The first three findings are sometimes also present in patients with trichomoniasis .
Amsel criteria for diagnosis of BV (at least three criteria must be present):
●Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
●Vaginal pH >4.5
●Positive whiff-amine test, defined as the presence of a fishy odor when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge
●Clue cells on saline wet mount . For a positive result, at least 20 percent of the epithelial cells on wet mount should be clue cells. The presence of clue cells diagnosed by an experienced microscopist is the single most reliable predictor of BV

13. Gram's stain Cytology Culture is mostly performed in research studies
 Gram’s stain of vaginal discharge is the gold standard for diagnosis of BV but
is mostly performed in research studies
Cytology   
The Papanicolaou smear is not reliable for diagnosis of BV.
If a cytology smear suggests BV (ie, shift in flora from predominantly lactobacilli to predominantly coccobacilli with or without clue cells), the patient should be asked about symptoms, and if symptomatic, she should undergo standard diagnostic testing for BV and treatment, if appropriate.
Treatment of asymptomatic women is not routinely indicated
Culture 
 Because BV represents complex changes in the vaginal flora, vaginal culture has no role in diagnosis

14. TREATMENT 
Bacterial vaginosis (BV) resolves spontaneously in up to one-third of
nonpregnant and one-half of pregnant women.
Treatment is indicated for relief of symptoms in women with symptomatic infection and to prevent postoperative infection in those with asymptomatic
infection prior to abortion or hysterectomy .
Treatment of BV may also reduce the risk of acquiringSTDs , including HIV. For this reason, some experts support the concept of treating all women with BV regardless of presence or absence of symptoms; however, we agree withCDC recommendations to not treat asymptomatic women.
Asymptomatic pregnant women with previous preterm births may also benefit, but screening and treatment of these women is controversial

15. Nonpregnant women
Drugs — Metronidazole or clindamycin administered either orally or intravaginally .
Oral medication is more convenient, but associated with a higher rate of systemic side effects than vaginal administration.
 Tinidazole is a reasonable oral alternative.
Metronidazole — The efficacy of metronidazole has been established. The oral regimen we recommend is 500 mg twice daily for seven days.
Treatment with a single oral dose of 2 grams of metronidazole has lower efficacy and is no longer recommended for treatment of BV. Alcohol should not be consumed during therapy and for one day after completion of therapy.

16. Vaginal therapy with 0.75 percent metronidazole gel 5 grams once daily for five days is as effective as oral metronidazole (5 grams of gel contains 37.5 mg of metronidazole) .The choice of oral versus vaginal therapy should depend upon patient preference.
Side effects of metronidazole include a metallic taste, nausea (in 10 percent of patients), transient neutropenia (7.5 percent), a disulfiram-like effect with alcohol, prolongation of INR in patients taking vitamin K antagonists (eg, warfarin), and peripheral neuropathy.
Gastrointestinal side effects are less common with vaginal administration .Allergy to metronidazole is uncommon; it manifests as rash, urticaria, pruritus, and rarely, anaphylaxis, which can be successfully treated by oral desensitization

17. Clindamycin 
 The preferred regimen is a seven-day course of 2 percent clindamycin cream vaginally (5 grams of cream containing 100 mg of clindamycin phosphate), but may be less effective than the metronidazole regimens
Alternative regimens include oral clindamycin (300 mg twice daily for seven
days) or clindamycin ovules (100 mg intravaginally once daily for three days.
Intravaginal clindamycin therapy has been associated with an increased prevalence of clindamycin resistant anaerobic bacteria in the vagina posttreatment .
This effect persisted in most women for at least 90 days after clindamycin treatment. In contrast, increased resistance to metronidazole was not observed in women treated with that drug.
Clindamycin cream should not be used concurrently with latex condoms, which may be weakened.
Pseudomembranous colitis has been reported with both oral and topical clindamycin.

18. Tinidazole 
 Tinidazole is a second generation nitroimidazole. It has a longer half-life than metronidazole (12 to 14 hours versus 6 to 7 hours) and fewer side effects.
a single dose regimen appears to be as effective as vaginal clindamycin cream

19. Probiotics 
 Probiotics (live microorganisms which confer a health benefit on the host when administered in adequate amounts) have been used alone and as adjunctive therapy to antibiotics for treatment of BV and prevention of relapse
In the United States, the content of these products is not standardized and often of poor quality

20. Less effective and ineffective therapies
Triple-sulfa creams, erythromycin, tetracycline, ampicillin, amoxicillin, lactic acid gel, acetic acid gel, ascorbic acid, azithromycin, chlorhexidine, hydrogen peroxide, and povidone-iodine vaginal douches are significantly less effective than metronidazole and clindamycin and should not be used

21. We suggest symptomatic relapse be treated initially with a seven-day course of oral or vaginal metronidazole or clindamycin. The treatment regimen may be the same or different from the initial or previous treatment regimen.
We believe any patient with more than three documented episodes of BV in the previous 12 months should be offered a long-term maintenance regimen consisting of maintenance metronidazole gel.
Long-term clindamycin regimens, oral or topical, are not advised because of toxicity and lack of documented efficacy .
Accordingly, if any of the aforementioned antimicrobials fail, we prescribe metronidazole gel 0.75 percent or an oral nitroimidazole for 7 to 10 days followed by twice weekly dosing of gel for four to six months .Secondary vaginal candidiasis was a common side effect.

22. Pregnant women
Symptomatic BV infection — All women with symptomatic BV should be treated to relieve bothersome symptoms. Oral treatment is effective and has not been associated with adverse fetal or obstetrical effects. The therapeutic options include:
●Metronidazole 500 mg orally twice daily for 7 days
●Metronidazole 250 mg orally 3 times daily for 7 days
●Clindamycin 300 mg orally twice daily for 7 days
Some clinicians avoid use of metronidazole in the first trimester because it crosses the placenta, and thus has a potential for teratogenicity. However, meta-analysis has not found any relationship between metronidazole exposure during the first trimester of pregnancy and birth defects , and the CDC no longer discourage the use of metronidazole in the first trimester . An additional concern is that the drug is mutagenic in bacteria and carcinogenic in mice, but there is no evidence of harm in humans.

23. It is the second most common cause of vaginitis symptoms (after bacterial vaginosis) and accounts for approximately one-third of vaginitis cases. 
Identification of vulvovaginal Candida is not necessarily indicative of candidal disease, as the diagnosis of vulvovaginitis requires the presence of vulvovaginal inflammation. 
MICROBIOLOGY — Candida albicans is responsible for 80 to 92 percent of episodes of vulvovaginal candidiasis and C. glabrata accounts for almost all of the remainder

24. RISK FACTORS 
 Sporadic attacks of vulvovaginal candidiasis usually occur without an identifiable precipitating factor. Nevertheless, a number of factors predispose to symptomatic infection :
●Diabetes mellitus — Women with diabetes mellitus who have poor glycemic control are more prone to vulvovaginal candidiasis than euglycemic women .In particular, women with Type 2 diabetes appear prone to non-albicans Candida species.
●Antibiotic use — Use of broad spectrum antibiotics significantly increases the risk of developing vulvovaginal candidiasis. As many as one-quarter to one-third of women develop the disorder during or after taking these antibiotics because inhibition of normal bacterial flora favors growth of potential fungal pathogens, such as Candida. Administration of lactobacillus (oral or vaginal) during and for four days after antibiotic therapy does not prevent postantibiotic vulvovaginitis .
●Increased estrogen levels — Vulvovaginal candidiasis appears to occur more often in the setting of increased estrogen levels, such as oral contraceptive use (especially when estrogen dose is high), pregnancy, and estrogen therapy.
●Immunosuppression — Candidal infections are more common in immunosuppressed patients, such as those taking glucocorticoids or other immunosuppressive drugs, or with human immunodeficiency virus (HIV) infection

25. ●Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices have been associated with vulvovaginal candidiasis, but not consistently. Spermicides are not associated with Candida infection

26. TREATMENT 
Treatment is indicated for relief of symptoms. Ten to 20 percent of reproductive age women who harbor Candida species are asymptomatic; these women do not require therapy [56].
The treatment regimen is based on whether the woman has an uncomplicated infection (90 percent of patients) or complicated infection (10 percent of patients).
Uncomplicated infections usually respond to treatment within a couple of days. Complicated infections require a longer course of therapy and may take two weeks to fully resolve.
Treatment of sexual partners is unnecessary. There is no medical contraindication to sexual intercourse during treatment, but it may be uncomfortable until inflammation improves

27. Uncomplicated infection — Criteria for uncomplicated infection include all of the following:
●Sporadic, infrequent episodes (≤3 episodes/year)
●Mild to moderate signs/symptoms
●Probable infection with Candida albicans
●Healthy, nonpregnant woman
The absence of superiority of any formulation, agent, or route of administration suggests that cost, patient preference, and contraindications are the major considerations in the decision to
prescribe an anti-fungal for oral or topical administration
We suggest use of oral fluconazole, given that most women consider oral drugs more convenient than those applied intravaginally

28. Complicated infections — Characteristics of complicated infections include one or more of the following criteria :
●Severe signs/symptoms
●Candida species other than C. albicans, particularly C. glabrata
●Pregnancy, poorly controlled diabetes, immunosuppression, debilitation
●History of recurrent (≥4/year) culture-verified vulvovaginal candidiasis
we suggest fluconazole (150 mg orally) for two to three sequential doses 72 hours apart for treatment of complicated infections, depending on the severity of the infection
If the patient prefers topical therapy, observational series report that complicated patients require 7 to 14 days of topical azole therapy (eg, clotrimazole,miconazole, terconazole) rather than a one- to three-day course
For severe Candida vulvar inflammation (vulvitis), low potency topical corticosteroids can be applied to the vulva for 48 hours until the antifungals exert their effect

29. Pregnancy 
Treatment of pregnant women is primarily indicated for relief of symptoms.
Vaginal candidiasis is not associated with adverse pregnancy outcomes .
We suggest application of a topical imidazole .(clotrimazole or miconazole) vaginally for seven days
Administration of oral azoles during the first trimester is not recommended
Although treatment of vaginal candida colonization in healthy pregnant women is unnecessary, in Germany treatment is recommended in the third trimester because the rate of oral thrush and diaper dermatitis in mature healthy newborns is significantly reduced by maternal treatment

30. Recurrent infection
Attempts should be made to eliminate or reduce risk factors for infection if present (eg, improve glycemic control, switch to lower estrogen dose oral contraceptive)
we believe that the optimal therapy for recurrent vulvovaginal candidiasis in nonpregnant women consists of initial induction therapy withfluconazole 150 mg every 72 hours for three doses, followed by maintenance fluconazole therapy once per week for six months
Therapy is then discontinued, at which point some patients achieve a prolonged remission, while others relapse. A short-term relapse, with culture confirmation of the diagnosis, merits reinduction therapy with three doses of fluconazole, followed by repeat weekly maintenance fluconazole therapy, this time for one year

31. A minority of women persist in relapsing as soon as fluconazole maintenance is withdrawn (fluconazole dependent recurrent vulvovaginal candidiasis). Symptoms in these patients can be controlled by months or years of weekly fluconazole.
Given the safety profile of low dose fluconazole, most experts do not suggest any laboratory monitoring; however, if other oral imidazoles (ketoconazole,itraconazole) are used, particularly if taken daily, then monitoring liver function tests is recommended. Idiosyncratic hepatotoxicity secondary to ketoconazole therapy is a concern, but rare in this setting
Alternative approaches that have been suggested include:
●Treat each recurrent episode as an episode of uncomplicated infection
●Treat each recurrent episode with longer duration of therapy (eg, topical azole for 7 to 14 days or fluconazole 150 mg orally on day 1, day 4, and day 7)
●The Infectious Diseases Society of America (IDSA) recommends 10 to 14 days of induction therapy with a topical or oral azole, followed byfluconazole 150 mg once per week for six months (clotrimazole 200 mg vaginal cream twice weekly is a nonoral alternative

32. INTRODUCTION — Trichomoniasis is caused by the protozoan Trichomonas vaginalis.
It is the most common non-viral sexually transmitted disease (STD) worldwide.
Women are affected more often than men.
Trichomoniasis is one of the three major causes of vaginal complaints among reproductive aged women, along with bacterial vaginosis and candida vulvovaginitis [1], and a cause of urethritis in men; however, the infection is often asymptomatic

33. CLINICAL FEATURES Women
In women, trichomoniasis ranges from an asymptomatic carrier state to an acute, severe inflammatory disease.
As many as 50 percent of infected women are asymptomatic, although many of these women eventually become symptomatic. Asymptomatic carriage can persist for prolonged periods of time (at least three months), thus it is often not possible to ascertain when or from whom the infection was acquired .
Vaginitis — Common signs and symptoms of acute infection include a purulent, malodorous, thin discharge associated with burning, pruritus, dysuria, frequency, lower abdominal pain, or dyspareunia. Symptoms may be worse during menstruation. Postcoital bleeding can occur.
Physical examination often reveals erythema of the vulva and vaginal mucosa. The classically described green-yellow, frothy, malodorous discharge occurs in 10 to 30 percent of symptomatic women. Punctate hemorrhages may be visible on the vagina and cervix ("strawberry cervix" in 2 percent of cases).
In chronic infection, signs and symptoms are milder and may include pruritus and dyspareunia, with scanty vaginal secretion.

34. Men — In men, T. vaginalis infection is asymptomatic in over three-quarters of cases and often transient (spontaneous resolution within 10 days)
However, untreated infection can persist for months . Symptoms, when present, are the same as those for urethritis from any cause and consist of a clear or mucopurulent urethral discharge and/or dysuria.
They may also have mild pruritus or burning sensation in the penis after sexual intercourse

35. CONSEQUENCES
Women — Untreated trichomonal vaginitis may progress to urethritis or cystitis. In addition, T. vaginalis has been associated with a range of adverse reproductive health outcomes, including cervical neoplasia ,posthysterectomy cuff cellulitis or abscess ,atypical pelvic inflammatory disease in women infected with HIV ,and infertility .It may also increase women's susceptibility to HIV-1 infection by up to two-fold.
Men — T. Vaginalis in men has been associated with prostatitis, balanoposthitis, epididymitis, infertility, and prostate cancer

36. DIAGNOSIS
Women — The diagnosis of trichomonas is based on laboratory testing (motile trichomonads on wet mount, positive culture, positive nucleic acid amplification test, or positive rapid antigen or nucleic acid probe test).
As with other types of vaginitis, none of the clinical features of trichomoniasis is sufficiently sensitive or specific to allow a diagnosis based upon signs and symptoms alone

37. TREATMENT 
 Treatment is indicated for both symptomatic and asymptomatic women and men.
Treatment reduces the prevalence of T. vaginalis carriage in the population, relieves symptoms, and reduces the risk of sequelae (including acquisition/transmission of human immunodeficiency virus [HIV]).
The 5-nitroimidazole drugs (metronidazole or tinidazole) are the only class of drugs that provide curative therapy of trichomoniasis.
Patients should be instructed to avoid intercourse until they and their partners have completed treatment and are asymptomatic, which generally takes about a week.
Clinicians should also screen the patient for other STDs when she presents with trichomoniasis

38. Nonpregnant women
5-nitroimidazole drugs — The 5-nitroimidazole drugs (metronidazole or tinidazole) are the only class of drugs that provide curative therapy of trichomoniasis.
We recommend treatment with a single 2 gram oral dose of either tinidazole or metronidazole (ie, four 500 mg tablets)
An alternative multidose regimen is metronidazole 500 mg orally twice a day for seven days
Oral is preferred to vaginal therapy since systemic administration achieves higher drug levels and therapeutic drug levels in the urethra and periurethral glands, which serve as endogenous reservoirs of organisms that can cause recurrence
Patients should be advised to not consume alcohol for 24 hours after metronidazole treatment and for 72 hours after tinidazole treatment because of the possibility of a disulfiram-like (Antabuse effect) reaction

39. Allergy to 5-nitroimidazole drugs — Given the low efficacy of any drug other than the 5-nitroimidazole drugs (see '5-nitroimidazole drugs' above), we suggest patients with allergies to metronidazole or tinidazole be referred for desensitization rather than using an alternative class of drugs
Follow-up — Follow-up is unnecessary for women who become asymptomatic after treatment or who were initially asymptomatic, given the high efficacy of 5-nitroimidazole drugs
Sex partners — Treatment of sex partners is indicated because maximal cure rates in infected women are achieved when their sexual partners are treated simultaneousl

40. Pregnant women
Symptomatic pregnant women — Metronidazole is the drug of choice for treatment of symptomatic trichomoniasis in pregnancy. Some clinicians avoid its use in the first trimester because it crosses the placenta, thus there is a potential for teratogenicity. The drug is mutagenic in bacteria and carcinogenic in mice; however, these effects have never been observed in humans.
Asymptomatic pregnant women — We suggest not treating asymptomatic infections during pregnancy because randomized trials have found that it does not prevent, and in some trials even increased, the risk of preterm delivery
Sex partners — Treatment of sexual partners is indicated. In cases where an asymptomatic pregnant woman is not treated, reinfection of the treated partner can be minimized by avoidance of sexual intercourse or use of condoms

41. Uterine fibroids

42. Common
25-30% of women over 35
Often asymtomatic
Incidentally detected on pelvic ultrasound

43. Symptoms related to fibroids:
menorrhagia
irregular menstruation (only for submucosal fibroids)
urinary (frequency, retention)
abdominal distention

44. How to follow up asymptomatic fibroids?
Ultrasound?
Usually no needed
Check symptoms and uterine size clinically every 6 months or ask patient to return if symptomatic

45. Post-myomectomy follow up: fibroids can recur after myomectomy
advice for pregnancy?
When?
Caesarean delivery needed?

46. Asymptomatic women Postmenopausal women
●We suggest expectant management of asymptomatic women, except in the case of a woman with moderate or severe hydronephrosis or a woman with a hysteroscopically-resectable submucous leiomyoma who is
pursuing pregnancy .
Postmenopausal women
●In the absence of postmenopausal hormonal therapy, leiomyomas generally become smaller and asymptomatic in postmenopausal women; therefore, intervention is not usually indicated.
We suggest evaluation to exclude sarcoma in a postmenopausal woman with a new or enlarging pelvic mass .The incidence of sarcoma is 1 to 2 percent in women with a new or enlarging pelvic mass, abnormal uterine bleeding, and pelvic pain.

47. Submucosal leiomyomas
●We recommend hysteroscopic myomectomy for women with appropriate submucosal leiomyomas that are symptomatic (eg, bleeding, miscarriage).This procedure allows future childbearing, usually without compromising the integrity of the myometrium, but is also an appropriate option in women who have completed childbearing since it is minimally invasive.
Abdominal myomectomy is performed in women with significant symptoms and a submucous leiomyoma(s) not amenable to hysteroscopic resection.

48. Women who desire fertility
Premenopausal women
Women who desire fertility
●We recommend abdominal myomectomy for treatment of symptomatic intramural and subserosal leiomyomas in women who wish to preserve their childbearing potential and who have no major contraindications to a surgical approach.
Hysteroscopic myomectomy is the preferred approach to submucosal leiomyomas. .

49. Laparoscopic myomectomy is an option for women with a uterus less than 17 weeks' size or with a small number of subserosal or intramural leiomyomas. Future childbearing is possible; however, the integrity of the uterine incision during pregnancy has not been evaluated adequately and may be inferior to abdominal myomectomy.
Due to reports of uterine rupture in pregnancy following some laparoscopic myomectomies, surgeons should discuss the risks and benefits of each option with patients, including possible risk of uterine rupture, as well as provide information regarding their experience with laparoscopic suturing.

50. Women who do not desire fertility
●Hysterectomy is the definitive procedure for relief of symptoms and prevention of recurrent leiomyoma-related problems. We suggest use of GnRH agonists prior to a potentially complicated hysterectomy (or myomectomy) if the surgeon feels reduction in uterine/myoma volume will significantly facilitate the procedure or if there is significant anemia which has not responded to iron therapy.
●For women with abnormal uterine bleeding related to leiomyomas who wish to undergo the least invasive procedure, we suggest a trial of placement of a levonorgestrel-releasing intrauterine contraception over other drug therapies .

51. ●Several more invasive options, both surgical and using interventional radiology, are available to symptomatic women (bleeding, pain, pressure) who have completed childbearing but wish to retain their uterus. There is no high quality evidence to recommend one procedure over another. Since fertility and pregnancy outcome may be adversely affected after many of these procedures, we suggest not performing these procedures (other than myomectomy) for women wishing to optimize future pregnancy.