Reviewer's□report 
□Management□of□Abnormal□Uterine□Bleeding□by□Northern,□Rural□and□Isolated□Primary□Care□ Title: 
Physicians:□PART□I:□How□Are□We□Doing? 
Authors: 
Simone□N□Vigod□( simone.vigod@utoronto.ca )
Donna□E□Stewart□( donna.stewart@uhn.on.ca )
□1□ □5□Jul□2002 Version: Date: 
□Dr□George□Vilos Reviewer: 
□A□paper□whose□findings□are□important□to□those□with□closely□related□research□interests Level□of□interest: 
□Unable□to□decide□on□acceptance□or□rejection□until□the□authors□have□responded□ Advice□on□publication: 
to□the□compulsory□revisions 
RE:□Management□of□Abnormal□Uterine□Bleeding□by□Northern,□Rural□and□Isolated□Primary□Care□ 
Physicians:□PART□I:□How□are□we□doing?□ 
Page□3□under□BACKGROUND,□line□15,□change□to□read□as□"it□is□essential□that□family□doctors□are□ 
confident□in□providing□initial□investigation□and□treatment□for□women□who□present□with□abnormal□uterine□ 
bleeding".□ 
Clinical□Scenario□ 
This□patient□is□a□39□year□old□woman□with□a□three□month□cyclic□and□significant□menorrhagia□and□no□other□ 
significant□history.□The□issue□of□the□"8□week□pregnancy□fibroid"□is□confusing.□Does□this□mean□that□the□ 
fibroid□itself□is□equivalent□to□8□weeks□pregnancy□or□the□uterus□together□with□the□fibroid□is□compatible□with□ 
an□8□week□pregnancy?□ 
Given□the□above□scenario□the□physicians□were□correct□in□ordering□a□pelvic□ultrasound□(87.1%)□since□the□ 
patient□is□already□known□to□have□a□fibroid□and□the□bleeding□is□cyclic□of□only□three□months□duration.□ Cervical□and□endometrial□polyps□as□well□as□neoplastic□lesions□do□not□present□with□cyclic□bleeding□but□ 
rather□abnormal□irregular□bleeding.□ 
Endometrial□biopsy□was□not□indicated□in□this□patient□since□she□is□less□than□40□years□of□age□and□no□other□ 
risk□factors□for□neoplasia□were□identified.□ 
D&C□has□been□clearly□documented□to□be□of□diagnostic□but□not□therapeutic□value.□ 
Coagulation□profile□to□identify□coagulopathies□is□not□indicated□for□this□patient.□The□patients□with□ 
VonWillebrands□disease□present□with□long□standing□histories□of□abnormal□bruising,□post□partum□ 
hemorrhage□and□heavy□and□abnormal□bleeding□during□their□teenage□years.□ 
Thyroid□function□profile□is□indicated□in□the□presence□of□other□clinical□signs□and□symptoms.□ 
Although□medical□therapy□is□effective□in□the□treatment□of□abnormal□uterine□bleeding□at□all□ages□almost□ 
100%□of□the□patients□prior□to□age□of□40□opt□up□for□a□permanent□surgical□treatment□rather□than□continuing□ 
with□medical□treatment□for□the□next□10□to□15□years.□ 
Page□8,□Discussion,□third□line□from□the□bottom□ 
Current□Clinical□Practice□Guidelines□recommend□a□pelvic□exam□but□no□pelvic□exam□will□detect□all□cervical
and□definitely□none□of□the□intra-uterine□polyps□as□a□cause□of□abnormal□uterine□bleeding.□A□pelvic□exam□is 
recommended□to□visualize□the□cervix□and□palpate□pelvic□masses□that□may□be□fibroids□or□other□adnexal□ tumors.□ 
Page□9,□second□line□should□read□"pelvic□exam□training□and□identification□of□cervical□lesions□and□uterine□ 
fibroids□would□allow□further□specific□investigation□such□as□ultrasound□and□treatment□to□be□instituted□ 
earlier□for□affected□women□thereby□decreasing□the□need□for□extensive□and□unnecessary□investigations□ 
and□costs□to□the□patients□and□the□health□care□system".□ 
Page□9.□If□VonWillebrand□disease□is□found□in□17%□of□women□it□usually□declares□itself□in□the□teenage□ 
years.□ 
Page□10,□Line□15.□Change□women□to□woman.□ 
I□believe□the□objectives,□discussion□and□conclusions□of□this□paper□are□misleading□and□should□be□ 
reconsidered□and□rewritten□in□light□of□the□available□guidelines□and□current□evidence.□ 
Competing□interests: 
None□declared.