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 Aug 2002 Version: Date:
 Prof Malcolm Munro Reviewer:
 A paper of limited interest Level of interest:
 Reject Advice on publication:
This paper is one of two apparently submitted for publication. It is unfortunate that I was not sent the 
second paper to allow evaluation of this one in the context of both. The investigation is a survey of rural 
and isolated family practitioners from Northern Ontario who were asked to provide demographical information and information regarding their management of a clinical case submitted as part of the 
survey document. Although the survey document is described, we do not see it's content with the 
exception of the case scenario. 
Comments 
The process is a useful one but I have a number of reservations. If one is to undertake such an 
endeavor it seems important that there be some consensus regarding the appropriateness of the 
answers. This requires some evidence based, where available, opinion based where not, notion of what
the answers should be. I do not see this in this report. Furthermore, the single case provided does not seem to me to give enough information regarding the breadth and depth of knowledge and ability of 
these practitioners. 
References 
First of all, the references are not uniformly of high quality. For example, in referencing hysterectomy 
rates, #1 is from an article in the Tampa tribune, for me, an unacceptable source in a peer reviewed 
paper. In addition, there exist a number of sources of evidence, and contemporary evidence-based guidelines, including those specifically designed for family practitioners, that are not included in the references that were used to judge the respondant's answers. The author's use reference #10 to 
support the notion that transvaginal ultrasound is neither sensitive or specific for the identification of 
patients with endometrial hyperplasia or carcinoma. However, this is an indirect reference from a policy statement, and does not necessarily reflect currently available evidence. This type of an approach to 
referencing, which is more than a little lazy, is prone to promote opinions and misinterpretations instead 
of the evidence as it is. 
Methods 
Without the survey instrument, I do not know whether or not the survey asked open-ended questions or 
multiple choice questions, an imiportant distinction. With respect to the evaluation of the responses, it 
seems that the tenor of the author's comments indicates adherance to diagnostic and therapeutic 
paradigms that may be biased. For example, where is their evidence that subclinical hypothyroidism 
causes cyclical heavy menstrual bleeding? They won'e find it. Or, there is an argument that a woman 
with a recent (3 year ago) full term pregnancy, and cyclic menses is at such low risk for endometrial 
neoplasia/hyperplasia that endometrial biopsy is unnecessary, and that the best and most rewarding 
technique would be sonohysterography (saline infusion sonography) or hysteroscopy. If practitioners 
believed this, then it might be most appropriate to refer such a patient to a gynecologist. The authors 
might have obtained more useful information if they presented a number of patients, including a patient 
without a myoma, when medical therapy would (likely) be clearly the most appropriate initial step. Then 
they would glean understanding into the management of specific AUB scenarios, rather than trying to 
get all the information from a single case in which there are genuine differences in opinion regarding 
appropriate management for a primary care provider. 
Interpretation 
There are some useful interpretative statements. But the crux of this paper is the appropriateness with 
respect to investigations and interventions. The weaknesses described above undermine the interpretation significantly. 
In conclusion, while the intent is noble, in my opinion, this paper should not be published. Instead, I 
would ask the authors to redo the survey instrument with appropriate input from those with interest and 
ability in the issues that surround the investigation and management of Abnormal Uterine Bleeding. 
Competing interests:
None declared.