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Appropriateness Criteria

Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hysteroscopic myomectomy Usually appropriate Strong N/A N/A 7 7 0 0 1 0 1 1 5 1 2
References Study Quality
11 (35216832) 2
10 (24303914) 2
9 (15760959) 1
8 (25172985) 4
7 (16603437) 1
6 (32726530) 4
5 (34877531) 1
4 (31678093) 2
3 (32532486) 3
Laparoscopic or open myomectomy Usually appropriate Strong N/A N/A 7 7 0 0 1 0 0 2 4 3 1
References Study Quality
4 (31678093) 2
12 (32192462) Good
11 (35216832) 2
13 (27393268) 1
14 (27896247) 4
Medical management Usually appropriate Strong N/A N/A 7 7 1 0 0 0 2 1 4 2 1
References Study Quality
32 (33567071) 2
31 (32748236) 3
30 (33715871) 1
29 (24630081) 1
28 (22296075) 1
27 (30969201) 1
26 (30303900) 1
25 (33596357) 1
24 (31468503) 1
23 (32459423) 1
22 (31971678) 1
21 (31594635) 1
20 (34711224) 1
19 (30303923) 1
18 (28579415) 1
17 (25516866) 4
16 (34011888) 4
MR-guided high-frequency focused ultrasound ablation Usually appropriate Strong N/A N/A 7 7 0 0 1 1 1 2 5 1 0
References Study Quality
41 (19013566) 4
40 (30217580) 2
39 (24075785) 2
38 (24998103) 2
37 (28421665) 1
36 (28063909) 1
35 (30696556) 1
34 (26658133) 1
33 (29628611) 4
Uterine artery embolization Usually appropriate Strong N/A N/A 7 7 0 0 1 0 0 2 6 1 1
References Study Quality
5 (34877531) 1
47 (17943348) 2
46 (28608747) 2
45 (34058169) 4
44 (27966042) 1
43 (33197612) Good
42 (23070101) 1
13 (27393268) 1
6 (32726530) 4
Laparoscopic uterine artery occlusion Usually not appropriate Limited N/A N/A 2 2 4 2 4 1 0 0 0 0 0
References Study Quality
15 (22526109) 2
Endometrial ablation Usually not appropriate Limited N/A N/A 1 1 7 1 3 0 0 0 0 0 0
References Study Quality
2 (28952185) Inadequate
Hysterectomy Usually not appropriate Expert Consensus N/A N/A 1 1 10 1 0 0 0 0 0 0 0
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Laparoscopic or open myomectomy Usually appropriate Strong N/A N/A 7 7 0 0 0 0 2 3 5 1 0
References Study Quality
4 (31678093) 2
12 (32192462) Good
13 (27393268) 1
Medical management Usually appropriate Strong N/A N/A 7 7 0 1 0 0 1 0 5 2 2
References Study Quality
32 (33567071) 2
31 (32748236) 3
30 (33715871) 1
29 (24630081) 1
28 (22296075) 1
27 (30969201) 1
26 (30303900) 1
25 (33596357) 1
24 (31468503) 1
23 (32459423) 1
22 (31971678) 1
21 (31594635) 1
20 (34711224) 1
19 (30303923) 1
18 (28579415) 1
17 (25516866) 4
16 (34011888) 4
MR-guided high-frequency focused ultrasound ablation Usually appropriate Strong N/A N/A 7 7 0 0 1 1 1 2 6 0 0
References Study Quality
40 (30217580) 2
39 (24075785) 2
38 (24998103) 2
37 (28421665) 1
36 (28063909) 1
35 (30696556) 1
34 (26658133) 1
33 (29628611) 4
Uterine artery embolization Usually appropriate Strong N/A N/A 7 7 1 0 0 0 0 0 6 1 3
References Study Quality
43 (33197612) Good
42 (23070101) 1
13 (27393268) 1
5 (34877531) 1
Hysterectomy May be appropriate Strong N/A N/A 6 6 0 0 0 0 4 5 2 0 0
References Study Quality
58 (26272688) 4
57 (26264829) Good
56 (22269187) 4
55 (33259542) 1
54 (20526776) 2
53 (32376318) 2
52 (31479034) 1
51 (29286988) 2
50 (27335259) 4
Hysteroscopic myomectomy May be appropriate Strong N/A N/A 6 6 0 0 0 0 3 4 4 0 0
References Study Quality
5 (34877531) 1
4 (31678093) 2
3 (32532486) 3
Endometrial ablation Usually not appropriate Strong N/A N/A 3 3 2 1 3 4 1 0 0 0 0
References Study Quality
48 (27575538) 2
49 (32984945) 2
Laparoscopic uterine artery occlusion Usually not appropriate Limited N/A N/A 3 3 4 1 3 2 1 0 0 0 0
References Study Quality
15 (22526109) 2
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Strong N/A N/A 7 7 0 1 0 0 3 0 5 0 2
References Study Quality
64 (34553161) 1
63 (26071673) 1
62 (21134503) 1
61 (21422847) 1
60 (21784734) 1
Uterine artery embolization Usually appropriate Strong N/A N/A 7 7 1 0 0 0 1 1 5 2 1
References Study Quality
69 (29496654) 4
68 (29032946) Inadequate
67 (21717251) 2
66 (28516272) 2
65 (21850565) 2
Hysterectomy May be appropriate Strong N/A N/A 6 6 0 0 0 0 3 4 3 0 1
References Study Quality
58 (26272688) 4
57 (26264829) Good
56 (22269187) 4
55 (33259542) 1
54 (20526776) 2
53 (32376318) 2
52 (31479034) 1
51 (29286988) 2
50 (27335259) 4
MR-guided high-frequency focused ultrasound ablation Usually not appropriate Expert Consensus N/A N/A 3 3 4 1 4 1 0 0 1 0 0
Endometrial ablation Usually not appropriate Limited N/A N/A 2 2 4 2 4 1 0 0 0 0 0
References Study Quality
59 (25460320) 1
Hysteroscopic myomectomy Usually not appropriate Expert Consensus N/A N/A 2 2 3 3 1 2 1 0 1 0 0
Laparoscopic or open myomectomy Usually not appropriate Expert Consensus N/A N/A 2 2 2 7 2 0 0 0 0 0 0
Laparoscopic uterine artery occlusion Usually not appropriate Expert Consensus N/A N/A 2 2 5 2 1 0 3 0 0 0 0
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hysteroscopic myomectomy Usually appropriate Moderate N/A N/A 8 8 0 0 0 1 0 0 1 5 4
References Study Quality
4 (31678093) 2
Medical management Usually appropriate Strong N/A N/A 7 7 0 1 0 2 2 0 6 0 0
References Study Quality
32 (33567071) 2
31 (32748236) 3
30 (33715871) 1
29 (24630081) 1
28 (22296075) 1
27 (30969201) 1
26 (30303900) 1
25 (33596357) 1
24 (31468503) 1
23 (32459423) 1
22 (31971678) 1
21 (31594635) 1
20 (34711224) 1
19 (30303923) 1
18 (28579415) 1
17 (25516866) 4
16 (34011888) 4
Uterine artery embolization May be appropriate Limited N/A N/A 6 6 0 0 0 0 2 4 4 1 0
References Study Quality
73 (19692192) 2
MR-guided high-frequency focused ultrasound ablation May be appropriate Strong N/A N/A 5 5 0 1 1 2 3 3 1 0 0
References Study Quality
72 (19640736) 2
71 (23099002) 2
70 (32676291) 4
Hysterectomy Usually not appropriate Limited N/A N/A 3 3 2 0 5 3 1 0 0 0 0
References Study Quality
50 (27335259) 4
Endometrial ablation Usually not appropriate Expert Consensus N/A N/A 2 2 5 3 1 1 0 1 0 0 0
Laparoscopic or open myomectomy Usually not appropriate Expert Consensus N/A N/A 2 2 4 2 4 1 0 0 0 0 0
Laparoscopic uterine artery occlusion Usually not appropriate Expert Consensus N/A N/A 2 2 5 2 2 2 0 0 0 0 0
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hysterectomy Usually appropriate Strong N/A N/A 8 8 1 0 0 0 0 0 4 1 5
References Study Quality
57 (26264829) Good
56 (22269187) 4
55 (33259542) 1
54 (20526776) 2
51 (29286988) 2
50 (27335259) 4
Laparoscopic or open myomectomy May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 0 4 7 0 0 0
Uterine artery embolization May be appropriate Limited N/A N/A 6 6 0 0 0 1 3 5 2 0 0
References Study Quality
76 (31834160) 4
75 (25765878) 3
74 (26372352) 4
Hysteroscopic myomectomy May be appropriate Strong N/A N/A 5 5 0 0 1 0 5 4 1 0 0
References Study Quality
5 (34877531) 1
4 (31678093) 2
3 (32532486) 3
MR-guided high-frequency focused ultrasound ablation Usually not appropriate Expert Consensus N/A N/A 3 3 3 2 2 1 2 0 1 0 0
Endometrial ablation Usually not appropriate Expert Consensus N/A N/A 2 2 3 3 2 2 1 0 0 0 0
Laparoscopic uterine artery occlusion Usually not appropriate Expert Consensus N/A N/A 2 2 5 2 2 1 1 0 0 0 0
Medical management Usually not appropriate Expert Consensus N/A N/A 2 2 2 4 1 2 2 0 0 0 0
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hysteroscopic myomectomy Usually appropriate Strong N/A N/A 7 7 1 0 0 0 0 3 4 1 2
References Study Quality
11 (35216832) 2
10 (24303914) 2
9 (15760959) 1
8 (25172985) 4
7 (16603437) 1
Laparoscopic or open myomectomy Usually appropriate Strong N/A N/A 7 7 1 0 0 0 1 1 5 0 3
References Study Quality
77 (17349643) 1
78 (11098042) 2
Uterine artery embolization May be appropriate Limited N/A N/A 6 6 0 0 1 3 0 3 3 0 1
References Study Quality
46 (28608747) 2
Medical management May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 2 3 2 1 1 0 1 0
References Study Quality
79 (32430027) 1
MR-guided high-frequency focused ultrasound ablation May be appropriate Limited N/A N/A 5 5 0 0 0 3 6 1 1 0 0
References Study Quality
82 (21570071) 4
81 (21611041) 4
80 (17292361) 4
Laparoscopic uterine artery occlusion Usually not appropriate Expert Consensus N/A N/A 2 2 5 3 0 2 0 0 0 1 0
Endometrial ablation Usually not appropriate Limited N/A N/A 1 1 6 3 0 2 0 0 0 0 0
References Study Quality
2 (28952185) Inadequate
Hysterectomy Usually not appropriate Expert Consensus N/A N/A 1 1 9 1 0 0 0 0 0 0 1
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.