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What predicts a successful smoking cessation attempt?
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
Evidence-based answers from the Family Physicians Inquiries Network
What is the appropriate diagnostic evaluation of fibroids?
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
Although transvaginal sonography (TVS) has inconsistent sensitivity (0.21–1.00) and specificity (0.53–1.00), its cost-efficiency and noninvasiveness make it the best initial test for ruling in fibroid disease (strength of recommendation [SOR]:B, based on expert opinion, a systematic review, and prospective studies).
Sonohysterography (SHG) and hysteroscopy have superior sensitivity, specificity, and more discriminating positive and negative likelihood ratios for diagnosing fibroids than does TVS (SOR:B, systematic review). SHG is less painful, less invasive, and more cost-effective than hysteroscopy (SOR:B; single, prospective comparative study and cost comparison).
Magnetic resonance imaging (MRI) had comparable precision to TVS in a single study, but it is too expensive to be a good initial test for fibroids (SOR:C, expert opinion and an uncontrolled prospective study). One study reported a strong correlation between ultrasound and bimanual examination (SOR:C, retrospective case review).
Evidence summary
Uterine myomas are usually diagnosed by incidental visualization during pelvic sonography or bimanual palpation of an enlarged, mobile uterus with irregular contours.1 In a retrospective chart review of obese and nonobese patients with known uterine fibroids, clinical estimate of uterine size by bimanual examination correlated with both ultrasound fibroid sizing and posthysterectomy pathology analysis.2 Additional diagnostic testing is indicated for patients with suspected fibroids and abnormal uterine bleeding, increased pelvic girth, pelvic pressure contributing to urinary frequency or constipation, or pelvic pain with intercourse or other physical activity.3
TVS has high sensitivity for detecting myomas in a uterus of <10-week size. The use of high-frequency probes improves the sensitivity for diagnosing small myomas, although their precise location with respect to the uterine cavity often remains uncertain. Localization of fibroids in a larger uterus or when there are many tumors is limited.4 Also, TVS may fail to detect small fibroids and subserosal myomas. A systematic review of 9 heterogeneous studies evaluating TVS found wide ranges for sensitivity and specificity (TABLE).5 The cost of TVS is less than half of sonohysterography or diagnostic hysteroscopy, based on Medicare allowable pricing data.6
SHG uses an intrauterine saline contrast medium with transvaginal ultrasonography. This office-based procedure is more invasive than TVS but requires no anesthesia. SHG is more sensitive and specific than TVS in detecting submucous myomas and focal endometrial lesions.7 In a prospective study of 81 symptomatic patients, using a gold standard of surgical pathology, SHG demonstrated more discriminating positive and negative likelihood ratios (LR+, LR–) for detecting myomata than did TVS or hysteroscopy.8 A prospective study of 56 symptomatic patients with a gold standard of hysteroscopic or surgical pathology similarly found SHG to be superior to TVS.7 In a systematic review of 7 studies, SHG demonstrated a clinically significant LR+ of 29.7. There was too much heterogeneity in the data to calculate an LR– (TABLE).5
Hysteroscopy is as accurate but more invasive than SHG in evaluating uterine myomata. In a systematic review of 4 studies, hysteroscopy had a pooled LR+ of 29.4 for diagnosing fibroids. Due to study heterogeneity, a pooled LR– could not be calculated.5 A prospective, blinded comparative study of SHG and hysteroscopy for diagnosing fibroids in 117 women found SHG to have a higher failure rate (22% vs 6%) but a statistically significant lower median pain score: 1.6 (interquartile range 0.48–3.03) vs 3.2 (1.58–5.18) (P<.001)—than hysteroscopy.9 Failure of SHG was most commonly due to cervical stenosis.
In a double-blinded comparative study of 106 consecutive premenopausal women undergoing hysterectomy for benign reasons, MRI and TVS detected myomas with equal precision (TABLE). MRI is preferred in cases for which exact myoma mapping is necessary and those with multiple myomas or large uteri who are scheduled for advanced surgical procedures.4 MRI costs up to twice as much as sonohysterography or diagnostic hysteroscopy, when comparing Medicare allowable pricing data.6
TABLE
Evaluations of diagnostic tools for fibroids
| DIAGNOSTIC TOOL | PASRIJA ET AL7 | BONNAMY ET AL8 | DUEHOLM ET AL4 | FARQUHAR ET AL5 | ROGERSON ET AL9 |
|---|---|---|---|---|---|
| Summary characteristics of trial | Prospective, 56 pts, symptomatic, gold standard hysteroscopy or hysterectomy pathology | Prospective, 81 symptomatic pts, gold standard of “clinical survey” or histopathology | Double-blind, 106 premenopausal pts undergoing hysterectomy for benign reasons | Systematic review including 19 studies with significant heterogeneity | 117 women; SHG compared with outpatient hysteroscopy (gold standard) |
| TVS | (9 studies) | ||||
| Sensitivity | 84.8 | 65 (43–84) | 99 (92–100) | 21–100 | |
| Specificity | 79 | 94 (79–99) | 91 (75–98) | 53–100 | |
| PPV | 82.4 | 96 (88–99) | |||
| NPV | 82 | 97 (82–100) | |||
| LR+ | 4.0 | 10 (2.6–4.1) | 11 (3.0–50) | 1.61–62.25 | |
| 0.19 | 0.4 (0.2–0.7) | 0.01 (0.11–0) | 0.03–0.80 | ||
| SHG | (7 studies) | ||||
| Sensitivity | 94.1 | 91 (72–99) | 57–100 | 85.2 | |
| Specificity | 88.5 | 94 (79–99) | 96–100 | 87.3 | |
| PPV | 91.4 | 74.3 | |||
| NPV | 92 | 93.2 | |||
| LR+ | 8.2 | 15 (3.8–56) | 29.7 (17.8–49.6) | 6.7 | |
| LR– | 0.067 | 0.1 (0.02–0.4) | 0.06–0.47 | 0.17 | |
| Hysteroscopy | (4 studies) | ||||
| Sensitivity | 88 (62–98) | 53–100 | |||
| Specificity | 94 (79–99) | 97–100 | |||
| LR+ | 14 (3.5–52) | 29.4 (13.4–65.3) | |||
| LR– | 0.1 (0.04–0.5) | 0.08–0.48 | |||
| MRI | |||||
| Sensitivity | 99 (92–100) | ||||
| Specificity | 86 (71–94) | ||||
| PPV | 92 (83–97) | ||||
| NPV | 97 (85–100) | ||||
| LR+ | 7.1 (03.2–16.7) | ||||
| LR– | 0.012 (0.11–0) | ||||
| Italicized values were not reported in the original studies, but calculated for this review. Numbers in parentheses represent 95% confidence levels. | |||||
| LR+ = positive likelihood ratio (a value greater than 10 is clinically significant and the higher the value, the more helpful the test at ruling in the diagnosis); LR– = negative likelihood ratio (a value less than 0.1 is clinically significant and the lower the value, the more helpful the test at ruling out the diagnosis). | |||||
| PPV, positive predictive value; NPV, negative predictive value; TVS, transvaginal sonography; SHG, sonohysterography; MRI, magnetic resonance imaging. | |||||
Recommendations from others
A 1994 American College of Obstetrics and Gynecology (ACOG) bulletin stated that uterine fibroids can be diagnosed with 95% certainty by examination alone.10 ACOG recommends augmenting physical examination with ultrasonography in cases involving obese women or when adnexal pathology cannot be excluded based on examination alone. This bulletin also points out that routine ultrasonography does not improve long-term clinical outcomes for fibroids. A more recent bulletin (2000) addressed management but not evaluation or diagnosis of leiomyomas.11
A 2003 guideline from the Society of Obstetrics and Gynecology of Canada recommends against routine ultrasonography, since it rarely affects the clinical management of uterine fibroids. However, it emphasizes the importance of ruling out underlying endometrial pathology in women with abnormal uterine bleeding.12
When evaluating potential fibroids, a reasonable first step is a sonogram
Lynda DeArmond, MD
Waco Family Practice Residency Program, Waco, Tex
In the asymptomatic patient with an enlarged, irregularly contoured uterus on routine exam, the differential includes fibroids, fibroids, and fibroids. My usual next step is to get a sonogram. The test is noninvasive, well-tolerated by patients, and significantly less expensive than the alternatives. It quickly and easily gives a great deal of useful information regarding the size, shape, consistency of the myometrium and the endometrium, from which we can reassure the patient regarding the benign natural history of this finding, especially in the perimenopausal woman. If the patient presents with symptoms of abnormal bleeding, pelvic pressure, or adnexal findings on exam, the review suggests that further workup may be indicated. However, the sonogram remains a very useful initial test even in this case.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
1. Mayer DP, Shipilov V. Ultrasonography and magnetic resonance imaging of uterine fibroids. Obstet Gynecol Clin North Am 1995;22:667-725.
2. Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma. Obstet Gynecol 1998;92:109-112.
3. Becker E, Jr, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-247.
4. Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-415.
5. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493-504.
6. 2004 Interactive Physician Fee Schedule. Missouri Medicare Services. Available at: www.momedicare.com/provider/disclosure/fee2004.asp.
7. Pasrija S, Trivedi SS, Narula MK. Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal bleeding. J Obstet Gynaecol 2004;30:27-33.
8. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
9. Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient hysteroscopy with saline infusion hysterosonography. BJOG 2002;109:800-804.
10. ACOG. ACOG Technical Bulletin no. 192. Uterine leiomyomata. Int J Gynaecol Obstet 1994;46:73-82.
11. ACOG. ACOG Practice Bulletin no. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000.
12. Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC Clinical Practice Guideline no. 128. The management of uterine leiomyomas. May 2003.
Evidence-based answers from the Family Physicians Inquiries Network