Mirena its role in menorrhagia dr. jyoti bhaskar,lecture -3

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Mirena its role in menorrhagia dr. jyoti bhaskar,lecture -3

  1. 1. Lecture 3 MIRENA Its role in Menorrhagia Dr. Jyoti Bhaskar “Save Uterus Campaign” Lecture Series (1 to 4 )
  2. 2. MIRENA Its role in Menorrhagia Dr. Jyoti Bhaskar Dr. Sharda Jain Dr. Jyoti Agarwal
  3. 3. Mirena (LNG IUS) is a Magic Stick
  4. 4. What is Mirena - LNG IUS • Progestin releasing intrauterine system • T shaped polyethylene frame • Contains 52 mg levonorgestrel • Releases 20 µg LNG daily
  5. 5. Mirena : local mode of action Prevents endometrial proliferation • Thickens cervical mucus • Inhibits sperm motility Serum Levels are 4 times lower than after oral ingestion
  6. 6. Benefits of local action No significant change in • • • • • • Blood pressure Lipid profile Coagulation factors Carbohydrate metabolism Liver function Bone mineral density
  7. 7. Mirena has an additional advantage of providing reversible contraception. Menorrhagia Contraception
  8. 8. Efficacy of LNG IUS in Idiopathic Menorrhagia
  9. 9. Bleeding pattern in the first 5-year period Ammenorhea 26% Infrequent 3.7% Regular 70.3% Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21
  10. 10. Comparison of Rx Modalities Progesterone or LNG IUS LNG IUS reduces menstrual blood loss more effectively and has a higher likelihood of treatment success than oral medroxyprogesterone acetate. Obstet Gynecol. 2010
  11. 11. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing Intrauterine System in Primary Care against Standard Treatment for Menorrhagia (ECLIPSE) Trial Improvements in MMAS scores were significantly greater (lesser score= more severity) Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J for the ECLIPSE Trial Collaborative Group N Engl J Med 2013;368:128-37 Daily routine work, social and family life, and psychological and physical well-being 11
  12. 12. LNG IUS versus Hysterectomy When patients were given the option of mirena a significant percentage of women cancelled their hysterectomy Pekka Lähteenmäki et al. 1998 316: 1122 (6) 12
  13. 13. Finnish trial (multicentric RCT 236 pts) • Mirena improves the quality of life as effectively as surgical treatment at 1 year. • Women ranked their satisfaction with a mean score of 7 / 10. • Less than 5% of women required subsequent operative treatment • Mirena is more cost effective than hysterectomy in the short term
  14. 14. Mirena is as effective as endometrial ablation in reducing heavy menstrual bleeding • In sept 2009 , the US FDA approved mirena as a treatment for heavy menstrual bleeding Obstet gynecol 2009;1104-1116
  15. 15. Emerging new indications for use of mirena
  16. 16. ENDOMETRIOSIS ADENOMYOSIS
  17. 17. Mirena provides long term relief of chronic pelvic pain Obstet gynecol 2012;119:519-526
  18. 18. FIBROIDS Significant reduction in both the uterine volume and
  19. 19. Endometrial Hyperplasia • Beneficial effects are observed by1 year. • Treatment should be reliably monitored through regular 6-montly outpatient follow up Eur J Obstet Gynecol Reprod Biol. 2008
  20. 20. Early-stage Endometrial Carcinoma May have a role in selected patients willing to preserve fertility • Endometrial protection for women on tamoxifen • Women With Clotting Disorders Or Under Anti Thrombotic Treatment Conservative treatment of early endometrial cancer: preliminary results of a pilot study. Gynecol Oncol. 2011; 120(1):43-6
  21. 21. Are there any drugs that interact with mirena ? • Women using mirena may be reassured that • No drugs are known to interact with mirena • Can be used safely with ATT • No effect on BMD Not to be used as Emergency Contraceptive
  22. 22. PRACTICAL TIPS TO SUCCESS
  23. 23. COUNSELLING Is it not very costly as compared to oral medication? Doctor, I am spotting daily? What do I do? I have not had periods since 6 months? Am I in menopause?
  24. 24. Counselling- Three problems !!! • Spotting after insertion • Amenorrhea in 25 % of women • Price
  25. 25. Irregular Bleeding or spotting • May last for 4-6 months COC or Progesterone is used to tide over this period • GnRHa can also be used Acceptance depends on good pre insertion counselling
  26. 26. COST EFFECTIVENESS LNG IUS • Cost- Rs 8205/• Insertion cost – Rs. 2000 - 5000 Covered by Insurance ORAL PROGESTERONE 1 mnth – Rs. 3000 6 months Rs. 18000 1 Yr Rs. 36000 No insurance
  27. 27. How long ? NICE GUIDELINES : If inserted > 45 yrs of age and has complete amenorrhea may continue to use it until menopause. It can be removed at mid 50s as long as it controls the bleeding HRT Change it after 4 years “licenced” Contraception < 45years…..5 years > 45 years ….7 years
  28. 28. Sonographic Evaluation
  29. 29. My Journey with LNG- IUS Oman to Republic of Ireland to India 2001 -- 2010 --- 2013
  30. 30. My Journey with LNG IUS • 2 – 4 cases of Hysterectomy/month • 4-5 cases of Hysteroscopy/D&C/ Mirena Insertion per theatre • 2-4 cases of Mirena Insertion / week in OPD for contraception. Cost of Mirena- 120 euros Paid by patient
  31. 31. My Journey with LNG IUS • Inserted in unmarried girls, morbidly obese, DM , HT patients. • Women with Fibroids, adenomyosis, endometriosis, complex hyperplasia. • Not used in HRT patients.
  32. 32. Lifecare Experience with MIRENA in Heavy Bleeding
  33. 33. Used in 41 cases INCLUDING FIBROIDS AND ENDOMETRIOSIS • It can replace the need of hysterectomy in 50 % of cases. • Especially useful when future fertility is desired Expulsion in 3 (UBT , hysterectomy , reinsertion )
  34. 34. Mirena Positive Side • Effective after 4 month • Major Surgery is saved – Mortality - Morbidity Cost Effective
  35. 35. UBT v/s Mirena Great Great Great 4th Month Jaan Nikaal Deta Hai Really troublesome But one should TRY

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