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Mirena ppt for 2 july 14
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  • The sinequa non of dub is heavy periods. <br />
  • FIGO classification: Munro MG, Critchley H, Broder MS, Fraser IS; for the FIGO Working Group on Menstrual Disorders. International Journal of Gynecology and Obstetrics 113 (2011) 3–13 <br />
  • Medical therapy is usually considered a first-line treatment for idiopathic HMB <br /> Marret H, Fauconnier A, Chabbert-Buffet N, et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):133-7. doi: 10.1016/j.ejogrb.2010.07.016. Epub 2010 Aug 4. <br />
  • Endometrial ablation (EMA) <br /> Can be offered to patients as initial treatment for HMB but is considered appropriate only for patients who have completed their family. <br /> The patients, however, will require reliable contraception afterwards. <br /> It is also not suitable for women with a large uterus <br /> Hysterectomy <br /> Remains the definitive treatment for HMB with high satisfaction rates, <br /> Should not be used as first-line treatment in cases with primary HMB unless all other treatments are contraindicated or refused by the patient. <br /> Uterine fibroid embolization <br /> This technique is new and still experimental, and requires a body of work before being implemented in clinical practice. <br />
  • Mirena <br />
  • Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Contraception. 2013;87:409-15. <br /> A prospective, randomized controlled trial was conducted to compare 5-year follow-up of <br /> LNG-IUS or thermal balloon ablation (TBA) for the treatment of HMB. Hysterectomy rates, <br /> hemoglobin level, bleeding pattern, well-being status and satisfaction rates were assessed. <br /> Results <br /> After 5 years of follow-up the results were as follows (Table 5): <br /> „„ Women treated with a TBA had higher rates of hysterectomy (24%) compared to the LNGIUS <br /> group (3.7%) due to treatment failure (p=0.039). <br /> „„ Use of LNG-IUS resulted in higher mean hemoglobin (±SD) levels in comparison to the TBA <br /> group (14.1±0.3 vs. 12.7±0.4 g/dl, p=0.009). <br /> „„ Menstrual blood loss was significantly higher in the TBA when compared to the LNG-IUS <br /> group (45.5% vs. 0.0% p&lt;0.001) . <br /> „„ The psychological general well-being index scores were similar. Patient acceptability, <br /> perceived clinical improvement and overall satisfaction rates were significantly higher in <br /> women using LNG-IUS. <br /> Five-year follow-up of HMB treatment with LNG-IUS was associated with higher efficacy and satisfaction ratings compared to TBA. <br />
  • WHY SHOULD’NT A HYSTERECTOMY BE AVOIDED IF THE BENEFIT CAN BE PROVIDED TO A GOOD NO, OF PATIENTS BY A SAFER ALTERNATIVE TT MODALITY COZ HYSTERECTOMY DOES CARRY RISKS OF ANAESTHESIA ETC <br />

Mirena ppt for 2 july 14 Presentation Transcript

  • 1. LNG – IUS (Mirena) In HMB Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar
  • 2. Heavy Periods
  • 3. More than 1 in 5 30s & 40s suffer from HEAVY PERIODS (Unmanageable)
  • 4. Causes of HMB FIGO Classification Munro MG, Critchley H, Broder MS, Fraser IS; for the FIGO Working Group on Menstrual Disorders. International Journal of Gynecology and Obstetrics 113 (2011) 3–13
  • 5. Heavy menstrual bleeding An important cause of morbidity • 30% of women in reproductive age group suffer with Menorrhagia • 60% of these women will ultimately undergo hysterectomy
  • 6. Non surgical methods of management of HMB • Pharmacological – Levonorgesterol -Intrauterine System (LNG-IUS) – Antifibrinolytics – NSAIDS – GnRH analogues – Oral contraceptives – Cyclic progestins Marret H, Fauconnier A, Chabbert-Buffet N, et al. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):133-7. Medical therapy is usually considered a first-line treatment for idiopathic HMB GnRH – Gonadotrophin Releasing Hormone
  • 7. Surgical methods of management of HMB • Endometrial ablation (EMA) – Considered appropriate only for patients who have completed their family. – It is also not suitable for women with a large uterus • Hysterectomy – Remains the definitive treatment for HMB – Should not be used as first-line treatment in cases with primary HMB unless all other treatments are contraindicated or refused by the patient. • Uterine fibroid embolization – New and still experimental In patients where pharmacological treatment is ineffective or inappropriate, or the patient does not want drugs, and in patients with certain histological abnormalities of endometrium, non pharmacological treatment is more suitable National Collaborating Centre for Women’s and Children’s Health. Heavy Menstrual Bleeding Clinical Guideline. London: RCOG Press for NICE; 2007.
  • 8. Hysterectomy • Second most frequent surgical procedure in women of reproductive age group • 90% for benign reasons • Promptly offered following a diagnosis.
  • 9. Value Study(BJOG - 2004) survey of outcomes of 37,000 hysterectomies • Operative and postoperative complication rate of 3.5% and 9 % respectively were reported • Postoperative mortality of 0.38 / 1000. • Psychological implications 35-45% • Hysterectomy should not be taken up
  • 10. Dilemma!! of Treatment Aim - Quality Personal life - Family life - Preserve the feminity of a women - ↓ Frequent leave from office Age Severity Fertility
  • 11. Treatment of Heavy Periods Individualized • age • need for contraception • desire to retain uterus • Nature and severity of complaints • presence of any pelvic pathology • outcome of previous treatment • cost of treatment • time away from work
  • 12. Present Practice TVS/D&C Drugs Another D&C Hysterectomy
  • 13. Options AvailableOptions Available Mirena / Endometrial Ablation Drug therapyDrug therapy Hysterectomy
  • 14. Options available Alternatives to Hysterectomy
  • 15. NICE Guideline (Jan 2007) management of heavy menstrual bleeding • If future childbearing is desired LNG – IUS is the first line intervention • If future child bearing is not desired Endometrial ablation
  • 16. MIRENAMIRENA Its role in menorrhagiaIts role in menorrhagia
  • 17. MIRENA Inspired by : Prof.Osama Showki
  • 18. Mirena (LNG IUS) is a Magic Stick
  • 19. 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
  • 20. Mirena has an additional advantage of providing reversible contraception. Menorrhagia Contraception
  • 21. • Progestin releasing intrauterine system • T shaped polyethylene frame • Contains 52 mg levonorgestrel • Releases 20 µg LNG daily What is Mirena - LNG IUS
  • 22. Mirena : local mode of action Prevents endometrial proliferation • Thickens cervical mucus • Inhibits sperm motility serum levels are 4 times lower than after oral ingestion
  • 23. Benefits of local action No significant change in • Blood pressure • Lipid profile • Coagulation factors • Carbohydrate metabolism • Liver function • Bone mineral density
  • 24. Efficacy of LNG IUS in Idiopathic Menorrhagia
  • 25. Bleeding pattern in the first 5-year period Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21 Infrequent 3.7% Regular 70.3% Ammenorhea 26%
  • 26. 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
  • 27. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing Intrauterine System in Primary Care against Standard Treatment for Menorrhagia (ECLIPSE) Trial 30 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
  • 28. LNG IUS: Efficacy 97% Reduction in Menstrual Blood Loss over 1 year of therapy Significant increase in Hemoglobin and Serum Ferritin level
  • 29. LNG IUS versus TXA/MFA and MPA: MBL Reduction Significant reduction in MBL as compared to TXA/ MFA as well as MPA, with higher likelihood of treatment success with LNG IUS MFA = Mefenamic acid: Medroxy progesterone acetate
  • 30. LNG-IUS vs. thermal balloon ablation (TBA) prospective randomized controlled trial 5 year follow up results across various parameters with use of LNG-IUS vs. TBA Five-year follow-up of HMB treatment with LNG-IUS was associated with higher efficacy and satisfaction ratings compared to TBA. Patient acceptability, perceived clinical improvement and overall satisfaction rates were significantly higher in women using LNG-IUS. Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Contraception. 2013;87:409-15.
  • 31. LNG IUS versus Hysterectomy 34 When patients were given the option of mirena a significant percentage of women cancelled their hysterectomy Pekka Lähteenmäki et al. 1998 316: 1122 (6)
  • 32. 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
  • 33. Emerging new indications for use of mirena
  • 34. ENDOMETRIOSIS ADENOMYOSIS
  • 35. Mirena provides long term relief of chronic pelvic pain Obstet gynecol 2012;119:519-526
  • 36. FIBROIDS Significant reduction in both the uterine volume and
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. PRACTICAL TIPS TO SUCCESS
  • 41. 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?
  • 42. Counselling- Three problems !!! • Spotting after insertion • Amenorrhea in 25 % of women • Price
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. Sonographic Evaluation
  • 47. Experience with MIRENA in Heavy Bleeding
  • 48. Used in 235 cases INCLUDING FIBROIDS AND ENDOMETRIOSIS Updated on 26/6/2014 Expulsion in 3 (UBT , hysterectomy , reinsertion ) • It can replace the need of hysterectomy in 2/3rd of cases. • Especially useful when future fertility is desired
  • 49. • Moderate Size • Multiple • With Heavy bleeding • Young (wanted child - 2) FIBROIDS 16 cases Effective Size ↓ - 25 – 30 %
  • 50. • Grade IV with cyst • Sever Dysmenorrhoea & • Bleeding Problem Endometriosis 15 Cases Effective – Except 1st 4 month
  • 51. DUB / adenomyosis Few Keen for future childbearing Rest Causes EFFECTIVE – Except 1st 4 month
  • 52. UBT v/s Mirena Great Great Great 4th Month Jaan Nikaal Deta Hai Really troublesome But one should TRY
  • 53. Mirena Positive Side • Effective after 4 month • Major Surgery is saved – Mortality - Morbidity Cost Effective
  • 54. Mirena Trouble shooting 1st 4th Month OCP GnRh Agonist ?
  • 55. As Teacher we Trying • POSITIVE ATTITUDE which is contagious • Improve Knowledge / Share Exp. • Motivate you to try Give A Lot - Expect a Lot
  • 56. If you want to Become one !! ALL
  • 57. KJ Carlson, NEJM 328:856, 1993 HYSTERECTOMY as Treatment Should be last resort
  • 58. Mirena and uterine balloon therapy isMirena and uterine balloon therapy is thus a new horizon to your patient andthus a new horizon to your patient and yourselfyourself BE BOLD, WALK ALONG NEW PATHS EXPERIENCE IT YOURSELF
  • 59. Thank You