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  • The sinequa non of dub is heavy periods.
  • Mirena


  • 1. Mirena An alternatives to Hysterectomy in Heavy menstrual Bleeding Dr. Jyoti Agarwal Dr. Sharda Jain DR. Jyoti Bhaskar
  • 2. Heavy Periods
  • 3. More than 1 in 5 30s & 40s suffer from HEAVY PERIODS (Unmanageable)
  • 4. 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
  • 5. Hysterectomy • Second most frequent surgical procedure in women of reproductive age group • 90% for benign reasons • Promptly offered following a diagnosis.
  • 6. 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
  • 7. Dilemma!! of Treatment Aim - Quality Personal life - Family life - Preserve the feminity of a women - ↓ Frequent leave from office Age Severity Fertility
  • 8. 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
  • 9. Present Practice TVS/D&C Drugs Another D&C Hysterectomy
  • 10. Options AvailableOptions Available Mirena / Endometrial Ablation Drug therapyDrug therapy Hysterectomy
  • 11. Options available Alternatives to Hysterectomy
  • 12. 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
  • 13. MIRENAMIRENA Its role in menorrhagiaIts role in menorrhagia
  • 14. MIRENA Inspired by : Prof.Osama Showki
  • 15. Mirena (LNG IUS) is a Magic Stick
  • 16. 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
  • 17. Mirena has an additional advantage of providing reversible contraception. Menorrhagia Contraception
  • 18. • Progestin releasing intrauterine system • T shaped polyethylene frame • Contains 52 mg levonorgestrel • Releases 20 µg LNG daily What is Mirena - LNG IUS
  • 19. Mirena : local mode of action Prevents endometrial proliferation • Thickens cervical mucus • Inhibits sperm motility serum levels are 4 times lower than after oral ingestion
  • 20. Benefits of local action No significant change in • Blood pressure • Lipid profile • Coagulation factors • Carbohydrate metabolism • Liver function • Bone mineral density
  • 21. Efficacy of LNG IUS in Idiopathic Menorrhagia
  • 22. 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%
  • 23. 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
  • 24. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing Intrauterine System in Primary Care against Standard Treatment for Menorrhagia (ECLIPSE) Trial 27 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
  • 25. LNG IUS versus Hysterectomy 28 When patients were given the option of mirena a significant percentage of women cancelled their hysterectomy Pekka Lähteenmäki et al. 1998 316: 1122 (6)
  • 26. 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
  • 27. Emerging new indications for use of mirena
  • 29. Mirena provides long term relief of chronic pelvic pain Obstet gynecol 2012;119:519-526
  • 30. FIBROIDS Significant reduction in both the uterine volume and
  • 31. 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
  • 32. 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
  • 33. 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
  • 35. 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?
  • 36. Counselling- Three problems !!! • Spotting after insertion • Amenorrhea in 25 % of women • Price
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. Sonographic Evaluation
  • 41. Experience with MIRENA in Heavy Bleeding
  • 42. Used in 141 cases INCLUDING FIBROIDS AND ENDOMETRIOSIS Updated on 1/9/2013 Expulsion in 13 (UBT , hysterectomy , reinsertion ) • It can replace the need of hysterectomy in 50 % of cases. • Especially useful when future fertility is desired
  • 43. UBT v/s Mirena Great Great Great 4th Month Jaan Nikaal Deta Hai Really troublesome But one should TRY
  • 44. Mirena Positive Side • Effective after 4 month • Major Surgery is saved – Mortality - Morbidity Cost Effective
  • 45. KJ Carlson, NEJM 328:856, 1993 HYSTERECTOMY as Treatment Should be last resort
  • 46. 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