Role of mirena in heavy periods

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Role of mirena in heavy periods

  1. 1. ROLE OF MIRENA IN HEAVY PERIODS DR. JYOTI BHASKAR MD MRCOG
  2. 2. My Journey with LNG- IUS Oman to Republic of Ireland to India 2001 -- 2010 --- 2013
  3. 3. 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
  4. 4. Our Experience • Over 300 cases Observed • Inserted in 100 cases personally • 70 for DUB, 30 for Contraception
  5. 5. 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.
  6. 6. My Journey with LNG IUS • Amenorrhea in 40% after 1 year • Reduction of bleeding in 90% • 1 patient – absolute failure – removed within 1 month. • Irregular spotting was the main cause for removal ( 20%) • Significant Pain relief in post surgery endometriosis
  7. 7. WHY MIRENA? • Patient satisfaction • Comparison with other techniques • Emerging New Indications • Cost Effective • Ease of insertion and Removal
  8. 8. Patient Satisfaction •8
  9. 9. 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%
  10. 10. Mirena in the treatment of menstrual disorders: a survey of UK patients' experience. 1056 patients – 1995-2003 • The majority 73% of women continued to use the Mirena. • Women ranked their satisfaction with a mean score of 7.07/10. • The commonest side-effect experienced was spotting (19%). • Less than 5% of the women required subsequent operative treatment J Obstet Gynaecol. 2008; 28(7):728-31
  11. 11. Comparison of Rx Modalities LNG IUS First-line treatment for menorrhagia . Hormonal Method is acceptable • Ongoing Treatment for more than 1 year is anticipated NICE GUIDELINES- CG44 Heavy menstrual bleeding: 2January 2007
  12. 12. Progesterones or LNG IUS LNG IUS reduces menstrual blood loss more effectively and has a higher likelihood of treatment success than oral medroxyprogesterone acetate. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy bleeding Obstet Gynecol. 2010
  13. 13. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding • LNG IUS is more effective than cyclical norethisterone (for 21 days) as a treatment for heavy menstrual bleeding. • Women with an LNG IUS are more satisfied and willing to continue with treatment but experience more side effects, such as intermenstrual bleeding and breast tenderness Cochrane summaries ;November 10, 2010
  14. 14. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing Intrauterine System in Primary Care against Standard Treatment for Menorrhagia (ECLIPSE) Trial •14 LNG-IUS lead to greater improvement in women’s assessments of the effect of heavy menstrual bleeding on their daily routine, including work, social and family life, and psychological and physical well-being NEJM 2013
  15. 15. LNG IUS vs Surgical Approach SOURCES • Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006 • Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy Obstet Gynecol. 2009 • Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine BMJ. 2010 • The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial. BJOG. 2007 • The effect of hysterectomy or levonorgestrel-releasing intrauterine system on BJOG. 2010
  16. 16. Surgery versus long term hormone treatment for‐ heavy menstrual bleeding LNG IUS‐ • Improves the quality of life as effectively as surgical treatment at 1 year • It is more cost effective than hysterectomy in the short term This version published: 2010;
  17. 17. LNG vs Surgical Approach • Surgical treatment is more effective at reducing menstrual blood loss at 1 year • Therapeutic results are comparable at two years for endometrial ablation
  18. 18. LNG vs Surgical Approach • Sexual function is better post- hysterectomy although the risk of urinary tract infections and stress incontinence is higher • Hysterectomy stopped all bleeding but caused serious complications for some women
  19. 19. Time to think again !! • Hysterectomy: • 40% morbidity rate • 10 per 10,000 surgeries mortality rate • In a recent survey of the outcomes of 37,000 hysterectomies, the overall operative and postoperative complication rates were 3.5% and 9%, respectively Reference: Dicker et al., 1982; Lilford R, 1997
  20. 20. LNG IUS versus Hysterectomy •20 Percentage of women who cancelled their Hysterectomy when given the option of LNG IUS in management of Menorrhagia Pekka Lähteenmäki et al. 1998 316: 1122 (6)
  21. 21. EMERGING INDICATIONS
  22. 22. ENDOMETRIOSIS ADENOMYOSIS
  23. 23. Endometriosis • Mirena after operative laparascopy for endometriosis was more effective compared to the group that was only treated surgically. • Comparing use of GNRH analog to Mirena: equally effective in reducing chronic pelvic pain. The analogue was superior in reducing the amount of blood flow. Human Reproduction 2005
  24. 24. Use of LNG IUS for recurrence of symptoms in women who have surgery for endometriosis There is limited but consistent evidence showing that postoperative LNG-IUD use reduces the recurrence of painful periods in women with endometriosis Cochrane summaries :Published Online: January 31, 2013
  25. 25. FIBROIDS
  26. 26. FIBROIDS • Use of the LNG-IUS appears to lead to a significant reduction in the uterine volume of women with menorrhagia • Reduces the MBL in women with uterine leiomyomas. Efficacy of the levonorgestrel-releasing intrauterine system in uterine leiomyoma. Int J Gynaecol Obstet. 2012 Jan Kriplani A, Awasthi D, Kulshrestha V, Agarwal N.
  27. 27. Endometrial Hyperplasia • Beneficial effects are observed by the majority within 1 year. • Treatment can be reliably monitored through regular 6-montly outpatient endometrial Pipelle surveillance The effectiveness of a levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of endometrial hyperplasia--a long-term follow-up study Eur J Obstet Gynecol Reprod Biol. 2008
  28. 28. Early-stage Endometrial Carcinoma • Combined Operative HSC and LNG IUS for 12 months • May have a role of safe and conservative management of early EC • In selected patients willing to preserve fertility Conservative treatment of early endometrial cancer: preliminary results of a pilot study. Gynecol Oncol. 2011; 120(1):43-6
  29. 29. OTHER INDICATIONS • In protection of endometrium from endometrial hyperplasia during CCHRT • Endometrial protection for women on tamoxifen • Women With Clotting Disorders Or Under Anti Thrombotic Treatment
  30. 30. PRACTICAL TIPS TO SUCCESS
  31. 31. 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?
  32. 32. Counselling- Three problems !!! • Spotting after insertion (explain) • Amenorrhea in 25 % of women • Price
  33. 33. Irregular Bleeding • May last for 4-6 months • Acceptance depends on good pre insertion counselling • Use COC or Progesterone to tide over this period • GnRHa too has a role
  34. 34. COST EFFECTIVENESS LNG IUS • Cost- Rs 8205/- • Insertion cost – Rs. 2000/ Rs.5000 Covered by Insurance ORAL PROGESTERONE 1 mnth – Rs. 3000 6 months Rs. 18000 1 Yr Rs. 36000 No insurance
  35. 35. SIDE EFFECTS • Altered patterns of menstrual bleeding • Hormonal symptoms • Ectopic pregnancy – 1 in 20 • Uterine expulsion ( 1 in 20) • Perforation ( 1-2/1000) • Ovarian cysts • Pelvic Infection
  36. 36. Insertion tips • Screening for STI, Cervical Screening • Antibiotic Coverage( Optional) • Insertion Tip – tighten and then LOCK
  37. 37. DURATION Menorrhagia: It can be removed at mid 50s as long as it controls the bleeding HRT Change it after 4 years “licenced”
  38. 38. Mirena after five years • Contraception: -<45years…..5 years ->45 years ….7 years NICE GUIDELINES : “if inserted >45 and has complete amenorrhea may continue to use it until menopause”
  39. 39. Sonographic Evaluation
  40. 40. EXTRA TIPS • Not be used as Emergency Contraception • Can be used with ATT • No effect on BMD
  41. 41. PROMISING NEW LNG IUSPROMISING NEW LNG IUS • LNG-IUS12 and LNG-IUS16 • For Nulliparous and Postmenopausal • Phase III trial results are now being analyzed and "hopefully they will be ready soon." Fertil Steril 2012.
  42. 42. •42 Effective alternative to Surgery Preserves Fertility Convenient Highly effective in reducing blood loss Well Tolerated High User Satisfaction LNG IUS In Menorrhagia Take Home Messages!!!! New Indications
  43. 43. Mirena is a new horizonMirena is a new horizon to your patient and yourselfto your patient and yourself BE BOLD, WALK ALONG NEW PATHS EXPERIENCE IT YOURSELF
  44. 44. ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com &

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