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Role of mirena in heavy periods
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Role of mirena in heavy periods

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  • 1. ROLE OF MIRENA IN HEAVY PERIODS DR. JYOTI BHASKAR MD MRCOG
  • 2. My Journey with LNG- IUS Oman to Republic of Ireland to India 2001 -- 2010 --- 2013
  • 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. Our Experience • Over 300 cases Observed • Inserted in 100 cases personally • 70 for DUB, 30 for Contraception
  • 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. 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. WHY MIRENA? • Patient satisfaction • Comparison with other techniques • Emerging New Indications • Cost Effective • Ease of insertion and Removal
  • 8. Patient Satisfaction •8
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. EMERGING INDICATIONS
  • 22. ENDOMETRIOSIS ADENOMYOSIS
  • 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. 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. FIBROIDS
  • 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. 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. 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. 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. PRACTICAL TIPS TO SUCCESS
  • 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. Counselling- Three problems !!! • Spotting after insertion (explain) • Amenorrhea in 25 % of women • Price
  • 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. 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. 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. Insertion tips • Screening for STI, Cervical Screening • Antibiotic Coverage( Optional) • Insertion Tip – tighten and then LOCK
  • 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. 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. Sonographic Evaluation
  • 40. EXTRA TIPS • Not be used as Emergency Contraception • Can be used with ATT • No effect on BMD
  • 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 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. 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. 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 &