Management of menorrhagia according to latest guidelines. It is just summary of the latest guidelines.

1. Amalina Mohd Daud
0917298
Management of
Menorrhagia

2. Outline
 Pharmacological treatment
 Surgical treatment
 Lifestyle modifications

3. Pharmacological treatment
Choices
1. Hormonal treatment
2. Non-hormonal treatment

4. HORMONAL TREATMENTS

5. LNG-IUS
Vertical stem: release daily
doses of 20 micrograms of
LNG
Effects:
-prevent endometrial
proliferation
-thicken cervical mucus
-suppress ovulation
Cost effective when compared with
other hormonal and non hormonal
treatments
Reduction of MBL between 71-96%
-benefit seen after 6 months

6. COCP
Contain estrogen and
progestogen in
combinations
Act on HPO axis to
suppress ovulation and
fertility
-cause withdrawal
bleeding
Reduces MBL by 43 %
- Greater than naproxen
- Lesser than danazol and
tranexamic acid
Less benefit with higher
cost

7. Oral Progestogen
Progesterone
-hormone produced during luteal
phase
-cause secretory transformation of
endometrium  bleeding when
levels fall
Reduction of MBL by 84% (93% : LNG)
Requires long course regimen

8. Danazol
Anti-estogenic and anti-progesteronic
activity
-antiproliferative to endometrium
-anovulatory by preventing GnRH at
pituitary
Reduce MBL by 50%
Significant androgenic side effects
-weight gain
-acne
-hirsutism
-voice changes
Reversible with treatment cessation

9. GnRH-analogues
Synthetic peptide that act like a
natural GnRH but with longer
biological half life
Action
1. Flare effect
-increase FSH and LH
2. Profoung hypogonadal
effect
- after 10 days
downregulation
No follicular development, estrogen
production, no ovulation, no
progeterone, no menses
Treatment
1. Hormonal sensitive cancer
-breast cancer, prostate cancer
2. Estrogen dependant lesion
- leiomyoma, endometriosis
Reduces MBL but with high
adverse effects

10. Non-hormonal treatments

11. Tranexamic acid
Competitive inhibitor of
plasminogen activator
-antifibrinolytic agents
Menorrhagia
-Reduced breakdown of fibrin
preformed clot in spiral
endometrium arterioles  reduce
MBL
Reduce MBL by 34-59% Cost effective when compared with other
NSAIDS and no treatment
-not when compared with LNG-IUSHowever,
-not reduce dysmenorrhea
-not a contraceptive
-not regulate cycles
Dosage:
1g ( 2 tablets) 3-4x daily from onset of
bleeding up to 4 days

12. NSAIDs
Reduce prostaglandin synthesis
by inhibiting COX
Prostaglandin:
- Inflammatory response
- Pain pathways
- Uterine cramps
- Uterine bleeds
Reduces MBL 20-49% but tranexamic
acid and danazol reduces MBL greater
-better AE profile than danazol
Less cost effective than LNG and
tranexamic acid
Treatment of
dysmenorrhea
However,
- Not contraceptions
- Not to be used in bleeding
disorders

13. Recommendation for
Pharmaceutical Approach

14. Recommendations
 Considered in
- no structural or histological abnormalities
- fibroid <3 cm that not distort uterus
 Choices depends on wish to conceive
 If either can, follow order
1. LNG-IUS
2. Tranexamic acid or COCP
3. Oral Progestogen

15.  If treatment is needed during investigations or before
definite treatment
- tranexamic acid or NSAIDs
 If coexist with dysmenorrhea  NSAIDs
 Stop NSAIDs and tranexamic acid if no improvement
after 3 cycles
 GnRH-a
-recommended prior to surgery
-other treatments of uterine fibroids (UAE, surgery)
is
contraindicated

16.  Not to be used as HMB treatment
-Danazol
-Ethamsylate
- Oral progestogen during luteal phase

17. Surgical treatments

18. Endometrial Ablation
Indications
- Severe bleeding that impact quality of life
- Not want to remain fertile
- Normal size uterus, small fibroids
How it works?
- Remove endometrial lining will stop heavy
bleeding
- Recurrence occur and repeated surgery can be
done
- Effective contraception after surgery

19. Effect on MBL
- Reduce MBL and improve quality of life
- Less effective than hysterectomy
Unwanted outcomes
-vaginal discharge
- Increasing dysmenorrhea
- Infection (less common)

20. Hysterectomy
Indications
- Heavy bleeding with failed other treatment options
- Don’t want to remain fertile
- Want period to stop
- Or, large fibroids
Adverse Outcomes
- infection-common
- Intraoperative hemorrhage, damage abdominal
organs, urinary dysfunction
- With oophorectomy menopausal like syndrome

22. Uterine artery embolization
(UAE)
Indications
- Heavy bleeding
- Large fibroids
How it works?
- Small particles introduced into artery supply to the uterus
 fibroid shrinks
Adverse outcomes
- Persistent vaginal discharge
- Post-embolisation syndrome: pain, nausea, vomiting and
fever
- Need additional surgery
- Premature ovarian failure
- hematoma
Fertility
maintained!

23. Myomectomy
Indications
- Heavy bleeding
- Large fibroids
How it works?
- Fibroids are removed
Adverse outcomes
- Adhesion ; pain and impaired fertility
- Need additional surgery
- Recurrence of fibroids
- Perforation (hysteroscopic route)
- infection