4. More than 1 in 5
30s & 40s suffer from
HEAVY PERIODS
(Unmanageable)
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. Hysterectomy
• Second most
frequent surgical
procedure in women of
reproductive age group
• 90% for benign reasons
• Promptly offered
following a diagnosis.
7. 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
8.
9.
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
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
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
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
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
28. 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)
29. 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
34. 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
35. 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
36. 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
38. 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?
40. 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
41. 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
42. 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
45. 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
48. KJ Carlson, NEJM 328:856,
1993
HYSTERECTOMY
as Treatment
Should be last resort
49. 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
Editor's Notes
The sinequa non of dub is heavy periods.
Mirena
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
