Management of menorrhagia


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

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Management of menorrhagia

  1. 1. Amalina Mohd Daud 0917298 Management of Menorrhagia
  2. 2. Outline  Pharmacological treatment  Surgical treatment  Lifestyle modifications
  3. 3. Pharmacological treatment Choices 1. Hormonal treatment 2. Non-hormonal treatment
  5. 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. 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. 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. 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. 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. 10. Non-hormonal treatments
  11. 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. 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. 13. Recommendation for Pharmaceutical Approach
  14. 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. 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. 16.  Not to be used as HMB treatment -Danazol -Ethamsylate - Oral progestogen during luteal phase
  17. 17. Surgical treatments
  18. 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. 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. 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
  21. 21. 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!
  22. 22. 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