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Management of Menorrhagia

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Management of Menorrhagia

  1. 1. Ben Savage Karen Pond Esyllt Iago
  2. 2.  Mrs Smith 25 yr old banker  PC- ◦ heavy periods and mild pain, which now affects her job  HPC- ◦ since she started periods at 13 ◦ Pain relieved by Ibuprophen ◦ Regular pad changes (20 per cycle) ◦ Some flooding ◦ Often tired ◦ Affecting quality of life
  3. 3.  Increased menstrual blood loss ->80ml/cycle  15% of women have diagnosis.  Quality of life assessment
  4. 4. Symptoms Signs  Change, increased menstrual blood loss  Flooding  Blood clots  Frequent pad changes  Pain  Conjunctival pallor  koilonychia
  5. 5.  Persistent postcoital bleeding.  Persistent intermenstrual bleeding.  Dyspareunia.  Dysmenorrhoea.  Pelvic pain and/or pressure symptoms.  Vaginal discharge.
  6. 6.  Haemotological: FBC; Clotting.  Biochemical: U&E; TFT; LFT.  USS  Laparoscopy  Biopsy
  7. 7. Dysfunctional uterine bleeding IUCD Fibroids Endometriosis/ Adenomyosis Hypothyroidism Endometrial Carcinoma Clotting abnormalities
  8. 8.  Family history (clotting disorders)  Anovulatory cycles (post menarche and pre menopausal)  Inadequate luteal phase
  9. 9.  Treat underlying pathology  Conservative ◦ Reassurance ◦ Coping strategies
  10. 10. IUD OCP (Oral contraceptive pill) NSAIDS Antifibrinolytics (Tranexamic Acid) Antiprostaglandin (Mephanemic Acid) Medroxyprogesterone acetate (long acting progestogen)
  11. 11. Endometrial Ablation/resection; Hysterectomy
  12. 12.  20mg Levonorgestrel released daily
  13. 13.  Review 2005 = 10 RCT comparing LNG-IUS Vs Surgery/pharmaceutical treatments.
  14. 14.  Only 1 RCT; Fraser 1991  Comparing COC with Nefenamic Acid, Naproxen and Danazol.  N=45.  Results = MBL was reduced by 43% by the COC.
  15. 15.  TRANEXAMIC ACID 1g tds/qds from bleeding onset for 4 days.  3 reviews : 1. 7 trials; overall MBL ⇓46.7% 2. T.A Vs Placebo ⇓93.96ml
  16. 16.  TRANEXAMIC ACID 1g tds/qds from bleeding onset for 4 days.  3 reviews : 1. 7 trials; overall MBL ⇓46.7% 2. T.A Vs Placebo ⇓93.96ml 3. 5 trials ⇓34.59%
  17. 17.  Lethaby A, Farquitiari C, Cooke I (2000)  AIM: To determine the effectiveness of antifibrinolytics in achieving reduction in HMB  Selection: RCT – reproductive age. No PCB/IMB. 4 used.
  18. 18.  Results: Antifibrinolytics compared to placebo  Significant reduction in mean blood loss  WMD -94.0 (CI -151.4 - -36.5)  Significant change in reduction of blood loss -110.2 (CI -146.5— -73.8)
  19. 19.  AF’s compared to:  Mefenamic acid WMD -73.0, 95% CI -123.4 to -22.6  Norethisterone - WMD -111.0, 95% CI -178.5 to -43.  Ethamsylate -WMD -100, 95% CI -143.9 to -56.1
  20. 20.  Women preferred Tranexamic acid (wasn't significant) – Flooding and sex life.  Conclusion – Antifibrinolytic therapy causes greater reduction in objective measurements of HMB compared to placebo and medical therapies
  21. 21. NSAIDs  Coulter A, Kelland J, Peto V, et al. 1995  Treating menorrhagia in primary care: An overview of drug trials and a survey of prescribing  Concluded that NSAIDs work. They are not the most effective but have a much better side-effect profile
  22. 22. NSAIDs  Mefenamic acid (ten studies) reduction in MBL = 29.0% [95% CI 27.9% to 30.2%];  Diclofenac (two studies) reduction in MBL = 26.9% [95% CI 23.3% to 30.6%];  Naproxen (five studies) reduction in MBL = 26.4% [95% CI 24.6% to 28.3%];  Ibuprofen (three studies) reduction in MBL =16.2% [95% CI 13.6% to 18.7%])
  23. 23.  2 RCT = no effect on menstrual bleeding, if given during the luteal phase.  One small trial of 44 women supports continuous progesterone between days 5-26. MBL ↓83%
  24. 24. Treatment Reduction in blood loss (%) Source of evidence Additional comment Levonorgestrel-releasing intrauterine system 71–90 Several high- quailty RCTs Compared favourably with other treatments in head-to-head trials in terms of effectiveness and patient satisfaction Tranexamic acid 29–58 Several high- quality RCTs No long-term outcomes have been reported Nonsteroidal anti- inflammatory drugs 20–49 Several high- quality RCTs Mefenamic acid most effective, ibuprofen significantly less effective Also effective treatment for menstrual pain Combined oral contraceptive 43 One small RCT (n = 45) Other benefits including regulation of cycles and reduction in breast pain High-dose oral progestogen* 83 One small RCT (n = 44) Not as effective or preferred as the levonorgestrel-releasing intrauterine system Requires long-term use Long-acting progestogen 22–47† No direct evidence from RCTs Data extrapolated from large trials of women requiring long-term contraception Danazol About 50 Several high- quality RCTs Use limited by frequent, clinically significant adverse effects Etamsylate About 13 Several high- quality RCTs Least effective treatment for menorrhagia RCT = randomized controlled trial * Use in both the follicular and luteal phases. Use in the luteal phase only is ineffective. † Figure relates to the proportion of women with amenorrhoea after 1–2 years of use with depot medroxyprogesterone acetate. Data from: [National Collaborating Centre for Women's and Children's Health, 2007]
  25. 25.  Lethaby A, Sheppard S, Farquhar C, Cooke I 1999  Selection: RCT comparing endometrium techniques (any) Vs Hysterectomy- 7 used.  Results – Significant advantage of Hysterectomy in the improvement of HMB (OR 0.04 (0.01-0.02) – at 1 yr  Satisfaction rates )OR 0.5 (0.3-0.8) compared with ablation.
  26. 26.  Repeat surgery OR 16.7 (5.8- 48.6)  Conclusion: Hysterectomy more effective at reducing bleeding symptoms  Endometrial resection offers an alternative - short term.  Nagele 1998 and Bourdez 2004 majority of women would chose ablation over hysterectomy if success of 50%
  27. 27. Thank you for listening Any Question

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