GnRH Analogues in Heavy Menstrual Bleeding

1. The Role of GnRH Analogues In The
Management Of Heavy Menstrual
Bleeding
Dr. Christine Lee
MBBS, MRCOG

3. Heavy Menstrual Bleeding
Medical Treatment
Progestins/
COCP
Tranexamic
Acid/NSAIDs
Gestrinone/
Danazol
LNG-IUS GnRHa

4. What are Gonadotrophin Releasing
Analogues?
• A type of drug that
acts as an agonist
of the GnRH
receptor, the
biological target of
gonadotropin-
releasing hormone
(GnRH).
Triptoreline Acetate
Leuproreline Acetate

5. GnRHa
• Synthetic peptides administered by
intramuscular, subcutaneous or intranasal route
for short-term use.
• Continuous delivery preparations have a much
longer half-life than the natural GnRH in a
pulsatile manner from the hypothalamus.

6. GnRHa
• Sustained presence of GnRH results in low FSH
and LH production, and a profound
hypoestrogenic or menopausal state.
• As there is no endometrial stimulation,
menstruation does not take place.
• Studies have demonstrated excellent efficacy,
with an amenorrhea rate of up to 90% with
GnRH agonist use.

7. Using A Negative Feedback For
Good!

9. GnRHa

11. Uterine Fibroid
• Most common benign tumors of the female
reproductive tract.
• Asymptomatic tumors are not usually treated.
• Symptomatic fibroids require intervention due to
large size, rapid growth, degeneration, or
associated with menorrhagia.
• Fibroids may be associated with infertility and
higher incidence of spontaneous pregnancy loss.

12. • Surgical removal of the tumor
(hysterectomy or myomectomy)
is currently the only effective
therapy.

13. • Estrogen may stimulate the
growth of fibroid, and these
tumours regress in
hypoestrogenic states, such
as menopause.
• GnRH agonist produce
profound hypoestrogenism
and thus have been used
for medical treatment of
leiomyomata.

14. Reduction In Uterine Size
• Treatment with any GnRH agonist for a 3-month
period results in a 40% to 60% decrease in the
mean uterine volume.
• The maximum reduction in uterine volume is
usually noted by the third month of treatment, and
the extent of reduction is related to the degree of
hypoestrogenism achieved during treatment.
• Uterine volume returns to pretreatment size within
3 to 6 months.

15. • Convert midline
incision to suprapubic
transverse incision
• Smaller midline
incision
• Laparoscopic surgery
• Less complicated
surgery

16. Anaemia and Blood Loss
• Menorrhagia-related Anaemia: Concomitant
administration of iron with GnRH agonist therapy
may lead to a significant increase in serum iron
and hemoglobin concentrations and reduce the
need for blood transfusion pre-operatively.
• Reduced blood loss intra-operatively leads to
reduced blood transfusion and transfusion-
related complications.

17. Alternative to Hysterectomy:
Endometrial Ablation
• Endometrial ablation entails
destruction of the entire
endometrial layer by means of
laser, electrocautery,
electrosection, or heating,
leaving the uterine cavity intact
but scarred and devoid of
endometrium.

20. Endometrial Ablation
• To achieve maximum ablation, the endometrium
should be as thin as possible at the start of
ablative treatment.
• Because of their hypoestrogenic effects, GnRHa
in usual doses administered for approximately 8
weeks have been found to be very effective in
achieving the desired endometrial thinning
before the procedure.

22. What is the Catch?
• Flushing, vaginal dryness, headaches and
decreased libido.
• Most of the side effects can be attributed
to low estrogen levels.
• Limitation of these menopausal symptoms
can be achieved with ‘add-back’ hormone
replacement therapy (HRT).

23. ‘Add-back’ Hormone Replacement
Therapy
• A prolonged hypoestrogenic
state leads to bone
demineralization.
• ‘Add-back’ HRT is necessary
after 6 months of use to
protect bone mineral density.

24. • Usually the GnRH agonist is
commenced alone and
discontinued after 6 months.
• ‘Add-back’ HRT is introduced
if the woman continues
treatment for > 6 months, or
sooner if symptomatic.

25. Take Home Message
• Achieve reduction in uterine size to
convert a midline laparotomy incision to
pfannenstial incision, or to convert open
surgery to laparoscopic surgery and can
reduce complexity of operation.
• Reduce the need for blood transfusion.
• To enable successful endometrial ablation.
• Limitation: menopausal side effects.

27. Dr. Christine Lee
MBBS, MRCOG