This document provides guidelines for the management of menorrhagia (abnormal uterine bleeding). It discusses medical management including hormonal therapies like combined oral contraceptives and progestogens. It also discusses minimally invasive surgical procedures for endometrial ablation like hysteroscopic ablation and newer techniques like microwave and radiofrequency ablation. Other procedures mentioned include uterine artery embolization and hysterectomy if other options fail. It provides details on treatment approaches, expected outcomes, advantages and disadvantages of different treatment modalities.

1. DEPT OF OG

2. Management
 Control menorrhagia.
 Prevent or treat anaemia.
 Prevent recurrence.
 Treat the cause

3. Acute bleeding
 IV premarin 25 mg 6–8 hourly,24-48 hrs
 Endometrial regeneration
 intravenous tranexamic acid 1 gm with 25 mg of
oestrogen
 inhibits tissue plasminogen activator which is a
fibrinolytic enzyme, whose level increases in abnormal
uterine bleeding
 oestrogen for 21 days
 progestogen added for 10 days
 3–6 cycles will regularize the cycles

4.  NSAID- mefenamic acid 500 mg t.i.d along with
antacids.naproxen,Ponstan,Ibuprofen
 Mirena IUCD
 Arterial embolization is required in case of varicosity
of uterine vessels
 uterine tamponade using Foley catheter for 24 hours
can control bleeding in the acute episode
 Anti-TB treatment in endometrial tuberculosis

5.  Blood transfusion may be required to correct anaemia
 Van Willebrand’s disease-Desmopressin
 intravenously or by nasal spray
 1.5 mg/mL – total 150–300 mg in 30 mL diluted

6. chronic menorrhagia
 maintain a menstrual calendar noting duration and
extent of blood loss.
 General measures to improve the health status of the
patient.
 proper diet,
 adequate rest during menses,
 oral haematinics,
 vitamins and protein supplements

7. Hormone Therapy
 Oestrogen therapy alone is not recommended
 Progestogens are the main hormones
 Progestogen induces oestradiol 17 b-dehydrogenase
which converts oestradiol to weak oestrone which in
turn suppresses E2 receptors, DNA synthesis and has
anti-mitotic activity.
 endometrial atrophy.

8. progestogens
 10–30 mg a day
 arrest bleeding in 24–48 hours,
 5 mg daily is given for 20 days
 Withdrawal bleeding occurs 2–5 days
 further course of 5 mg daily for 20 days is started on
the second or third day of the periods cyclically for 3 to
6 months
 Duphaston (10 mg) does not suppress ovulation
 norethisterone, duphaston, DMPA , Gestrinone

9. OC PILLS
 oral contraceptive pills,3-6 cycles
 not recommended >35
years,obese,diabetics,smokers,migraine etc
 Seasonale - combined oestrogen and progestogen
 84 days with a gap of 6 days in a three-monthly
treatment.
 Menstruation occurs during the tablet-free period
 Danazol - androgenic side effects.
 200 mg daily for 3–4 cycles

10. NSAID
 Nonsteroidal anti-inflammatory drugs taken during
menstruation for 4–5 days
 mefenamic acid 500 mg t.i.d along with antacids.
 naproxen,
 ponstan and
 ibuprofen.
 control menorrhagia by 70% in ovulatory cycles, post-
IUCD and poststerilization menorrhagia.
 inhibit cyclo-oxygenase and prostaglandin
productions.

11. ETHAMSYLATE
 Ethamsylate reduces capillary fragility
 500 mg four times a day
 5 days prior to anticipated period, up to 10 days
 reduces menorrhagia by 50%
 ovulatory cycles.

12. ANTIFIBRINOLYTICS
 Antifibrinolytic agents—Tranexamic acid 1–2 g four
times a day for 6–7 days
 Ethamsylate combined with 250 mg tranexamic acid is
also advocated.
 Combined tranexamic acid with mefenamic acid

13. GnRH Analogue
 Depot injection 3.6 mg given monthly for 4–6 months
 anti-oestrogenic action causes menopausal symptoms
and osteoporosis.
 add-back therapy 5–10 mg norethisterone or tibolone
 GnRH takes 4 weeks to act
 not effective in acute episodes of bleeding.

14. SERM(selective oestrogen receptor
modulator)
 ormeloxifene
 centchroman
 nonhormonal
 60 mg twice weekly for 12 weeks to 6 months
 Weekly
 It does not cause breast or uterine cancer
 anti-oestrogenic effect
 agonist to cardiovascular system and
 bone protective.
 lengthens the follicular phase and delays menstruation.
 It can cause functional cyst, dyspepsia and headache at times.

15. Combined oral
contraceptives
20–30 μg EE 2+
progestogen
seasonale–3 monthly
Nausea, headache,
hypertension,
hyperglycaemia,
thrombosis, liver and gall
bladder disease, breast
cancer
Progestogens 5–10 mg tablet TDS for
3 weeks cyclically
Continuous 3 monthly
3 monthly injections
Implant
Weight gain, depression,
headache, acne,
abnormal lipid profile,
breast tumours
Gestrinone 2.5 mg twice weekly Thromboembolic
episodes
Danazol 100–200 mg daily Acne, hirsutism, weight
gain, reduced HDL,
cholesterol

16. GnRH analogues 4 weekly injections Menopausal symptoms,
osteoporosis, loss of
libido,
Tranexamic acid 1 g 6 hourly Nausea, vomiting
diarrhoea, headache,
visual disturbances,
intracranial thrombosis

17. NSAIDS Mefenamic acid 500 mg
tid
Nausea, vomiting,
dyspepsia, gastric ulcer,
diarrhoea,
thrombocytopenia
Ethamsylate 500 mg four times daily Nausea, headache, rash
Mirena IUCD 52 mg levonorgestrel Less than those of oral
progestogen—because its
action is local resulting in
endometrial suppression.
However, it takes 2 to 3
months to reduce
menorrhagia and the
effect lasts for 5 years
Ormeloxifene 60 mg twice weekly functional cyst, dyspepsia
and headache

19. MIRENA
 directly suppresses endometrium with minimal side effects
 no action on the ovaries
 E2 and progesterone levels remain normal
 It reduces blood loss by 70–90% in 3 months
 Contraceptive action.
 retained for 5 years
 irregular bleeding during the first 3 months,
 25% - amenorrhoeic by 1 year.
 80% conceive by 12 months
 Mirena is also useful in women with uterine fibroid,
adenomyosis

20. Advantages of Mirena
Advantages of Mirena IUCD over ablative techniques:
 Low cost
 OPD procedure—no hospitalization
 Preservation of fertility after its removal
 Pregnancy occurs within a year. The only disadvantage
is occasional systemic side effects of progestogen.

21. Disadvantages of Mirena
 Slightly difficult to insert.
 Takes 3 months before it becomes effective.
 Amenorrhoea in 20–25%
 Ectopic pregnancy in 0.2 per 100 women.
 Hysterectomy in 25% by the end of 3 years because of
recurrence of menorrhagia.

22. Minimal Invasive Surgery (MIS)
 safe, effective
 lesser morbidity than hysterectomy,
 costeffective
 quicker recovery.
 Hysterectomy is avoided in many cases.
 Histopathological diagnosis must
 Fertility is not possible following ablative therapy.
 destroy 2–3 mm of myometrium, if recurrence of
menorrhagia has to be avoided.

23. Minimal Invasive Surgery (MIS)
 First generation—Hysteroscopic endometrial
ablation by resectoscope, loop, rollerball coagulation
and laser [transcervical endometrial resection
(TCRE)].
 Second generation—radiofrequency induced thermal
ablation, Cavaterm balloon therapy, microwave
endometrial ablation (MEA), laser therapy
 Uterine tamponade
 Bilateral uterine artery embolization.

24. Hysteroscopic endometrial
ablation
 Soon after the menstrual period
 Endometrium is thinned out (progestogens, danazol or GnRH
for 4–6 week prior to the procedure).
 general anaesthesia,Hysteroscope used
 destroys 4–5 mm endometrium and forms uterine synechiae
Contraindications
 Uterine size >12 weeks
 Uterine fibroid
 Scarred uterus
 Young woman desirous of pregnancy
 Adenomyosis—TCRE can cause dysmenorrhoea
 Genital infection
 Uterine cancer or preinvasive cancer, atypical hyperplasia

25. Complications
 Anaesthetic complications.
 fluid overload (glycine 1.5%), pulmonary oedema, hypertension,
hyponatraemia,
 anaphylactic reaction with dextran,haemolysis and at times
death.
 Uterine, bowel and bladder injury with burns and vaginal fistula.
 Embolism, infection and haemorrhage.
 Menorrhagia recurs in 25% cases by the end of 3 years and needs
repeat TCRE or hysterectomy.
 Dysmenorrhoea in a few women, and haematometra due to
cervical stenosis.

26. Radiofrequency-induced thermal
ablation (RITEA)
 Blind procedure using radiofrequency electromagnetic
thermal energy
 destroys the endometrium at 66°C.
 0.6 mm metallic probe is inserted transcervically
under general anaesthesia
 rotated over 360° for 20 min.
 About 85% get cured
 30% amenorrhoeic by 1 year.

27. Advantages of RITEA
 cheaper when compared to TCRE,
 does not require skills of hysteroscope and
 complications of distending media are avoided.
 Contraindications and complications are similar to
those of TCRE.

28. Cavaterm balloon therapy
 central computer system, battery and a disposable silicon
rubber balloon catheter 5 mm in diameter.
 Under local anaesthesia, the catheter is inserted
transcervically into the uterine cavity, and the balloon is
distended with 15–30 mL sterile solution such as 5%
glucose or 1.5% glycine.
 The heating element in the balloon raises the temperature
to 87°C (187°F),maintained for 8 min over a pressure of
160–180 mm Hg to exert a tamponade effect.
 The catheter has an inherent safety design related to time,
pressure and temperature
 automatically deactivated to avoid complications.

30.  About 6 mm of endometrium gets destroyed, so
preoperative endometrium thinning is not required
 70–90% resume normal cycles
 15% become amenorrhoeic 1 year.
 Hysteroscopy is not required.
 Cramping felt in the first few hours is treated with NSAIDs
 antibiotics are given.
 Contraindications are endometrium thicker than 11 mm
and others similar to TCRE.

31. Microwave endometrial ablation.
 Utilizes magnetic energy
 works at the frequency of 9.2 GHz. It is an
 OPD procedure, done under local anaesthesia.
 8 mm applicator with
 no need of preoperative endometrial thinning.
 Temperature of 80°C is maintained for 3 min
 50% become oligomenorrhoeic and 40% amenorrhoeic.
 6 mm endometrium gets ablated.
 No earthing is required unlike in TCRE.
 Total operating time is 12 min.
 Hysteroscopy is also not required. The contraindications and
complications are similar to other ablative procedures.

33. vesta system.
 single-use
 multi-electrode intrauterine balloon to ablate the endometrium.
 triangular shaped silicon inflatable electrode carrier
 The controller unit is connected to a standard electro surgical
generator.
 It regulates energy to each balloon electrode plate.
 The temperature is set at 75°C.
 The balloon is inflated with air following cervical dilatation up to
No 9.
 The procedure takes 5 min under local anaesthesia.
 Ninety to ninety-four per cent are cured of menorrhagia
 instrument is very expensive

34. Uterine tamponade
 Goldrath advocated uterine tamponade in acute
episodes of bleeding
 inserting a Foley catheter, distending with 30 mL fluid
and leaving the catheter for 24 h

35. NovaSure
 NovaSure - impedance-controlled endometrial
ablation
 bipolar radiofrequency
 vaporizes endometrium up to myometrium
 latest and safest procedure
 takes just 90 sec

37. ELITT
 Endometrial laser intrauterine thermotherapy
 new laser therapy
 destroys the entire endometrium as well as 1–3.5 mm
of myometrium.
 OPD procedure,takes 7 min.
 ‘GyneLase’.

38. Bilateral uterine artery
embolization.
 Primarily used in uterine fibroids
 extended in intractable AUB in a young woman to
preserve her reproductive function.
 in abnormal uterine bleeding complicated by varicose
uterine vessels.

39. Hysterectomy
 If medical/MIS fails or menorrhagia recurs.
 In older women more than 40 years not desirous of
childbearing, and who opt for hysterectomy as a
primary treatment or ablation fails.
one-time procedure,
safe and cures abnormal uterine bleeding,

40.  abdominal route
 laparoscopic assisted vaginal hysterectomy (LAVH)
 laparoscopic hysterectomy
 vaginal hysterectomy

41. Vaginal hysterectomy is contraindicated if:
1. Uterus is grossly enlarged.
2. Previous surgery with possible adhesions, fixity and
limitation of uterine mobility.
3. Presence of endometriosis or adnexal mass.
4. Nulliparous women or women with a very narrow
vagina.
In a woman less than 50 years, ovaries should be
conserved unless they are diseased

42. complications of hysterectomy
 Ovarian atrophy due to devascularization
 menopausal symptoms and its complications.
 Adhesions of the ovaries to the vaginal vault causing
ovarian residual syndrome, dyspareunia and chronic pelvic
pain.
 Vault prolapse.
 Sexual dysfunction—dyspareunia due to a short vagina.
 Chronic abdominal pain due to postoperative pelvic
adhesions.
 Urinary and bowel symptoms due to denervation.
 Psychological disturbances.

43. 1. Medical treatment should be the first line of treatment,
unless contraindicated. The drawbacks are the side effects
of hormones and symptoms can return once the hormone
therapy is stopped. Prolonged therapy may not be
desirable.
2. If medical therapy fails or is contraindicated, consider
Mirena IUCD.
3. If Mirena fails or side effects develop, go for ablative
techniques. Second generation ablative techniques are
safer, quick to perform and are equally effective.
4. When the above methods fail, consider hysterectomy.

44. THANK YOU

48. Ovulatory cycles - oral nonsteroidal
anti-inflammatory drugs (NSAIDs)
 mefenamic acid 500 mg t.i.d along with antacids.
 naproxen,
 ponstan and
 ibuprofen.
 Blood loss is reduced by 30–40%.
 antiprostaglandins and inhibit cyclo-oxygenase
activity.
 decrease the menstrual bleeding
 no effect on the duration of menstrual bleeding
 taken only during menstruation

49.  Cyclic oral contraceptive pills.
 Progestogens in endometrial hyperplasia.
 Mirena IUCD.
 Minimal invasive surgery includes endometrial
thermal ablation, endometrial resection and others
 Hysterectomy in selected cases.
 GnRH—It is not effective in acute bleeding as it takes
4 weeks to cause effect.