This document discusses the use of Mirena (LNG IUS) for treating complicated cases of menorrhagia that are inoperable or difficult to treat. It presents several case studies where Mirena successfully controlled bleeding in patients with conditions such as renal transplants, multiple C-sections, fibroids, endometriosis, and obesity. Mirena is shown to be an effective long-term treatment for menorrhagia, reducing blood loss in many cases to normal levels with few side effects. It is particularly useful for cases where other medical or surgical options carry more risks or complications. Studies comparing Mirena to procedures like endometrial ablation find that Mirena achieves similar or better control

1. A BOON FOR COMPLICATED AND
INOPERABLE CASES
By:
DR. MRS. MANJUSHREE BOOB
M.D., D.N.B., FICMCH, FICOG
DIPLOMATE OF NATIONAL BOARD.
CONSULTING OBSTETRICIAN GYNAECOLOGIST
INFERTILITY & LAPAROSCOPIC SURGEON
SHUBHAM HOSPITAL BADNERA ROAD, AMRAVATI

2. REAL LIFE SITUATION
• YOUNG LADY 28 YRS. OLD
• SEVERE MENORRHAGIA REPEATED
• Hb% 5 - 8gm%
• M/4 8 – 10 / 28 – 30 / HOW +++ 6 – 8 Pads WITH
CLOTS.
• O/H  PARA 1 – FTN 2 YRS. ANXIOUS TO HAVE
FURTHER CHILDBEARING.
• P/V / TVS  UTERUS BULKY
• T/T  NOT RESPONDING TO ORAL HORMONES
AND D & C MIRENA INSURTED 4 ur fACT.

3. CASE STUDY- 2
• 48 YRS OLD.
• SEVERE MENORRHAGIA.
• H/O RENAL TRANSPLANT & ON REGULAR
ANTI PLATELET DRUGS.
• NOT FIT FOR SURGERY.
• MIRENA INSURTED 3 YRS. BACK.
RESULT: GOOD CONTROL FOR BLEEDING

4. CASE STUDY- 3
• 37 YRS. OLD.
• PARA – 4. ALL C SECTION ALIVE – 2
• H/O HERNIA REPAIR BY PROLENE MESH.
• SEVERE MENORRHAGIA SINCE 2 YRS.
• TVS MULTIPLE FIBROID
• SIZE -- & 2-3 IN NUMBER
• T/T MIRENA.

5. CASE STUDY- 4
• 4 CASES OF 45 – 48 YRS. OLD.
• PREV 3 C- SECTION.
• SEVERE MENORRHAGIA
• NOT RESPONDING TO DRUGS AND
D & C
• T/T  MIRENA

6. CASE STUDY- 5
• 32 YRS OLD.
• SEVERE MENORRHAGIA SINCE 2 YRS.
• TVS FIBROID OF SIZE 3 X 3 CM.
INTRAMURAL
• NOT WILLING FOR SURGERY
• PARA 2
• MIRENA INSERTED.

7. CASE STUDY- 6
• 30 YRS OLD.
• PARA 1 WITH ITP
• SEVERE MENORRHAGIA SINCE 2 YRS.
• MIRENA INSERTED.

8. CASE STUDY- 7
• 34 YRS OLD.
• PARA 1 – LCB 1 YR.
• MENORRHAGIA
• TVS CHOCOLATE CYST AND
ENDOMETRIOSIS
• OPERATIVE L’SCOPY CYSTECTOMY
WITH BIPOLAR FULGERATION DONE.
• MIRENA INSERTED.
• BLEEDING AND PAIN REDUCED

9. CASE STUDY- 8
• 45 YRS OLD FEMALE
• WEIGHING 95 KG.
• SEVERE HT AND DM
• MENORRHAGIA
• D & C DONE
• MIRENA INSERTED.

10. MIRENA:
BOON FOR COMPLECATED AND
INOPERABLE CASES
CAFETARIA APPROACH
MENORRHAGIA
DUB FIBROID ELSE
ENDOMETRIUM
• ORAL OR INJECTABLE HORMONES
• MIRENA
• THERMA CHOICE
• TCRE
• HYSTERECTOMY
VAGINAL LAPAROTOMY
LAPAROSCOPIC
“ T/T SHOULD BE TAILORMADE TO THE PATIENT
AND HER DISEASE ”

11. Therapeutic Use of LNG IUS
• Prevention of anemia
• Treatment of menorrhagia / dysmenorrhea
• Alternative to sterilization
• Endometrial protection with ET
• Promising findings:
Treatment of endometriosis / adenomyosis
Endometrial protection with Tamoxifen
Treatment of endometrial hyperplasia

12. Normal
menstrual cycle
Menorrhagia
Metrorhagia
MBL 40 ml
Over 80ml
Variable
Bleeding pattern of Menorrhagia
280Days

13. Menstrual Blood Loss before and
after LNG-IUS insertion
0
20
40
60
80
100
Baseline 3 months 6 months 12 months
MBL
(estimated
by PBACs
score)
p<0.0001
p<0.0001
p<0.0001
97
32
22
16
Vera Grigorieva,
Fertil. Steril. 2003

14. LNG-IUS
Only careful fundal insertion
No special surgical skills
Takes care of contraception
Therapeutic in adenomyosis
Cost for five years low
Fertility preserved
Has shown to replace
hysterectomy
Resection
Operation with complications
Specialist with endoscopic skills
Intrauterine and ect. pregnancies
Adenomyosis a problem
Cost for five years high;
recurrencies
Fertility lost
Hysterectomy increased
LNG-IUS and Endometrial
Resection in Menorrhagia

15. Summary of LNG-IUS
• LNG-IUS is effective and inexpensive
medication in the treatment of
menorrhagia

16. MIRENA® in the Symptomatic
Treatment of Endometriosis

17. Endometrial Hyperplasia, Effect of
MIRENA®

18. LNG IUS: Mode of action
• Prevention of endometrial proliferation
• Thickening of cervical mucus
• Local effects on the endometrium
• Effects of ovum fertilization, without complete
inhibition of ovulation
• Minor effect on ovarian function

19. LNG IUS

20. Bleeding &
spotting days per
month
LNG IUS (n = 1495)
Nova-T (n = 739)
8
6
4
2
0
Meannumberofdays
Months
Meannumberofdays
0
4
8
12
16
0 2 4 6 8 10 12
Bleeding per month in 1st year
Andersson et al., 1994
p < 0.001
Bleeding days per
month

21. Contraceptive efficacy of LNG IUS
•Overall pregnancy rate: 0.16 per 100 woman-years
•European multicentre study: cumulative gross pregnancy
r ate
- 1-year rate LNG IUS: 0.1%Cu IUD: 1.0%
- 5-year rate LNG IUS: 0.5%Cu IUD: 5.9%
•Risk of ectopic pregnancy: 0.06 per 100 woman-years.
Ectopic rate for women not using any contraception: 0.3-
0.5 per 100 woman-years

23. What is menorrhagia?
• Menstrual bleeding (bleeding occurring at
normal intervals (21─35 days), but with
– Heavy flow (≥ 80 mL) or
– Duration (≥ 7 days)
• Excessive menstrual blood loss can cause
apprehension, embarrassment and
inconvenience and, over several cycles, may
cause iron deficiency anaemia

24. Causes of menorrhagia
• Idiopathic
• fibroids
• endometriosis / adenomyosis
• genital infections
• polyps
• hyperplasia
• malignancy
• coagulation or endocrine disorders
• medications

25. Medical therapy for menorrhagia
• Mirena®
• Progestogens (oral or injectable)
• Tranexamic acid
• Non-steroidal anti-inflammatory agents
• Combined oral contraceptives
• Danazol
• GnRH analogues
74-97%
32-50%
47-54%
20-50%
43%
50%
>90%

26. Surgical options for
menorrhagia
• Hysterectomy
– Vaginal
– Abdominal
– Laparoscopic
• Endometrial ablation/resection
– Laser
– Thermal balloon
– Microwave
– Transcervical resection of the endometrium (TCRE)
– Fluid instillation
– Cryotherapy

27. Summary of studies comparing Mirena®
with
endometrial ablation/resection
97% (36 months)
99% (36 months)
19
22
Rauramo et al, 2004
Mirena
TCRE
90% (12 months)
98% (12 months
30
29
Istre and Trolle, 2001
Mirena
TCRE
71% (6 months)
50% (6 months)
25
25
Barrington et al., 2003
Mirena
Thermal balloon
82% (median 20.9 month)
73% (median 8.3 months)
20
35
Henshaw et al., 2002
Mirena
Microwave ablation
Reduction in menstrual
blood loss (duration of
assessment)
NStudy
TCRE; transcervical resection of the endometrium