4. More than 1 in 5
30s & 40s suffer from
HEAVY PERIODS
(Unmanageable)
5. Causes of HMB
FIGO Classification
Munro MG, Critchley H, Broder MS, Fraser IS; for the FIGO Working Group on Menstrual Disorders. International Journal of Gynecology and
Obstetrics 113 (2011) 3–13
6. Heavy menstrual bleeding
An important cause of morbidity
• 30% of women in
reproductive age group
suffer with Menorrhagia
• 60% of these women
will ultimately undergo
hysterectomy
7. Non surgical methods of management of
HMB
• Pharmacological
– Levonorgesterol -Intrauterine System (LNG-IUS)
– Antifibrinolytics
– NSAIDS
– GnRH analogues
– Oral contraceptives
– Cyclic progestins
Marret H, Fauconnier A, Chabbert-Buffet N, et al. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):133-7.
Medical therapy is usually considered a first-line treatment for
idiopathic HMB
GnRH – Gonadotrophin Releasing Hormone
8. Surgical methods of management of HMB
• Endometrial ablation (EMA)
– Considered appropriate only for patients who have completed their
family.
– It is also not suitable for women with a large uterus
• Hysterectomy
– Remains the definitive treatment for HMB
– Should not be used as first-line treatment in cases with primary
HMB unless all other treatments are contraindicated or refused by
the patient.
• Uterine fibroid embolization
– New and still experimental
In patients where pharmacological treatment is ineffective or inappropriate,
or the patient does not want drugs, and in patients with certain histological
abnormalities of endometrium, non pharmacological treatment is more
suitable
National Collaborating Centre for Women’s and Children’s Health. Heavy Menstrual Bleeding Clinical Guideline. London: RCOG Press for NICE; 2007.
9. Hysterectomy
• Second most
frequent surgical
procedure in women of
reproductive age group
• 90% for benign reasons
• Promptly offered
following a diagnosis.
10. Value Study(BJOG - 2004)
survey of outcomes of 37,000 hysterectomies
• Operative and
postoperative
complication rate of
3.5% and 9 %
respectively were reported
• Postoperative
mortality of 0.38 /
1000.
• Psychological
implications 35-45%
•
Hysterectomy should not be taken up
11.
12.
13. Dilemma!! of Treatment
Aim - Quality Personal life
- Family life
- Preserve the feminity of a women
- ↓ Frequent leave from office
Age
Severity
Fertility
14. Treatment of Heavy Periods
Individualized
• age
• need for contraception
• desire to retain uterus
• Nature and severity of complaints
• presence of any pelvic pathology
• outcome of previous treatment
• cost of treatment
• time away from work
18. NICE Guideline (Jan 2007)
management of heavy menstrual bleeding
• If future childbearing is desired
LNG – IUS is the first line intervention
• If future child bearing is not
desired
Endometrial ablation
22. Mirena is as effective as
endometrial ablation in reducing
heavy menstrual bleeding
• In sept 2009 , the US FDA approved
mirena as a treatment for heavy menstrual
bleeding
Obstet gynecol 2009;1104-1116
23. Mirena has an additional advantage
of providing reversible contraception.
Menorrhagia
Contraception
24. • Progestin releasing
intrauterine system
• T shaped polyethylene
frame
• Contains 52 mg
levonorgestrel
• Releases 20 µg LNG daily
What is Mirena - LNG IUS
25. Mirena : local mode of action
Prevents endometrial
proliferation
• Thickens cervical
mucus
• Inhibits sperm motility
serum levels are 4 times lower than
after oral ingestion
26. Benefits of local action
No significant change in
• Blood pressure
• Lipid profile
• Coagulation factors
• Carbohydrate metabolism
• Liver function
• Bone mineral density
28. Bleeding pattern in the first 5-year period
Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21
Infrequent
3.7% Regular
70.3%
Ammenorhea
26%
29. Comparison of Rx Modalities
Progesterone or LNG IUS
LNG IUS reduces menstrual blood loss more
effectively and has a higher likelihood of
treatment success than oral medroxyprogesterone
acetate.
Obstet Gynecol. 2010
30. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing
Intrauterine System in Primary Care against Standard Treatment for
Menorrhagia (ECLIPSE) Trial
30
Improvements in MMAS scores were significantly greater
(lesser score= more severity)
Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J for the ECLIPSE Trial Collaborative Group N Engl J Med 2013;368:128-37
Daily routine work, social and family life, and psychological and physical well-being
31. LNG IUS: Efficacy
97% Reduction in
Menstrual Blood Loss over
1 year of therapy
Significant increase in
Hemoglobin and Serum
Ferritin level
32. LNG IUS versus TXA/MFA and MPA: MBL
Reduction
Significant reduction in MBL as compared to TXA/ MFA as well as MPA, with higher
likelihood of treatment success with LNG IUS
MFA = Mefenamic acid: Medroxy progesterone acetate
33. LNG-IUS vs. thermal balloon ablation (TBA)
prospective randomized controlled trial
5 year follow up results across various parameters with use of LNG-IUS vs. TBA
Five-year follow-up of HMB treatment with LNG-IUS was associated with
higher efficacy and satisfaction ratings compared to TBA.
Patient acceptability, perceived clinical improvement and overall
satisfaction rates were significantly higher in women using LNG-IUS.
Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Contraception. 2013;87:409-15.
34. LNG IUS versus Hysterectomy
34
When patients were given the option of mirena
a significant percentage of women cancelled
their hysterectomy
Pekka Lähteenmäki et al. 1998 316: 1122 (6)
35. Finnish trial
(multicentric RCT 236 pts)
• Mirena improves the quality of life as
effectively as surgical treatment at 1 year.
• Women ranked their satisfaction with a
mean score of 7 / 10.
• Less than 5% of women required subsequent
operative treatment
• Mirena is more cost effective than
hysterectomy in the short term
40. Endometrial Hyperplasia
• Beneficial effects are observed by1
year.
• Treatment should be reliably
monitored through regular 6-montly
outpatient follow up
Eur J Obstet Gynecol Reprod Biol. 2008
41. Early-stage Endometrial Carcinoma
May have a role in selected patients
willing to preserve fertility
• Endometrial protection for women on tamoxifen
• Women With Clotting Disorders Or Under Anti
Thrombotic Treatment
Conservative treatment of early endometrial
cancer: preliminary results of a pilot study.
Gynecol Oncol. 2011; 120(1):43-6
42. Are there any drugs that interact with
mirena ?
• Women using mirena
may be reassured that
• No drugs are known
to interact with
mirena
• Can be used safely
with ATT
• No effect on BMD
Not to be used as Emergency Contraceptive
44. COUNSELLING
Is it not very costly as
compared to oral
medication?
Doctor, I am spotting
daily? What do I do?
I have not had periods
since 6 months? Am I
in menopause?
46. Irregular Bleeding or spotting
• May last for 4-6 months
COC or Progesterone is used to tide over
this period
• GnRHa can also be used
Acceptance depends on good
pre insertion counselling
47. COST EFFECTIVENESS
LNG IUS
• Cost- Rs 8205/-
• Insertion cost – Rs.
2000 - 5000
Covered by Insurance
ORAL
PROGESTERONE
1 mnth – Rs. 3000
6 months Rs. 18000
1 Yr Rs. 36000
No insurance
48. How long ?
NICE GUIDELINES : If inserted > 45 yrs of
age and has complete amenorrhea may
continue to use it until menopause.
It can be removed at mid 50s as long as it controls the
bleeding
HRT
Change it after 4 years “licenced”
Contraception
< 45years…..5 years
> 45 years ….7 years
51. Used in 235 cases
INCLUDING FIBROIDS AND ENDOMETRIOSIS
Updated on 26/6/2014
Expulsion in 3
(UBT , hysterectomy , reinsertion )
• It can replace the need of hysterectomy in
2/3rd
of cases.
• Especially useful when future fertility is
desired
52. • Moderate Size
• Multiple
• With Heavy bleeding
• Young (wanted child - 2)
FIBROIDS
16 cases
Effective
Size ↓ - 25 – 30 %
53. • Grade IV with cyst
• Sever Dysmenorrhoea
&
• Bleeding Problem
Endometriosis
15 Cases
Effective – Except 1st
4 month
54. DUB / adenomyosis
Few Keen for future childbearing
Rest Causes
EFFECTIVE – Except 1st
4 month
60. KJ Carlson, NEJM 328:856,
1993
HYSTERECTOMY
as Treatment
Should be last resort
61. Mirena and uterine balloon therapy isMirena and uterine balloon therapy is
thus a new horizon to your patient andthus a new horizon to your patient and
yourselfyourself
BE BOLD, WALK ALONG NEW
PATHS
EXPERIENCE IT YOURSELF
FIGO classification: Munro MG, Critchley H, Broder MS, Fraser IS; for the FIGO Working Group on Menstrual Disorders. International Journal of Gynecology and Obstetrics 113 (2011) 3–13
Medical therapy is usually considered a first-line treatment for idiopathic HMB
Marret H, Fauconnier A, Chabbert-Buffet N, et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):133-7. doi: 10.1016/j.ejogrb.2010.07.016. Epub 2010 Aug 4.
Endometrial ablation (EMA)
Can be offered to patients as initial treatment for HMB but is considered appropriate only for patients who have completed their family.
The patients, however, will require reliable contraception afterwards.
It is also not suitable for women with a large uterus
Hysterectomy
Remains the definitive treatment for HMB with high satisfaction rates,
Should not be used as first-line treatment in cases with primary HMB unless all other treatments are contraindicated or refused by the patient.
Uterine fibroid embolization
This technique is new and still experimental, and requires a body of work before being implemented in clinical practice.
Mirena
Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Contraception. 2013;87:409-15.
A prospective, randomized controlled trial was conducted to compare 5-year follow-up of
LNG-IUS or thermal balloon ablation (TBA) for the treatment of HMB. Hysterectomy rates,
hemoglobin level, bleeding pattern, well-being status and satisfaction rates were assessed.
Results
After 5 years of follow-up the results were as follows (Table 5):
„„ Women treated with a TBA had higher rates of hysterectomy (24%) compared to the LNGIUS
group (3.7%) due to treatment failure (p=0.039).
„„ Use of LNG-IUS resulted in higher mean hemoglobin (±SD) levels in comparison to the TBA
group (14.1±0.3 vs. 12.7±0.4 g/dl, p=0.009).
„„ Menstrual blood loss was significantly higher in the TBA when compared to the LNG-IUS
group (45.5% vs. 0.0% p&lt;0.001) .
„„ The psychological general well-being index scores were similar. Patient acceptability,
perceived clinical improvement and overall satisfaction rates were significantly higher in
women using LNG-IUS.
Five-year follow-up of HMB treatment with LNG-IUS was associated with higher efficacy and satisfaction ratings compared to TBA.
WHY SHOULD’NT A HYSTERECTOMY BE AVOIDED IF THE BENEFIT CAN BE PROVIDED TO A GOOD NO, OF PATIENTS BY A SAFER ALTERNATIVE TT MODALITY COZ HYSTERECTOMY DOES CARRY RISKS OF ANAESTHESIA ETC
