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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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ESSAY 137 - MENORRHAGIA

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		Posted by Sarwat F. Sat Jan 15, 2005 04:55 am
Treatment options available to a woman with learning disabilities presenting with menorrhagia can be evaluated by dividing them into medical and surgical treatments. Medical treatment depends on cause. For disorders related to hypothyroidism or bleeding diathesis, thyroid hormone replacement and correction of clotting factors will be needed. In case of dysfunctional uterine bleeding medical treatment starts with prostaglandin synthetase inhibitors which reduce the blood flow by 25%. However with heavy periods she may need antifibrinolytics like tranexemic acid as well which reduce blood flow by 50 %. Hormonal preparations like progesterone containing drugs and Oral contraceptive pills are also very effective (50% reduction in blood flow) for control of menorrhagia. However in a patient with subnormal mental abilities compliance with oral medications is a problem. Similarly Danazol is also effective in controlling menorrhagia but it has menopausal side effects like hot flushes and mood changes in addition to being an oral drug with low compliance esp for this patient. Injectable drugs include depot medroxy progesterone and gonadotrophin releasing hormone analogues. DMPA is administered three monthly thus lowering the problem of compliance but has side effects like headaches, nausea acne and mood changes. Gonadotrophin releasing hormone analogues are administered by monthly injections. They also obviate the issue of compliance but are associated with side effects of estrogen deficiency like hot flushes dry skin, mood changes. These can be reduced by add back therapy. High cost is also a problem with GnRH analogues. Intrauterine contraceptive device like mirena is also an option which effectively reduces blood flow and has minimal systemic side effects of progesterone. However if this patient is a nulliparous dilatation of cervix and IUD insertion may be a problem making IUD a less favourable option. Surgical options include uterine artery embolisation, endometrial ablation and hysterectomy. Multidisciplinary care with collaboration of a psychiatrist will be needed as these surgical options are not recommended for women wishing to conserve their fertility. If fertility is not an issue uterine artery embolisation is an effective treatment. It is associated with side effects which resolve in short period of time like abdominal pain, pyrexia and vomiting after the procedure. Endometrial ablation can be done as a day case procedure, is cost effective and has quite less complications as compared to hysterectomy. However patient satisfaction may vary from 55 to 75% and menstrual blood loss may remain unacceptable necessitating hysterectomy. Patients may also continue having vaginal discharge for 3 weeks or so. In patients presenting with subnormal mental abilities there is also a risk of sexual abuse and pregnancy. Hysterectomy may prevent the risk of getting pregnant in addition to control of menorrhagia. Hysterectomy is also associated with disadvantages like anaesthetic and surgical complications like hemorrhage, bladder and uretric damage and postoperative complications like wound infection, prolonged hospital stay, urinary tract infections, respiratory difficulties, thromboenbolism and granulation tissue formation. A woman with learning disabilities may not be able to take care of herself and menorrhagia may aggravate the need of her care. He care takers including her partner must be involved in deciding the most suitable option for her giving all the pros and cons of all treatment options available. To ensure that treatment is in accordance with law, consent must be in accordance with the guidelines that is Bolitho modification which states that court is not bound to hold that practice is acceptable unless experts have reached a defensible conclusion. Advice from a psychiatrist may be sought in difficult cases. In all cases assessment of patient’s competency to consent should be entered in patient’s notes.
		Posted by Nibedita R. Sat Jan 15, 2005 12:57 pm
Objective assessment of menstrual blood loss is important, as 50% of women complaining of heavy menses have measured loss within normal limits. Reassurance and supportive care is all that is necessary in such cases. Medical management includes NonHormonal ? NSAIDs- Mefenamic acid commonly used, reduces menstrual loss by 20-40% in 75% women with mennorhagia. Reduces dysmenorrhoea that frequently accompanies ovulatory DUB and menstruation related headache and diarrhoea. They have a better side effect profile compared to tranexemic acid. Tranxemic Acid ? antifibrinolytic agent, reduces menstrual blood loss by 50% and is suitable for most young women. Also effective in reducing blood loss associated with bleeding diathesis, fibroid and IUCD. However, there are dose related GI side effects. Serious side effects like intracranial thrombosis has been documented. Hormonal ? Combined Oral contraceptive pill ? reduces menstrual blood loss by 50%. Can be safely used in young women provided they do not have contraindicating factors. Provide effective contraception and reduces incidence of PID and protect against ectopic pregnancy. They need compliance for their timely and daily administration. It must be administered by the carer. Tranexemic acid, Mefenamic acid and COCP are RCOG recommended first line treatment in primary/ secondary care. Synthetic Progestogens ? such as Norethisterone or MPA are ineffective in the treatment of ovulatory DUB, especially when used in low doses and for 5-10 days in the luteal phase. However, in anovulatory DUB, cyclical norethisterone is effective if given at higher doses. But there is higher possibility of unwanted premenstrual symptoms and androgenic side effects. Depo-medroxyprogesterone acetate induces amenorrhoea in 50% of users at 1year which may not be acceptable to a young woman. This is safe and effective regimen and requires three monthly administration, which is advantageous in this woman, but there is a risk of irregular bleeding. Minera intrauterine system ? associated with 86% reduction of menstrual blood loss at three months and 97% at 12 months. Causes amenorrhoea in 35% cases and oligomenorrhoea in majority. Provide a highly effective and reversible method of contraception for 5 years. Reduces PID, ectopic pregnancy and dysmenorrhoea; but its insertion in multiparous woman may be difficult and require trained staff and general anaesthetic. There may be irregular bleeding during the first 3-4 months after insertion. Danazol is effective in reducing menstrual blood loss. However the clinical use of the drug has been limited by its dose related androgenic side effects like weight gain, acne, hirsutism and hot flushes. Gestrinone taken twice weekly significantly reduces blood loss. Associated with androgenic side effects but milder than danazol. Not licenced for use in the treatment of menorrhagia. GnRH analogues result in amenorrhoea but are associated with menopausal symptoms and loss of bone mineral density. May be used for intractable menorrhagia over short term especially to regress the endometrium before TCRE and prior to myomectomy to reduce size of fibroid. Surgical management ? surgical options are endometrial resection/ ablation and hysterectomy. Though they are effective treatment of menorrhagia, are almost never indicated in young women. The capacity of this woman to understand and give valid consent needs to be assessed by a psychiatrist. Informed consent provides the legal justifation for the provision of treatment to a patient ranging from physical contact, ingestion of medication to surgical procedure. No such treatment could be administered without the patient?s valid consent. The result of psychiatrist assessment if suggests that the lady cannot give valid consent, the lawful authority will provide a certificate for her examination and treatment. Womens relatives need to be involved in her care, but they cannot provide consent. It is the duty and responsibility of the doctor to treat a woman who is unable to provide consent, provided a certificate is obtained from the court. The importance of meticulous documentation at every stage cannot be ignored, especially in this circumstance.
		Posted by narmin B. Sun Jan 16, 2005 02:20 am
The treatment options are medical , insertion of progesterone releasing coil (Mirena), endometrial ablation and hysterectomy. When choosing the type of treatment in addition to the severity of bleeding, previous treatments and the need for preserving patient?s fertility; her severe learning disability also should be considered. Therefore the method of treatment should need as little as cooperation from the patient. In medical treatment, combined oral contraceptive pill (COC) can be given. Contraindications such as thrombosis, focal migraine should be excluded from reviewing patient?s notes or contacting with her GP or family. C.O.C not only reduces bleeding but also it is a reliable contraception in this young woman. It can be given every month or every three months.The disadvantage is the need for daily use. Therefore it should be given only when there is a reliable carer who takes this responsibility. Depo medroxy progesterone acetate (Depo-Provera) is another hormonal method. It needs to be injected every 12 weeks. It not only produces amenorrhoea in 80 to 90% of patients, but also it is a reliable method of contraception. Side effects are depression, weight gain and breast tenderness. Considering the characteristics of this medication, this is a good medical choice in this woman. Medications such as mefenamic acid and antifibrinolytics (Tranexamic acid) are also effective in reducing blood loss. They are needed to be taken 3-4 times a day during period. Complete cooperation from carers is required. Good point about these medications is their small side effects which are gastrointestinal symptoms.Tranexamic acid should not be given in the presence of history of thrombosis. Although GnRh analogues produce amenorrhoea, but they need to be injected monthly and also they can cause menopausal symptoms and osteoporosis. Therefore after six months of use they should be given with add-back therapy. Another method is the insertion of progesterone releasing coil (Mirena).This is a good method in this woman as it not only reduces blood loss significantly, but also it is a reliable method of contraception. Because their effect is mainly in the uterus, their systemic effects such as depression, weight gain and breast tenderness are not common. It can be inserted during the period but sometimes patient may need local infiltration of anaesthetic agents . If it can not be inserted by this way, general anaesthetic may be required. For this kind of insertion obtaining a consent form is required but as the patient is unable to understand the risks and benefits of the treatment, legal permission should be obtained before the procedure. Ablation of the endometrium is another option. There are various methods such as transcervical resection on endometrium (TCRE), thermachoice and microwave ablation. These methods are used when the other methods were unsuccessful . They produce oliogomenoorhoea or amenorrhoea in more than 70% of patients,. These methods are performed under general anaesthesia and therefore obtaining permission from legal authorities before the operation is required. Complications are in the form of anaesthetic problems and damage to the uterus, and and pulmonary oedema. Another point is that the patient should not get pregnant after this procedure. Therefore sterilisation at the time of surgery may need to be considered especially in this patient. The final method of treatment is hysterectomy with preservation of the ovaries. It should be avoided in this young woman if possible. But if the other methods fail and the patient has severe bleeding this method can be considered. It is possible to send a medical report to legal authority in order to obtain permission for this surgery. The good point is it will stop the bleeding and there will be no need for further operation for this reason. But it is a major operation and associated with mortality and morbidity. To ensure that the administration of treatment is in accordance with the law, the necessary precautions should be taken before starting any treatment. Good documentation is important.Obtaining a second opinion from another doctor regarding traetment and legal aspect of it is also helpful. In the case on insertion of Mirena under local infiltration, there is no need to obtain a consent form but the carers and family member should be informed. In case of general anaesthetic,major surgery and sterilisation, not only the carers and close member of family but also a family lawyer or the court of law should be informed to obtain a legal permission for surgery otherwise it will be considered as a violation of patient?s rights which may be liable to persecution.
		Posted by SWATI M. Sun Jan 16, 2005 12:03 pm
Aims of treatment is to alleviate her symptoms of heavy bleeding to improve quality of life and treat anemia caused by increased blood loss. Conservative approach may be undertaken as 50% of the women complaining of excessive loss have loss within normal limits. This will be appropriate if degree of anemia is not severe suggesting normal loss. Medical options involve hormonal and nonhormonal drugs. Antifibrinolytics ,tranexamic acid reduces blood loss by 50%.It has gastrointestinal side effects. A serious complication of intracranial thrombosis has been documented .NSAID?s such as mefenamic acid, ibuprofen are effective in reducing blood loss by 25-30%relieves associated dysmenorrhea, headache and has no influence on fertility. These drugs need to be administered during period of heavy loss and will be easier for carers to administer than hormonal which need to be taken cyclically. Combined oral pills reduce blood loss by 50% , provides contraception. Contraindications such history of thromboembolism, liver disease should be excluded. If taking hepatic inducing drugs it might reduce efficacy with low dose pills and need high dose pills. Carers need to ensure drug administration as it needs to be taken daily for 21 days otherwise may have breakthrough bleeding. Progesterones such as nor ethisterone if given for 21 days are effective in reducing blood loss. Side effects such as abdominal bloating, mastalgia may occur. GnRHa are effective in reducing blood loss but are expensive , available in injectable form , concerns about loss of bone mineral density with prolonged use. Danazol is effective but androgenic side effects such as hirsutism , acne , voice changes which may be permanent limits its use and may be unacceptable in young women. Mirena is effective in reducing blood loss by 97% with 1 year use , provides contraception , not user dependent.It may cause irregular bleeding in initial 3 months period and insertion is painful ,difficult, particularly in nulliparous woman. It may cause amenorrhea in about 1/3rd of women and may be unacceptable to some women.Expensive initially but becomes cost effective with 5 year use. Surgical options includes conservative surgeries such as endometrial ablation or resection .It causes satisfaction in about 80% of women.Family has to be completed before this procedures and it may cause amenorrhea in 20 -30% women which may be unacceptable. Total abdominal hysterectomy is another surgical option but has psychological impact, impact on sexual life. Ovarian failure may occur earlier with hysterectomy and have long term consequences due to early menopause .This should only be considered in young woman if medical treatment fails or intractable bleeding. Women and career should be explained of the choices available. Clinician should judge competence of woman for consent to treat. Liaison with her psychiatrist is important. If clinician or psychiatrist think that this woman has severe mental disability and does not understand implication of treatment, permission from court should be requested as no relative or partner has legal power to consent to treatment of an adult.
		Posted by Vaijayanti R. Sun Jan 16, 2005 11:39 pm
Assess the menstrual blood loss; about 50% of women complaining of menorrhagia have a normal volume of menstrual flow. If the volume is normal, reassure the patient and her carers. Counselling for hygiene and contraception is offered. If menorrhagia is demonstrated, discuss with the carers and the patient regarding the treatment options available;their effect on the quality of life; need for contraception and desire for future fertility The first line medical therapy for menorrhagia with a normal sized uterus includes antifibrinolytics,NSAIDs and Combined oral contraceptive pills.Antifibrinolytics reduce menstrual loss by 50%;but are associatd with gastrointestinal side effects and do not provide any additional benefit ( contraception).NSAIDS also reduce menstrual blood flow(25%),and are associated with fewer side effects and do not protect against pregnancy.Combined oral contraceptive pills reduce menstrual blood flow by 50%, protect against conception and pid,benign breast disease,functional ovarian cysts,acne , but have their inherent associated risks especially venous thromboembolism. Secondline medical therapy ? progestogens -oral,long acting parenteral, iud systems. Oral norethisterone in higher doses(5mg8th hrly) for 21 days each cycle is quite effective, but is associated with side effects ( bloating, headache, depression). The disadvantage of oral medication is that it is carer dependant, and the patient will continue to menstruate regularly. Other drugs that have been propossed for the treatment of menorrhagia include Danazol, Gestrinone and GnRhanalogs; the higher incidence of side effects make them unsuitable for use. Depot medroxy progesterone acetate (150mg IM once in 3 months), is one option if amenorrhoea is requested.30% become amenorrhoic after the first injection, and 55% within 1 year.The advantages, apart from producing amenorrhoea include reviersible contraception,and the fact that it is carer independent.Disadvantages are irregular bleeding, and the fact that she will have to be brought to the hospital every 3 months. A better option is the LNG containing IUD ( 52 mg levonorgestrel). This produces amenorrhoea in over 80%, apart from being an effective reversible contraceptive.It is carer independent, and can be left in situ for 5 years.Insertion may be difficult in nulliparous women, and there may be irregular bleeding in the first few months which will subside gradually. Anemia resulting from the menorrhagia is treated with hematinic supplementation. Dietary counselling is also given. More permanent surgical methods are also available ? endometrial ablation, trans cervical resection of the endometrium and hysterectomy.However, such drastic measures need not be undertaken as there are equally effective long acting temporary methods available If there is no response within 6 months to any of the above methods, further investigations are offered to detect any underlying cause ? fibroids, endometrial polyps, bleeding disorders, thyroid dysfunction, and they are treated accordingly( hysteroscopic polypectomy) Care has to be taken to ensure that any intervention in this woman is within the law.A psychiatrist has to certify her capacity to comprehend the treatment/ interventions being planned, and their outcome.Her carers are involved in decision making, but cannot give consent as she is a major.Consent here will have to be obtained from the Court of Law. A second opinion from another Gynecologist regarding the treatment planned may be helpful.All such procedures have to be documented carefully .
		Posted by Iman B. Mon Jan 17, 2005 12:48 pm
Tranexamic acid is one of the first choices for treatment of menorrhagia, it has been proved very effective in decreasing the menstrual blood flow, it may be used indefinitely in the first heavy days of flow if a three month trial period has improved the complaint. It cannot be used in patients with history of a hypercoagulable state so a good history and family history of possible thrombophilia should be taken. The nonsteroidal anti inflammatory drugs as mefenamic acid have also proved to be effective in decreasing the amount of blood loss, they may be used during times of heavy flow. A good history will rule out contraindications of use as peptic ulcer or allergy. Ethamsylate, as an option, though it has been used for many years now, at the suggested dose doesn?t seem to be effective. Low dose oral progestogens used during the luteal phase don?t seem to be effective in controlling menorrhagia. To be effective fifteen miiligrams( five milligrams three times daily) for twenty one days of the cycle should be taken, this might cause unacceptable side effects to some patients, as bloating, and breast tenderness, and headache and irritability. Contraceptives are a good choice, and useful for long term use, especially if the patient is sexually active. The low dose oral contraceptive pill will if used properly cause a decrease in the amount of bleeding. The patient has a severe learning disability, so the possibility of her properly using the drug must be discussed, irregular use will cause irregular periods. Injectable-progestagens, the long acting medroxy progesterone acetate MPA, would be a good option, a three monthly injection which after the discomfort of the first one or two doses will cause a decrease in the amount of bleeding or amenorrhoea, considering the possibility that the patient may not be able to take oral medication with any degree of reliability would probably put this option as a good first choice. The patient is twenty three the duration of treatment needs to be discussed as well. Prolonged use of long acting progestogens may cause osteopenia and this side effect needs to be discussed with her and her carers as well as the duration of time this treatment will be used. Intrauterine system as the mirena is effective treatment of amenorrhoea, the same problem of irregular bleeds in the first few months of use as in using MPA, if they are acceptable to the patient make this an alternative to the MPA. Danazol, Gonadotrophin releasing hormone analogues, and Gestrinone as second line treatment have the disadvantage of largely unacceptable side effects, though they are effective in decreasing the amount of bleeding.It causes them to be used only for a brief period. Danazol and gestrinone have androgenic side effects the use of a contraceptive with them becomes essential if the patient is sexually active. For the possibility of virilization. Danazol causes permanent deepening of voice which is largely unacceptable to patients. Gonadotrophins releasing hormone analogues are useful in decreasing blood loss but their expense, and the possibility of osteoporosis limit their use to the short term for example before surgery. Although the patients uterus is normal sized, if the bleeding fails to resolve after three consequetive months of medical treatment hysteroscopy and an endometrial biopsy should be suggested to the patient. Usually fibroid or endometrial polpyps will cause intermenstrual bleeding rather than menorrhagia. A proper history to exclude possibility of intermenstrual or post coital bleeding is essential. Endometrial ablation or hysterectomy, if there is no wish for having a family, the option between endometrial ablation and hysterectomy could be given to the patient. It is usually a good idea from the start to make them realise that endometrial ablation although in many cases it will cause a marked improvement on the blood loss but sometimes doesn?t cause amenorrhoea. If the patient wishes for amenorrhoea, the more expensive and permanent hysterectomy would be the better option in the long term, the morbidity of both operations need to be carefully explained to the patient. The patient is said to have a severe learning disorder. To allow this person to make a decision in her own interests, she needs to be capable of grasping and retaining information in a logical manner. If the doctor finds that she is incapable of this then the decision for treatment should be conferred to the courts, a further opinion from a colleague will be helpful if he sees that she needs for example surgical intervention. In no way are her carers, though they may give their opinions and help to be the ones who decide on her best treatment option. It will be necessary to verify to what degree her learning disability affects her life, whether she will be able to take oral medications, whether her degree of menorrhagia is in fact over eighty ml. A pictorial blood assessment chart will be a useful guideto the actual blood loss including a full blood count to assess the level if any of anemia and treat it.
		Posted by vijaya L. Mon Jan 17, 2005 10:03 pm
Treatment for any woman in this situation would depend upon the extent of disability, presence of problems of hygiene and attitude and nature of the carers. Heavy periods in the presence of normal sized uterus is most probably due to dysfunctional uterine bleeding. But every effort should be made to rule out any possibility of pregnancy related causes and systemic diseases like von willebrand disease, thyroid/renal/liver dysfunction, in which case the treatment largely centers around correcting the disordered system. Cyclical administration of progestogens like norethisterone 5mg or medroxy progesterone 10mg, for the last 10 to 14 days is an effective treatment in reducing the blood loss, correcting the cycle length and preventing the unopposed stimulation of endometrium. This method also reduces the blood loss in ovulatory cycles where the pathology is at the endometrial level, but less effective then other available methods. Prostaglandin synthetase inhibitors like mefenamic acid taken in dose of 1500mg a day for 3 to 4 days during the periods reduces the menstrual blood loss by 30% and is very inexpensive. The major side effect is gastrointestinal irritation. Tranexamic acid (2-3gm/day) decreasing the lysis of fibrin clot is extremely effective in reducing the blood loss by up to 60%. The most feared adverse effect of thrombosis else ware is extremely rare and has been not reported with clinical doses. COCPS are as effective as prostaglandins and also provide contraception and predictable cycles. Danazole and gestrinone produce the very effective reduction in blood loss but are associated with androgenic side effects. All the above oral therapeutic drugs require daily input of care from the carers, and if chosen a method with contraception as well might be beneficial. Follow-up can be arranged with a community nurse. On the other hand LNG IUS system releasing 29micro grams of levonorgestrel at the endometrial level produces 70 to 80% reduction in the blood loss and also provides reliable contraception with least side effects. But careful counseling is necessary as 30% of them may have amenorrhoea and 50% may have irregular spotting for first 3 months, and nullipara require cervical dilatation for insertion. Endometrial resection or ablation is very invasive procedure and fertility can be compromised, this issue should be dealt with very sensitively. Nature and position of the carers should be assessed and when in doubt, court should be consulted for consent. Some times carers would ask for hysterectomy to avoid hygiene problems and fertility problems. This can be considered depending upon the disability but only after getting permission from the court.
		Posted by Vaijayanti R. Tue Jan 18, 2005 01:37 pm
Dr Paul, My answer has not been corrected - would be greatful if you would .... thnx
		Posted by SWATI M. Tue Jan 18, 2005 02:18 pm
Dear Dr.Paul, Please comment on my essay. Thanks.