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MRCOG PART 2 SBAs and EMQs

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Essay 222 - Menorrhagia

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		Posted by Srivas P. Sat Jan 27, 2007 03:44 am
a)The treatment given to her mainly focuses on improving her quality of life without resorting to quantifying the actual blood loss. If she wants to retain fertility, hormonal methods-LNG-IUS, COC and Oral norethisterone should not be given?Prefer NSAIDS and Tranexemic acid. Occasionally NSAIDs may not be tolerated by asthmatics?severe bronchospam may necessitate change. But presence of dysmenorrhoea favors NSAIDs over tranexamic acid. If contraception is acceptable to her, LNG-IUS should be offered after taking sexual history and ruling out high risk for STI. COC, Norethisterone between 5-25 days and Injectable DMPA are other options. Both LNG-IUS and DMPA may cause irregular bleeding and her acceptance of this is important. If she wishes regular cycles, has dysmenorrhoea or PMS, COC and oral norethisterone are better. Endometrial ablation may not be ideal as first line treatment even if she does not want fertility because she would need to continue contraception over prolonged periods. But this would be offered if she does not respond to pharmacologic methods and wishes to avoid major surgery also. This would need review by consultant. Availability of hysteroscopy and endoablative procedures has to be factored in. Family history of endometrial cancer associated with the rare HNPCC genes -after completing her family, hysterectomy could be a definitive treatment. COC is another option as it may not only control her bleeding, but also gives protection against endometrial cancer- but she would still need surveillance. b)Non hormonal medical methods do not regularize the cycles but are nearly as effective as hormonal methods in controlling bleeding. Tranexamic acid is an anti-fibrinolytic agent - reduces menstrual loss by nearly 50% and is more effective than NSAIDS. Can be given if she has HMB with IUCD use. The side effects sometimes may encourage discontinuation. These include nausea, vomiting, diarrhea, blurred vision or disturbance in colour vision, dizziness or lightheadedness, unusual tiredness or weakness. Discontinue if she has disturbed color vision,deranged LFT. May not be very effective for dysmenorrhoea but may decrease pain a little with decrease in bleeding. NSAIDs like Mefenemic acid decrease menstrual bleeding by 25-30%, but has more effect on dysmenorrhoea and has better side effect profile?occasional diahhoea and headaches but rarely it may exacerbate the bronchospasm in asthmatics and would need to be stopped. Both these methods would need to be taken during periods only and can be given as long as they are effective and control menstrual bleeding. No risks of VTE, genital cancers or unfavorable effect on CVS system like hormonal treatment. c) All progestogens administered by any route-intrauterine, injectable, oral tablets are effective in controlling excess bleeding. Common side effects of progestogens are headache, breast tenderness, acne, bloating and weight gain. Slight variation with individual methods. The oral and injectable methods can be given empirically for 3 months without any investigation or internal examination if the history is not suggestive of any co-morbidities. A gynecological exam is a must before deciding fitness for insertion of LNG-IUS. Main advantage with progestogens is avoidance of surgery and has good efficacy. LNG-IUS should be offered as first line option to her as it is very effective and reduces menstrual blood loss by 90% when used over 12 months. The systemic side effects of progestogens are likely to be lesser but she may occasionally have amenorrhea or irregular bleeding and may wish to stop use because of this. Rarely there can be perforation at the time of insertion. It is an invasive procedure and needs to be inserted or removed by health personnel. There is increased risk of infection in the first 20 days and after that it is same as baseline population. Advantages are if she wants to conceive later, return to fertility is immediate after removal. Over 1 year compares favourably with surgical methods like endometrial ablation and hysterectomy in patient satisfaction. Injectables may be given to control bleeding and decreases menstrual loss by 50% but can cause irregular bleeding and amenorrhea besides other systemic progestation effects. Advantages are 3 monthly dosage and effective contraception but return to fertility is very slow?may take 8 months after last injection. Other less common side effect is loss bone mineral density but this recovers as soon as injections are stopped. Oral progestogens given between 5-25 days of cycle is equally effective in controlling bleeding and can also regularize menstrual cycle. Systemic side effects of progestogens are same as above. Very rarely it can cause depression?then this should be stopped.
		Posted by Sarwat F. Sat Jan 27, 2007 05:40 am
Factors important in management of this woman include severity of symptoms, completion of family, fitness for surgery, availability of surgical expertise and wishes of woman. Nonhormonal treatments include nonsteroidal anti-inflammatory drugs which is effective in 25% cases. However it is associated with gastrointestinal side effects like gastritis. Next is tranexemic acid which is antifibrinolytic and is effective in 50% cases. It is also associated with gastrointestinal side effects. Uterine artery embolisation is a nonhormonal method for menorrhagia. It is done under radiographic guidance. It involves embolisation of uterine artery to reduce blood supply to uterus. However it is not a method of choice for women who have not completed their families as data is insufficient for concerns regarding premature ovarian failure. Other side effects include pyrexia, prolonged hospital stay in case of complications, vaginal discharge. Progesterones are effective in reducing heavy menstrual blood loss. Various routes include oral, injectable progesterone, implant, intrauterine system. Oral progesterone can be used for control of heavy bleeding. Injectables are used but they are associated with irregular spotting pervaginally. Implants are also associated with these symptoms but amenorrohea occurs in the long term. Side effects of progesterone include irregular vaginal bleeding, functional ovarian cysts and androgenic symptoms like acne and hirsutism. Intrauterine system that is MIRENA is effective in 85% cases. it consist of intrauterine system with local release of progesterone and is effective for 5 years. It can be inderted as an outpatient procedure. Side effects of progesterone are minimal as it effects locally
		Posted by Freha Z. Sat Jan 27, 2007 11:10 pm
Factors important are the age of patient, LMP and regularity of cycle . Subjective assessment of blood loss and effect on social life is important. Symptoms of anaemia should be checked and objective testing by FBC should be done. Her fertility wishes, contraceptive history should be noted. Previous treatment in promary care and any improvement should be noted. She should be given detailed account of treatment options available and should be able to make an informed decision. (b) Tranexamic acid and mefanaemic acid are first line non-hormonal treatment. Tranexamic acid is an antifibrinolytic agent. It reduces menstrual loss by 50% and is more effective than NSAIDs. It is not associated with increased risk of DVT. Its side effect are nausea, vomiting, diarrhoea and disturbance of colour vision which may warrant stopping treatment. Mefanemic acid is used to decrease menstrual loss by 25% and has better side effect profile. Unlike hormonal treatment both drugs are used for first few days of menstrual cycle of heavy bleeding. (c) Systemic progestogens such as norethisterone or Medroxyprogesterone are ineffective in the treatment of ovulatory dysfunctional uterine bleeding when low doses are used for 5-10 days in the luteal phase. However norethisterone is effective if given at higher dose(5mg three times a day) for three weeks out of four(day 5-26 of cycle). Depomedroxyprogesterone acetate is associated with amenorrhoea ( 55% after 12 month) but there is risk of irregular bleeding. Mirena is progestogen containing intra uterine device containing 52mg Levonargestrel which releases 20mcg/day. It is licenced for 5 years for contraceptive purposes. It is effective in treaetment of idiopathic menorrhagia and reduces menstrual bleeding in 97% in 12 months. Although there is breakthrough bleeding in first few months therefore careful counselling is required prior to insertion. It can produce amenorrhoea which is unacceptable to some. It can reduce dysmenorrhoea and chance of ectopic pregnancy compared to women not using contraception.It is also associated with reduced incidence of PID by action on cervical mucus and endometrium. It is however associated with increased risk of functional ovarian cysts and may be expelled from uterine cavity in first month or rarely may perforate. Fertility returns within 30 days after removal of device.
		Posted by Abi T. Sun Jan 28, 2007 01:56 am
A healthy 30 year old woman complains of a 3 year history of heavy regular periods for which no cause has been identified. (a) Which factors are important in influencing your management? [5 marks] (b) Critically Evaluate the non-hormonal medical treatment options. [5 marks] (c) Critically evaluate the use of progestogens as a treatment option. [10 marks] a)Menorrhagia is a common complaint among women and in the absence of pathology simple reassurance may be what they are seeking. However, the degree of disruption of her lifestyle may warrant definitive treatment and influence the choice of treatment offered to improve her quality of life. The presence of anemia indicates severity of blood loss and treatment has to include replenishing iron stores as well as minimizing further blood loss effectively. Her desire for fertility must be taken into account as offering a hormonal methods or endometrial ablation may not be suitable if she wishes to retain fertility. Patient\'s wishes have to be the most important factor in deciding the most suitable method for her and a discussion of risks,benefits and likely outcomes, with written information provided, will help her in making an informed choice. Medical history, allergies and fitness for surgery also influence choice of treatment offered, however as this lady is young and healthy she has a wide range of medical and surgical methods to choose from. b)Antifibrinolytics and NSAIDs are recommended first line treatment for menorrhagia. Reduction of blood loss is greater with antifibrinolytics compared to NSAID. Associated dysmenorrhoea is better treated with an NSAID. They are taken only during periods, hence avoid the need for daily medication. The incidence of thrombosis is not increased with long term use of antifibrinolytics.Its use does not interfere with fertilty. However use is limited by side effects such as nausea, vomiting and disturbance of colour vision, whereby use has to be discontinued. c)The choice of progestogens depends on wether contraception is required or not. Systemic progestogens such as norethisterone and medroxyprogesterone are ineffective in reducing menstrual loss in ovulatory dysfunctional bleeding. However their effect is improved if given in higher doses between days 5-26 of the cycle. Luteal phase progestogen treatment is ineffective and the use is not supported by current evidence. Their use is also limited by side effects such as irregular vaginal bleeding, nausea and breast tenderness. It is also not suitable if contraception is also required. The long acting depo-medroxyprogesterone induces amenorrhoea in 55% of women within 1 year and is a contraceptive. However use may be limited by side effects of irregular vaginal bleeding and weight gain. There is a long delay in return of fertility, hence may not be suitable in women wishing a shorter interval between pregnancies or if infertility is an issue. The POP are also effective in reducing menstrual losos in women where the COCP is contraindicated, and contraception is required. Again the side effects are irregular bleeding. Strict adherence to timing is required for effective contraception. The newer POPs such as Cerazette have a longer missed pill window. The LNG-IUS Mirena reduces menstrual loss by about 80% and avoids the need for surgery and is cost effective in the long term. It is more effective in reducing menstrual loss than non-hormonal medical treatment but not when compared with surgical ablative methods. Although the systemic release of progestogen is minute, the side effects of bloating, breast tenderness and weight gain are lesser compared to systemic progestogens. It also provides contraception. However patients must be counselled regarding irregular bleeding patterns in the first 3-4 months of use and the slight increase in incidence of functional ovarian cysts.
		Posted by Farzana N. Sun Jan 28, 2007 03:03 am
a) Management of this young pt .would be influenced by severity of symptoms and its effect on quality of life. Completion of family, desire for future fertility, fitness for surgery and availability of surgical expertise should be considered for surgical procedures such as TCRE or hysterectomy. Contraception needs may prompt hormonal treatment such as COCP or POP.Pt should be given written information and counseled well about the various treatment options. Her wishes should be respected in decision making. b) Non-hormonal medical treatment options include, antifibrinolytics-tranexamic acid, NSAIDs-mefenamic acid, and ethamsylate. Antifibrinolytics are effective first line treatment in reducing menstrual blood loss. they reduce the blood loss by 50%.Main advantage is .their proven efficacy by RCTs.They can be used if the pt wants to conceive and are not teratogenic.Side effects are dose dependent and can be reduced by giving drug on first 3-4 days of periods. No increase in incidence of VTE has been reported. Gastrointestinal side effects may limit its use. NSAIDs reduce the menstrual blood loss by 25-30%.They act by reducing the synthesis of prostaglandins, and are effective in cases of associated symptoms such as dysmenorrhea, headache and depression.Ethamsylate is believed to reduce capillary permeability, but recent evidence does not confirm its efficacy.Hence it is not widely used in treatment of menorrhagia. c) Progestogens are widely used in treatment of menorrhagia.They have endometrial suppressive effect and cause decidualization of stroma.Cyclical progestins are effective in high doses ,e.g. norethisterone 5mg tid from day 5 to 26 of the cycle side,.side effects at such high doses limit their use. Continuous preparation include oral tablets ,long acting i.m injections and subdermal implants.Irregular bleeding is the common with these preparations .LNG IUS is widely used and licensed for the treatment of menorrhagia.It delivers 20microgram of levenorgestrel to the endometrium / 24hrs,effective for 5yrs.It reduces blood loss by 80% at the end of 3-6months and >90% at 12months.Progestogenic side effects such as wt gain, bloatedness,breast tenderness are more with IUS than high dose cyclical preparation,but it has higher satisfaction rate.Compared with TCRE, reduction in blood loss is less with IUS,and side effects are more ,still pt satisfaction is similar in both groups.Hsterectomy has three times higher costs than LNG IUS insertion and hence it is an acceptable alternative to hysterectomy.
		Posted by Yasser S. Sun Jan 28, 2007 05:04 am
The management is influenced by patient\'s age and reproductive history. A patient seeking fertility cannot be offered treatments like contraceptive pills, Mirena, thermal ablation or hysterectomy. Another important factor is the degree of disruption caused by mennorrhagia in her lifestyle and employment. A person who has to take off sick every month due to heavy periods or whose social life is interrupted regularly needs definitive treatment. Presence of anemia can be helpful in assessing the degree of blood loss and the need of medical or surgical treatment, as most of the patients require reassurance only. Previous treatment history is important to decide further management. Presence of dysmennorrhea along with heavy periods should be recorded. Women\'s wishes regarding the mode of treatment should also be taken into account. Non hormonal medical treatment are mainly anti fibrinolytic and non steroidal anti inflammatory drugs. The anti fibrinolytic of proven benefit is tranexamic acid which is used during the periods. Recommended dose is 1gm 4-6hrly. It has shown very good results in reduction of the blood flow. Patient satisfaction rate is high. It is effective, safe and far less expensive than other treatment modalities and should be considered as first line of management. It is proven to be beneficial for patients with mennorrhagia in general as well as those with bleeding disorders. The side effects include nausea, headache and dizziness. The frequent dose may reduce patient compliance. There\'s no evidence of increase in thrombotic compliations by its regular and prolonged use. NSAID of choice is Mefenamic acid and is used as first line therapy. Its effect is more profound on the dysmennorrhea. It is usually very well tolerated by the patient and side effects are few. It is also used during the days of menstruation and is cost effective. Ethamsylate is a drug that reduces capillary fragility. Its use is no longer recommended as at the current recommended doses , it is not found to be an effective treatment of mennorrhagia. Progestogens are used either orally, parenterally or in Intauterine devices. The oral doses used in luteal phase are not found to be beneficial for the treatment of mennorrhagia. Instead, they are effective when given at high doses between day 5 and 28 of the cycle. Missing the dose and intermentrual bleeding are the common problems with there use. Depot Provera is useful as it induces periods of ammennorhea. It might not be acceptable for the patient to have no periods at all for a prolonged duration. The prostogenic side effects of bloating, mood swings, breast tenderness and acne may be unacceptable for the patient. The treatment of choice is the use of Levonorgestrel intrauterine system which is marketed by the name of Mirena and is licensed for the relief of menorrhagia. The results are comparable with hysterectomy in terms of quality of life and psychological well being. It is an effective and reversible method of contraception and is an added advantage for a women who wishes contraception. It is cost effective as compared to the surgical procedures. The patient requires proper councelling before use due to possible break through bleeding in the initial 3-6 months and progestogenic side effects. Spontaneous expulsion might result so she requires periodic reviews. Evidence supports that it is an effective treatment for menorrhagia and is a potential alternative to surgery. It is not the treatment of choice for women seeking pregnancy. Its use should be reserved for cases not responding to non hormonal treatment. Its efficacy in the patients with bleeding disorders is not yet fully established.
		Posted by neera B. Sun Jan 28, 2007 05:39 am
a) Severity of menorrhagia, presence of dysmenorrhea, its effect on her quality of life influence the management. Other factors like her desire to rtain fertility, desire to retain uterus, desire for permanent cure or temporary treatment , her preference for medical versus surgical management and hormonal versus non hormonal methods influence the management. Patient expectations like desire for amenorrhea and uterine size also effect the choice of treatment. Her compliance with and response to medical management effects further treatment. Patient should be fully informed of the treatment options, written information provided and her informed choice considered. b) Non hormonal treatment options include Tranexamic acid and mefanimic acid. Tanexamic acid, an antifibrinolytic decreases blood loss by over 50%, is effective both orally and parentally, is cheap, has good compliance because it is taken only during menses and can be taken long term.However it does not improve dysmenorrhea. Side effects like nausea , headache and dizziness may limit its use. Mefanimic acid, an NSAID is less effective than Traneximic acid as it decreases blood loss by 30%. It is also taken orally only during menses , is cheap and has high patient accptance . It also relieves dysmenorrhea, but may aggravate asthma and peptic ulcer. Ocassionally diarrhea and indigestion may occur. In the abscence of side effects , non hormonal methods can be taaken indefinitely. However they are less effective than many hormonal methods like Mirena and depot provera . Unlike surgical methods they provide temprary relief. They are especially useful where hormones are contraindicated or not desired by the woman. c) Progestogens are very effective inthe treatment of idiopathic menorrhagia. They are costeffective and help women to retain their fertility as well as their uterus. They may provide extra contraception when used as Merina, Depo provera and nor ethisterone 15 mg/day from day 5-26. In many women, surgery can be avoided by use of progestogens. However some women may become amenorrhoeic with Merina and repeated doses of depo provera. Progestogenic side effects breast tenderness, irregular vaginal bleeding, abdominal bloating may limit their use. Merina may cause achne, six fold increase chance of PID in the initial 20 days and a small chance of uterine perforation. Depo provera is associated with weight gain, premenstrual like syndrome and decreased bone mineral density. Return of fertility may be delayed to 8 months with depo provera, but is promptly resumed on removaal of Merina and stopping nor ethisterone. Progestogens can be used with estrogens in COC pill to treat menorrhagia, but nor ethisterone taken in luteal phase has not been found effective.
		Posted by kiria O. Sun Jan 28, 2007 10:34 am
30 years old with heavy regular periods for 3years,there are many factors would influance managment include , her symptoms such as sever anaemia and dysmenorrhea. Also, types of treatments and medication taken by the patient and side effects which may lead to discontinuation of treatments. Other factors which may affect her managment is fertility wishs and whether her family is completed or not. If her family is not completed surgical option and endometrial ablation is not possible. The effect of menorrhagia on her social life and work is important factor affecting her managment with her wishes regarding type of treatment must be taken into consideration. None hormonal medical treatment includes tranaxamic acid, none steroidal anti iflammatory(mefenamic acid). Tranaxamic acid is antifibrinolytic effective in reducing menstrual blood loss MBL (40%) given during the days of period but it cause nausia,vomiting and rarely venous thrombosis. Mefenamic acid is effective in reducing MBL but less effecive than tranaxamic acid. Its main advantge is effectivness in cases of dysmenorrhea and can be given with tranaxemic acid or a lone however, its associated with side effects such as GIT upsit and renal dysfunction. Progetagens are most commonly used agent in treatment of menorrhagia, and progetagen tablets are not effective in reducing MBL especially short regimen. However, high doses,longer duration of use e.g day5 to 21 for 3monthes is shown to be effective in reducing MBL. Medroxy progesteron acetate (MPA)injection given every 12 weeks, is effective in in reducing MBL but its associated with irregular bleeding and other side effects such as weight gain, fluid retension depression, mood changes and breast tendeness. Other form is implanon which is the only progetagen implant used 3 yearly, the amount of progestgen released slowly and in fixed rate not giving high intial level such as MPA so, it has less systemic progestagenic side effects and its usefull in woman with menorragia need long acting contraceptive. the main problem with implanon is irregular bleeding and difficulty in removing implant. Intra uterine system (Mirina) is very effective in reducing MBL 30% in the first 3 monthes and 95% in one year and may cause even amenorrhea in 25% of users in one year. It cause endometrial atrophy, can be used for5 years and associated with very low systemic progestagenic side effects and very effective in case of associated dysmenorrhea. However, the main problem is irregular bleeding in the first 3 months,functional ovaian cysts with increase in the rate of ectopic pregnancy(less than none contraceptive users). Also, mirina need experienced staff for accurate insertion.
		Posted by Parveen Q. Sun Jan 28, 2007 08:31 pm
The main factors which will influence her management will be the amount of blood loss and how much it interferes with her social, pysical, and emotinal life. If she has symptoms like dizziness, palpitation will point towards anaemia and haemoglobin level will influence the urgency of treatment. Her menstrual history, associated symptoms like dysmenorrhoea, intermentrual bleeding, dyspareunia, and history of postcital bleeding, smear history, will help in coming to right diagnosis and incorporating the appropriate teatment. Previous treatment history, failure of any particular treatment will help in choosing an alternate treatment, as options are wide with newer progestogens, and second generation endometrial ablation , and definitive treatment like hysterectomy. Her past obstetric history , and if her family is complete, and with her informed consent,endometrial ablative procedures can be done. If she is nulliparous, and any medical illness like diabetes , hypertension, and her BMI will point towards endometrial hyperplasia, and definitive treatment may be needed after doing TVUS , hysteroscopy, endometrial sampling. The rare coagulation disorder history can be elicited though it will present as heavy bleeding since menarche. The non hormonal treatment is NSAID, and Tranxaemic acid. NSAID act by reducing the endometrial prostagladin concentration. The most commonly NSAID is mefenamic acid. It can reduce blood loss by 25%, it is cheap, with few side effects. It can reduce dysmennorrhoea. Tranxaemic acid is an antifibrinolytic, used as a first line of management for menorrhagia. It is more efeective than NSAID, reducing blodd loss by 35-56%. The side effects are mainly gastrointestinal like nausea, vomitting, diarrohoea. The side effects are dose related, can be reduced by reducing the number of days to only first few days of bleeding. There is no link between this drug to thromboembolism in those with the past or family history of thrombosis. There are many prostogen preparations, from tablets, injectables, implants, IUS . Every one has its own risks and benefits. The woman should be allowed to take an informed choice. Oral progesterone , Norethisterone, has a role in anovulatory bleeding if given in the luteal phase. But for ovulatory bleeding, the dosage and duration has to be increased to three times daily from day 5-26 days. This is effective for short duration of mennorhagia, as the side effects like weight gain, mood changes, depression, loss of libido makes it less acceptable, though it is cheaper compared to ther forms. The injecatble , medroxy progesterone acetate is given once in 3months, it works as a contraceptive too, but the delay in susequent return of periods and irregular bleeding reduces the compliance. The implant, norplant, needs training for insertion , but can be used for a longer period of time upto 5years. The levonorgestrel intra uterine system(LNG IUS) reduces blood loss by 97%in 12 months, but the effect starts within 3months of insertion. It can be used long term upto 5years, subsequent contraception not needed, it increases the hb, ferritin concentration, effective for dysmennorhoea. But the amennorhoea rate is 35%. It is an effective treatment for dysmennorhoea, prementrual tension, endometriosis, and fibroid. It is an efficient, cost effective alternative to other medical forms and hystercetomy. But the systemic effects , intermentrrual bleeding, and the pain while inserting(the stem diameter is bigger than other copper IUCD), makes it less acceptable to few. The newer , frame less, fibroplant, releases less levonorgestrel compared to mirena, so the systemic side effects are less. It reduces blood loss, causes less pain, expulsion rate and amenorhoea is less.
		Posted by Randa E. Mon Jan 29, 2007 10:57 am
a)The impact the heavy cycles have on her physical, emotional and social quality of life are very strong influencing factors. Subjective assessment of the blood loss, e.g. clotting/flooding, are also important factors. Other factors like the presence of symptoms of anaemia like easy fatigability, shortness of breath and/or palpitations are also important. Other menstrual abnormalities including pre-menstrual syndrome, dysmennorhoea and cyclical mastalgia should be assessed. Her needs including the need for contraception as well as treatment or preference for non-hormonal treatments over hormonal ones are factors that should be noted. At the age of 30yrs, maintaining fertility might be an important factor. Management options should be discussed in detail with the patient and her wishes respected. Leaflets should be provided. b) Antifibrinolytic agents such as transexamic acid reduces the menstrual flow by up to 50% in some women with blood loss within <80ml/mnth. Studies have shown that they are better than prostaglandins synsthetase inhibitors at lowering menstrual flow. They are effective in reducing blood flow associated with IUCD, fibroids and bleeding diathesis. Their Sid-effects are related to the dose of drug prescribed. GIT side-effects can be reduced by limiting the no. of days to the 1st 3 or 4 days of the period. Serious SE are rare and may include intracranial thrombosis and colour vision disturbances. If these happen then therapy should be discontinued. The next popular choice are NSAID. The one used most often is mefenamic acid . It consistently reduces blood loss by about 25% in 1/3 of women. They also have beneficial effects on other symptoms including dysmenorrhoea, headache, nausea, diarrhoea and depression. SE include common ones e.g. indigestion and diarrhoea and rare ones e.g. peptic ulcers with possible bleeding. They are a cheap effective 1st line treatment for some women. They have less side effects when compared to antifibrinolytic agents. However both do not provide any contraception and this must be discussed with the patient before prescription. (c ) Systemic progestogens such as norethisterone and medroxyprogesterone acetate offer a logical approach. Norethisterone is not effective for the management of mennorhagia if given at a low dose for a short duration (5-10) days in the luteal phase. However it has shown to be more effective if the drug is given at a higher dose for 3 weeks out of 4 weeks as 5mg 3 times daily from day 5 to 26 of the cycle. Depo- medroxyprogesterone acetate is another option. It has the added benefit of being a contraceptive. It is associated with amenorrhoea, 30% after one injection, 55% after 12 mnths. It is associated with the risk of irregular vaginal bleeding. It is also associates with a small loss of bone density-largely recovered when treatment is stopped. It is not licensed for the treatment of menorhagia. An informed consent is needed when using it outside the licensed indication. This should be discussed and documented within the notes. Intra uterine progestogens in the form of the levonorgestrel intra-uterine system (Mirena) is another type. This delivers 20ug of levonorgestrel to the endometrium every 24 hrs in a sustained release formulation that can last up to 5 yrs. Studies showed that menstrual loss decreases by > 90% in 12mnths .It might offer a cost-effective and acceptable alternative to other medical treatment and surgery with a high satisfaction rate. It also provides the added benefit of contraception. The main side-effects associated with it is irregular breakthrough bleeding and spotting esp. within the 1st few mnths after insertion. Perforation at the time of insertion may also occur. There is also the slight increase of functional ovarian cysts. 20% of women using the system will become amenorrhoeic within 1 year. Fertility usually returns within 30 days after removal. These events must be discussed in detail prior to inserting the mirena. Women must be involved in the decision making process regarding their treatment options and to be provided with appropriate written information. Quality of life issues are important and must be addressed during the collaborative decision making process.
		Posted by Shyamaly S. Mon Jan 29, 2007 11:58 am
A healthy 30 year old woman complains of a 3 year history of heavy regular periods for which no cause has been identified. (a) Which factors are important in influencing your management? [5 marks] (b) Critically Evaluate the non-hormonal medical treatment options. [5 marks] (c) Critically evaluate the use of progestogens as a treatment option. [10 marks] A) The woman is central in the decision making process regarding treatment. The effect of menorrhagia on her quality of life should be assessed in taking a history- do her periods debilitate her, is she able to work/leave the house. Her Haemoglobin level is also important in assessing the severity of her menorrhagia. If her haemoglobin is normal and her quality of life is not seriously affected, she may opt for no treatment- reassurance that there are no abnormalities alone maybe sufficient. It is also important to know what treatments have already been tried in order to plan further management. A history of associated dysmenorrhoea would mean that NSAIDS maybe the first choice as this reduces blood loss as well as pain. Her wishes regarding fertility or contraception are important. If she is considering pregnancy non hormonal methods are her only option- progestagens should be avoided as they may virilize a female fetus. If she would like contraception, the combined oral contraception maybe a good option. Long-term contraception together with symptomatic control maybe achieved with the Levonorgestrel IUS or depot medroxyprogesterone acetate. Surgical methods of controlling her bleeding should only be considered when fertility is no longer necessary. Knowledge of her Past medical history and allergy status will also affect management, as a woman with NSAID hypersensitivity should not be given NSAIDS. B) Tranexamic Acid is an antifibrinolytic. It is the single most effective oral agent, which reduces menstrual blood loss by up to 50%. It needs only to be taken during periods. Unfortunately it cannot be used in women who have a prior history of DVTs and thrombophilia. Some women are troubled by side effects of nausea and vomiting. Mefanimic Acid is an NSAID. It is useful for both pain and bleeding and also needs only been taken during a period. Systematic reviews show that it reduces blood flow by 25% in 75% of women, so is not as effective as Tranexamic acid. It should not be given to women with NSAID hypersensitivity or GI ulcers, and some women suffer with GI side effects. Mefanimic acid and tranexamic acid can be given together and have a synergistic effect on reducing menstrual blood flow. A large number of tablets do need to be taken and many women do not tolerate the GI side effects. Etamsylate has also been used in the past to treat menorrhagia, but has since been abandoned as it does not show any reduction in menstrual blood loss. C) Oral progestagens eg Norethisterone and medroxyprogesterone acetate are the most commonly prescribed medications for menorrhagia. When given in a low dose in the luteal phase, it is not associated with reduction in menstrual loss. However, when given at a high dose from day5to26 of the cycle, it reduces blood loss significantly. Side effects include mood changes and bloating. It is not a contraceptive and cannot be given in liver disease. Progestagens can be combined with Oestrogen in the COC pill. They reduce blood loss by 50%, afford good cycle control, reduce dysmenorrhoea, act as a good contraceptive, can be tricycled to reduce menstrual frequency and confer protection against endometrial and ovarian cancer. However it increases cardiovascular risk in woman with risk factors hence is not recommended in such women over the age of 35. It is contraindicated in women with migraines and liver diseases. It is increases the risk of VTE, and its side effects include weight gain and mood change. Intra muscular preparations such as depot provera or the implant offer long term reduction in blood loss by means of their amenorrhoea rate (20% after 1 year) although they are not licensed for this purpose. They provide contraception (it takes up to a year before fertility is restored with depot), do not need daily tablet taking, however side effects include unpredictable bleeding pattern and weight gain and osteoporosis specifically with depot. The implant is expensive and therefore cost effective only after long-term use. The levonorgestrel IUS, which is now licensed for the treatment of menorrhagia is associated with a 90% reduction in blood loss and an amenorrhoea rate of 20%. It provides good, rapidly reversible contraception and reduces dysmenorrhoea. Patient satisfaction rates are higher than with endometrial ablative techniques at 1 year. Its use has reduced the number of benign hysterectomies by 50% conferring further cost benefits. It has minimal side effects because systemic levels are low, these include breast tenderness and ovarian cysts. It is an invasive procedure which may require a general anaesthetic for insertion and is expensive, so is cost effective when used for 5 years. Erratic bleeding can occur in the first 6 months which the woman needs to be carefully counselled about pre insertion.
		Posted by M M A. Mon Jan 29, 2007 05:41 pm
The management of this patient will depend on several factors, the most important of which is her desire to have children, or more children. However, the severity of the symptoms and its major impact on her quality of life. Treatment and any intervention should aim to improve her quality of life rather than focusing on menstrual blood loss. Symptoms of anemia should be checked and objective testing by full blood count should be done. The woman should be given the opportunity to review and agree treatment. She should have adequate time and support in the decision making process. Treatment and care should take into account the woman\'s needs and preferences. In this particular patient, pharmaceutical treatment should be considered as no structural abnormality is present. Antifibrinolytic agents are the first non-hormonal medical option . The most effective is the tranexamic acid . Its main advantage is that of proven efficacy . It is also cheap and does not increase the risk of venous thromboembolism. These drugs produce a 40 ? 50 % decrease in menstrual blood loss. Their side effects are nausea , vomiting , indigestion , diarrhea and headache . The non-steroidal ant-inflammatory agents {NSAIDs } are safe , such as the commonly used mefenamic acid . It reduces the menstrual blood loss by 25% , has better side effect profile compared to ,but it is not effective as tranexamic acid . Side effects of mefenamic are usually confined to gastric irritation. Norethisterone is the most commonly prescribed progestogens for menstrual problems. Cyclical progestogens , in the form of norethisterone are the least effective option in this patient , when used in low doses for 10 ? 14 Days in the luteal phase of the cycle. However, it is only effective if used at higher doses 5 mg three times daily ,from Day 5 to Day 26 of the cycle for three cycles. It is cheap but has side effects ,such as breakthrough bleeding ,breast tenderness , weight gain ,bloating and mood swings. Levonorgestrel-releasing intrauterine system ( Mirena ) is an option that has many advantages. It is administered once every five years , releasing 20 mcg levonorgestrel daily which affect the endometrium locally ,with minimal serum concentration. It is effective and provides additional reversible contraception if necessary. It reduces the menstrual blood loss by about 80 % within six months of insertion , and 97 % at 12 months . It causes a rise in haemoglobin and ferritin concentration by 47 % after one year. Although expensive , it is more cost-effective than the other options in the long term . It may be associated with irregular vaginal bleeding ,especially during the first 3-6 months . Proper counselling and patient education may increase tolerance. It may be associated with hormone-related problems such as breast tenderness , acne or headache and functional ovarian cyst which , if present , are generally minor and transient . Uterine perforation rarely may occur at time of insertion . It requires skill to insert and if ineffective , it will be removed . Side effects , or nuisance symptoms ,can be reduced by proper pre-insertion counselling . Appropriate counselling and patient education may increase tolerance.
		Posted by sailaja devi K. Tue Jan 30, 2007 05:43 am
The findings point towards diagnosis of dysfunctional uterine bleeding .Parity is important in planning the management , helps to determine whether a women wants more children and whether surgery is acceptable. Usage of any method of contraception helps in deciding plan of management.Wishes of the women about contraception / conception.Any history of fatigue,shortness of breath,palpitations to assess severity of anaemia due to heavy periods.History of other menstrual abnormalities like pre-menstrual syndrome ,dysmenorrhoea ,cyclical mastalgia and migraine. Subjective assessment of assessment of blood loss by any history of passing clots ,flooding ,effect on social life including time off work .Semiquantitative method of assessment of menstrual blood loss using pictorial blood assessment chart.History of previous therapy in primary care and any improvement. She must be involved in the decision making process regarding the treatment and must be provided with appropriate information .Quality of life issuses are important and must be addressed during decision making process .Identify the woman?s preference of treatment whether medical or surgical. Nonharmonal medical options include Antifibrinolytic and nonsteroidal anti-inflammatory drugs. Tranexamic acid ,mefanamic acid are RCOG recommended first line treatments in primary / secondary care .Among NSAIDS mefanamic acid is commonly used.It acts by inhibiting uterine prostaglandin production vasodilator PGE 2. Mefanamic acid reduces blood loss by 25 %. Mefanamic acid is associated with mild gastrointestinal side effects like nausea and vomiting,headache .Mefanamic acid has a better side-effect profile compared to tranexamic . Tranexamic acid is an antifibrinolytic agent .Fibrinolytic activity is greater in the endometrium of women with menorrhagia so antifibrinolytics are highly effective in reducing menstrual blood loss.It reduces blood loss by 50% and is more effective than NSAIDS.Side effects include nausea,vomiting, diarrhea . Serious side effects that were documented are intracranial thrombosis and central venous stasis retinopathy.It is not associated with an increased risk of DVT. Progestogens halt endometrial growth and allow for an organized sloughing of the endometrium. Side effects are nausea ,weight gain ,fluid retention,mood changes and depression. Progestogens increase LDL there by increasing cardiovascular risk. Progestogens can be administered orally or locally through an intrauterine device or intramuscular. Synthetic progestogens like norethisterone and medroxyprogesterone acetate are the most frequently prescribed medical management for the treatment of DUB in UK..Synthetic progesterone such as norethisterone or medroxyprogesterone are ineffective in the treatment of ovulatory dysfunctional uterine bleeding ,when used in low doses for 5-10 days in the luteal phase .But norethisterone is effective if given at high doses for days 5-26 of the cycle.Progesterone therapy decreases blood loss by 80 % .But oral therapy is less effective in terms of patient satisfaction and continuation rates compared to LNG ?IUS. The cyclical use of synthetic progestogens is best for treatment of anovulatory DUB to convert irregular ,unpredictable bleeding into regular , controlled bleeding Depo-medroxyprogesterone is associated with amenorrhoea but there is risk of irregular bleeding .Continued long acting progestogens renders most women amenorrhoeic and therefore could be considered for menorrhagia. Levonorgesterol intra-uterine system is an effective treatment of menorrhagia decreasing menstrual blood loss by 90 %.It suppress endometrial growth.The LNG ? IUS improves hemoglobin concentration.It should be considered as an alternative to surgical treatment.It acts as a contraceptive .Irregular bleeding occurs during the first 3-4 months after insertion so appropriate counseling is required..Amenorrhoea ocurrs in 35% of women ,raise fears of prgnancy so consel before insertion.Adverse effects like headache ,breast tenderness occur.Simple and cost-effective treatment for DUB. Progerterone IUD is no longer marketed.
		Posted by Fahima A. Tue Jan 30, 2007 05:45 pm
Her management will be influenced by the severity of symptoms ie how much it is affecting her quality of life, whether it is associated with other features like dysmenorrhoea or not, any previous treatment & its success, her fertility wishes, her contraceptive history and future contraceptive desire. All the available treatment including medical, hormonal & surgical should be discussed with her with evidenced based information & choice of treatment will be in a agreed plan. Non hormonal medical treatment includes mefenamic acid a non steroidal anti inflammatory agent, causes 20-30% improvement of menorrhagia . It also improves dysmenorrhoea & has better side effect profile. Tranexamic acid, a anti fibrinolytic agent is more effective ( 40-60% improvement ) But it may cause GI tract symptoms, rarely cerebral venous sinus thrombosis & visual disturbances . However it does not increase the risk of DVT. If the patient is anaemic and FBC shows low haemoglobin level Iron tablet is to be given though it may cause nausea, vomiting, constipation . Progestogen can be given in orally, intramuscularly or as an intrauterine device. To control her menorrhagia effectively oral norethisterone , medroxy progesterone should be given from 5th day of cycle upto 21 days for several cyle not only for 7 days. Side effects may be oedema, weight gain acne . It is not a contraceptive so additional barrier method should be use with it for contraception. Intramuscular depot medroxy progesterone acetate will control menorrhagia & also an effective contraceptive. It may cause irregular spotting & decreased bone mineral density though no evidence of increased fracture.Thre is delay in return of fertility after discontinuation of injection. Mirena IUS is inserted in the uterine cavity effectively control the symptoms about 97% in 6 months & about 30% patient becomes amenorrhoric. It is also an effective contraceptive can control the symptoms of dysmenorrhoea. Fertility returns after discontinuation of coil. However thre is some irregular spotting in first 6 months which will be improved over time.