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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> Essay 244- Menorrhagia
Essay 244- Menorrhagia Posted by Paul T.
Mon Aug 6, 2007 12:59 am
A healthy 40 year old mother of 3 children complains of regular heavy periods for which no cause has been found. (a) Evaluate the non-hormonal medical treatment options (5 marks). (b) Evaluate the hormonal treatment options (7 marks). (c ) Debate the premise that endometrial ablation is the most appropriate surgical treatment option (8 marks).
Posted by Idris O.
Mon Aug 6, 2007 05:21 pm
a) This patient has dysfunctional uterine bleeding and the non hormonal medical treatment are ferrous sulphate, tranexamic acid and mefenamic acid. Ferrous sulpate is cheap and effective in replacing iron lost during menstruation. Its effectiveness is however not immediate and need to be taken regularly for prolonged periods and compliance is affected by nausea, abdominal cramps and constipation. Tranexamic acid is cheap and effective. It causes relief of menorrhagia in up to 50% of patients. It does not increase the risk of thrombo embolic disease but compliance may be affected because of side effects of nausea,dizziness and abdominal cramps. Mefenamic acid is less effective and relieves menorrhagia in about 40%. It is more effective if pain accompany heavy periods and associated with the side effects of headache, dizziness and risk of peptic ulceration.

b) The hormonal methods include the combined pill.This is cheap and very effective in reducing menstrual blood loss (80-90%). It has the additional advantage of providing effective contraception. It may however, not be appropriate in this age group especially if she smokes, has raised BMI or risk factors for VTE. It also requires to be taking regularly which may affect compliance. The cyclical progestogen are not very effective reducing blood loss in less than 40% of the patients. They are cheap but has to be taking regularly which may affect compliance. They are associated with side effects of irregular vaginal bleeding, breast tenderness and mood swings. DMPA are rarely used but effective. It also provides effective contraception.It may be associated with irregular vaginal bleeding and sometimes amenorrhoea.The next progestogen is the IUS( Mirena coil). It is very effective in reducing menstrual blood loss by about 80% in 6/12 and up to 95% by 1year. It is administered once every 5years and provides additional benefit of contraception if desired. Although expensive it is more cost-effective in the long term and has reduced the need for surgery or hysterectomy. It is associated with the side effect of irregular vaginal bleeding in the first 6/12 and also cause acne, breast tenderness and the development of functional ovarian cyst. The GnRH analogue like zoladex or prostab are very effective and produce excellent results. They are however, very expensive and associated with side effects of menopausal symptons. They cannot be used for more than 6/12 except with add back therapy to prevent the risk of osteoporosis. Danazol is an alternative to GnRH analogue and also effective. It is no longer used because of its androgenic side effects of breast atrophy,acne and hirsutism.

c) The advantages of endometrial ablation in this 40 year old multiparous woman includes it avoids the complications associated with hysterectomy( bladder, bowel and ureteric injuries). It is usually performed as a day case procedure though overnight stay may be necessary for observation.It is associated with increased cost effectiveness compared with hysterectomy and rapid post operative recovery. The amenorrhoea rates varies from 10-75% with satisfaction rates of about 55-90% depending on individual operator result. The efficacy is improved with the pharmacological treatment of the endometrium with GnRH analogues.
The disadvantage is that the procedure may be complicated by haemorrhage requiring hysterectomy, perforation and fluid overload. This would be the best treatment for women with DUB at the latter end of reproductive life with a normal uterus, because the effectiveness decreases after the first year. It is essential to exclude endometrial pathology by sampling before treatment. In addition after treatment, menstrual blood loss may not alter or may remain unacceptable requiring further treatment.
If contraception is desired she would need to continue contraception and the treatment does not relief dysmenorrhoea or premenstrual syndrome if present. This 40 year old multiparous women may have only short term benefit from endometrial ablation if her only sympton was menorrhagia with an increased need for re-operation . Therefore endometrial ablation may not be the most appropriate surgical option. I would provide her with an information leaflet on endometrial ablation.
Posted by Valerie T.
Mon Aug 6, 2007 11:18 pm
a) Non hormonal medical treatment can be used and are beneficial in women who have heavy menstrual bleeding but want to conceive, whereas the hormonal treatments would be unsuitable in those women. It can also be used in women who do not want hormonal treatment or have contraindications. This form of treatment is also beneficial because they can be taken while doing any further investigations. Non hormonal treatment options are tranexamic acid, non steroidal anti-inflammatory drugs and ethamsylate.
Tranexamic acid is an effective oral tablet. It is an antifibrinolytic drug. One gram is taken 3 to 4 times a day, from the onset of bleeding for 4 days. It reduces the menstrual bloss loss significantly by 50%. It does not affect future fertility. However, it has limitations. It does not affect dysmenorrhea and does not regulate menstrual cycles. It has some sideeffects but they are not common such as indigestion and diarrhoea.
Non steroidal inflammatory drugs such as Mefanamic Acid or Naproxen also reduce blood loss but not as effectively as Tranexamic acid. They are oral tablets that reduce blood loss by reducing the levels of prostaglandin. They are taken cyclically only at the onset of bleeding for a few days. They are also beneficial because they do not affect future fertility. There are side effects such as indigestion and diarrhoea.
Ethamsylate is not as effective as Tranexamic acid and NSAIDs at reducing blood loss. It reduces blood loss by only 13%. There is insufficient evidence to support its use.

b) The hormonal treatment options are levonorgestrel intrauterine system, combined oral contraceptive pill and progestagens. The LNG-IUS is the first line treatment option for heavy bleeding. It is an intrauterine coil that contains a small dose of the progestagen levonorgestrel (20ug). It is effective and reduces blood loss by 71-96%. It is beneficial to women seeking a long term method of treatment. It can remain in the uterus for 5 years before it needs to be removed or changed. It is also provides contraception and is useful in women that do not want to conceive. It is also cost effective. The limitations are that it needs to be fitted. It requires equipment and someone with the skill of inserting it. Although it significantly reduces blood loss, the LNG-IUS may take 6 months to be effective
The COCP is a second line treatment for heavy menstrual bleeding. It is an oral tablet that contains both estrogen and progestogen. It reduces proliferation of the uterus.
It is effective in reducing blood loss but can also be used in women requesting contraception. It does have limitations. The first is compliance. It is not effective as contraceptive or reducing blood loss if they are not taken correctly and regularly. They can be used in women with a history of thromboembolism or migraines. It has sideeffects such as headaches, mood change and breast tenderness.
The progestogen only tablets are called norethisterone. This is the third line treatment option. The tablets have a dose of 15mg and are effective if taken from day 5 to day 26 of the menstrual cycle, reducing the blood loss by 83%. They function by reducing the proliferation of the endometrium. They are not effective if taken for 7 to 10 days during the luteal phase. They are limited by sideeffects such as headache, acne, weight gain and breast tenderness.
Medroxyprogesterone is an injectable progestagen and used to provide contraception. It does produce amenorrhea but it is not licensed for treatment of HMB. It also affects long term fertility with ovulation being delayed further to stopping the injections.
Danazol is a synthetic steroid. It reduces blood loss by 50% but its use is limited by severe androgenic sideeffects. The risks outweigh the benefits and therefore it should not be used.

c) Endometrial ablation is a surgical procedure that destroys the lining of the womb. There are different types, such as second generation balloon thermal and microwave ablation. They are also the first generation types such as rollerball and transcervical resection of the endometrium. It is the most appropriate method in some cases. If successful, it avoids a major operation and its inherent risks and complications. It is a day case procedure and therefore the patient has short stay in hospital and is cost-effective to the hospital.
On the other hand, it is not always the most appropriate because it is associated with a failure rate and the bleeding may still be unacceptable to the patient. The patient may need further treatment. The procedure may need to be repeated or to have a hysterectomy. It can be argued that she may have been better off opting for hysterectomy in the first place. This method also is unsuitable for women who want to maintain their fertility and wish to conceive. Women must use an effective method of contraception. This may not be acceptable to some women. This procedure would be unsuitable for women with uterine pathology such as endometrial cancer. Oncology treatment and further investigations would be required. A biopsy should be performed prior to the endometrial ablation. It is also unsuitable in women with structural abnormalities such as large fibroids greater than 3 cm. In these women the procedure will be unsuccessful. It has recognised risks such as infection and uterine perforation, although this is uncommon. It is not a suitable method in women who have had previous uterine surgeries such as caesarean section. Some women may have vaginal discharge and increased dysmenorrhoea postoperatively and may find it unsatisfactory.
Posted by Mohammad H.
Tue Aug 7, 2007 02:10 am
A healthy 40 year old mother of 3 children complains of regular heavy periods
for which no cause has been found. (a) Evaluate the non-hormonal medical treatment options (5 marks). (b) Evaluate the hormonal treatment options (7
marks). (c ) Debate the premise that endometrial ablation is the most appropriate surgical treatment option (8 marks).

a- Non-hormonal medical treatment options include mefenamic acid and tranxaemic acid .
Mefenamic acid is a non-steroidal anti-inflammatory that is associated with ~40%reduction in the menstrual blood loss.It also releives dysmenorrhea.
Tranxaemic acid IS associated with 40%-50% reduction in the menstrual blood loss .nO evidence to support that it increases the risk of thromboembolism.

b-hormonal treatment options :
Combined oral contraceptive pills (cocp) are associated with 50%-60% reduction in the menstrual blood loss and it releives dysmenorrhea. It is relatively cheap and provides a reliable method for conteaception if patient wishes.

Progestogens are effective in treatment6 of menorrhagia but should be used for 16 days to be effective .

Danazol is an androgenic drug that is effective in reducing menstrual blood flow but its use is restricted by its androgenic side effects.

Gonadotrophin releasing hormone antagonists (GnRHa)are relatively expensive drugs taht are effective in treatment of menorrhagia .they have menopausal symptoms so can be used for 6 months while treating anaemia or waiting for surgical intervention.

Levonorgestrel releasing intrauterine system (LNG-IUS) that releases locally 20ug levonorgestrel daily.It is associated with ~97%reduction of menstrual flow at one year of use and most women get their periods as spots. It releives dysmenorrhea,premenstrual tension, and reduce ectopic pregnancy as compared to non users of contraceptives .It provides reliable contraception for 5 years .It is associated with high patient satisfaction and reduced the need for hysterectomy.



c-Endometrial ablation is the destruction of the endometrial lininig for treatment of menorrhagia.It can be done using diathermy ,laser or heated balloon.It has the advantage of avoiding major surgical procedure with its complications.It gives results comparable to hysterectomy on the short term but on long term is associated with less satisfaction with ~50%of patients requiring surgical intervention and it did not reduce the rate of hysterectomy.Endometrial ablation can lead to hemorrhage ,uterine perforation and infection.It is not
suitable for patients withenlarged uterus (12 weeks or more),women requiring amenorrhea or suffering from dysmenorrhea.It does not provide contraception and a contraceptive should be used,. The effect of endometrial ablation on fertility and pregnancy outcome need to be evaluated so, it is not suitable if the patient is wishing to preserve her fertility.

It is the patient\'s choice after proper counselling about different options and providing written information leaflets to decide the mode of treatment.
Posted by Malar R.
Tue Aug 7, 2007 03:47 pm
The non hormonal options include tranexamic acid, mefanamic acid and other Nsaids.Tranexamic acid is cheap, easy to take and has no major side effects.It is effective in reducing flow in upto 70-80% of women.It does not affect fertility.It only needs to be taken during a period hence is practical.However contraception is still needed.

Mefenamic acid and other Nsaids such as diclofenac also reduce blood loss, though less then tranexamic acid. They will also help dysmenorrhoea if present.However they cannot be used in the presence of peptic ulcers or gastritis.They are easy to take and only need to be taken during a period.

The hormonal options include the combined oral contracetive pill (COC), progestogens such as depo provera,norethisterone and Mirena IUS.Danazol and GnRH analogues are also available.

The COC is cheap,easy to take and also provides contraception if required.It is effective at reducing menorrhagia and can also help dysmenorrhoea if present.It is protective against endometrial and ovarian cancer but can increase the incidence of thromboembolism, breast cancer and cervical cancer.Hence if this lady smokes or has a high BMI, the COC will be contraindicated.

Depo provera will reduce the blood flow and may render her amenorrhoeic.It will also provide adequate contraception.It does require repeat injections every 12 weeks and this may not be acceptable to the patient.It is associated with bone density loss with prolonged use, irregular vaginal bleeding and weight gain, side effects which may not be acceptable.

Norethisterone taken in the luteal phase or day1-21 will be unhelpful in this lady as her periods are regular. It will not help heavy bleeding.

Danazol is an anti oestrogen which may cause reduce blood loss and cessation of periods. However there is a risk of virilisation, voice changes, breast atrophy and acne.

The mirena IUS is an option. It reduces blood flow in women after about 6 months of insertion.It is expensive but effective in reducing blood loss. It is easy to insert, can be done under local anaesthetic and also acts as contraception if required.There is a small risk of pelvic infection around the time of insertion.Side effects from the progestogen is minimal but women may complain of bloating, mood swings and loss of libido.

GnRH analogues may be considered and are effective at reducing blood loss. However they can only be used for 6 months and render the patient menopausal causing vasomotor side effects.They can also cause osteoporosis if used for more than 6 months.

The advantages of endometrial ablation are avoiding major operation of hysterectomy and risk factors associated such as visceral damage.The patient recovery is shorter as is the hopital stay since it is mostly a day case procedure.The cost compared to hysterectomy is cheaper.The anaesthetic time is also shorter.The patient satisfaction rate for bleeding is upto 80%.It is also safer in patients who have had multiple laparotomies ( not involving uterus) where a hysterectomy will be dificult due to adhesions.

The disadvantages are that a skilled trained operator is required for the procedure especially for TCREs.It cannot be performed for women with a classical caesarean section.The hospital has to have the necessary equipment which is expensive.It is not suitable for women who wish to become amenorrheic. Contraception is still needed after the procedure. Some women will still need a hysterectomy for their menorrhagia afterwards hence increasing the costs.

Endometrial ablation is a very good option provided the patient is selected carefully and fully counselled and adequate equipment and operative skills are available.

Posted by Shahla  K.
Tue Aug 7, 2007 05:00 pm
Metfomin is nonhormonal medicine of first choice, it is non steroidal anti inflammatory drug with anti prostaglandin activity on endometrium ,it reduce menstrual loss by 25% it has to be taken with menstruation ,complication include peptic ulcer and exacerbation of asthma,it confer no contraception
Antifibrinilytic agents(tranexamic acid) reduce menstrual loss by 50%.
It does not induce thromboembolic phenomenon ,it has to be taken durig mensis.it does not work as contraceptives.nausea ,dyspepsia abdominal pain are unwanted effects.visual disturbance warn for discontinuation.
b)Combine oral contraceptive pills reduce menstrual loss by 50% ,it also cover her contraceptive wishes.there are many contraindication which should be screen in history.
Oral Progesteron(norethisteron) effective only in high dose,when taken from day5 of cycle for 21 days to reduce menstrual loss ,
Depoprovera is injectable progesterone it reduce menstrual loss by 80% in 3-6 month and 90% in 0ne year. It is not licensed for menorrhagia. It also provide contraception which may not her need.there are incidence of break through bleeding.in 25-50%of subjects.
Levenorgesterone containing intrauterine device release progesterone locally bring menstrual reduction in 75% of women in 3 months.it cause benign ovarian cyst. It is licensed for menorrhagia.
Danazole is another option it has more androgenic activity(acne ,hirsutism,oily skin) use only for short term basis,which are reversible except deepening of voice.it warn discotinuation .
Gestrinon is less androgenic then danazole.Gonadotrophin releasing hormones cause reduction in mensis and amenorrhea but its prolong use lead to osteoporosis.
C)Endometrial ablation cause destruction of endomtrium till its basal layer,Although amenorrhea in 40% of women but satisfaction achieve in 75%of subject,It avoid hysterectomy and its morbidities.It has been seen in 38% of women who return to seek another treatment after 3 year.
It is cheaper then hysterectomy,it can be perform as day care procedure ,
Selection of women for uterine ablation can avoid complication .
women who expect amenorrhea should be council,she should avoid pregnancy by using contraception as there is possibility of pregnancy, which may associate with complications.Ablation should also be avoid in women with PID,adenomyosis.
Procedure related risks are more with first generation technique (TCRE,REA) it require hysteroscopy and distention water, Excessive absorption of water is a complication.
Second generation(thermachoice,microwave) does not require expertise as first generation ,it is a blind procedure do not need hysteroscopy or distention media ,
Therefore endometrial ablation is good option for well selected women.with no fertility intention.

Posted by Jancy V.
Tue Aug 7, 2007 09:43 pm
The non hormonal treatment options are tranexamic acid and nonsteroidal anti inflammatory drugs, especially mefenamic acid. These are suitable for women with regular heavy menstrual loss without structural or histological abnormality. These can be started in primary health care prior to physical examination and imaging if the history suggests no histological or structural abnormality. Tranexamic acid 1 to 4 g per day in divided doses reduces menstrual blood loss by 50%. It has few side effects like headache, vomiting and indigestion. If menorrhagia is associated with dysmenorrhoea, NSAIDs would be the first line treatment and reduces blood loss by 25 to 50%. Side effects are vomiting, worsening of peptic ulcer and bronchial asthma. If no improvement is noted in 3 cycles, non hormonal treatment should be stopped.

The hormonal treatment is especially useful in women with heavy menstrual loss with failed non hormonal treatment and in those whorequire contraception. The options are LNG- IUS (Mirena), COCP, norethisterone, injectable progesterone and GnRH analogues. Mirena is the first choice in women who are willing for long term contraception. However, irregular bleeding is a side effect and women should be clearly advised on this and asked to persevere for 6 months. At 12 months of use, 97% report reduction in menstrual loss. Low dose combined OC pills provide contraception and significant reduction in blood loss with regular cycles. Norethisterone should be given 15 mg from day 5 to 26 of cycle , there is no role of luteal phase treatment alone. Injectable progesterone DMPA given at dose of 150 mg every 3 months , reduces blood loss but produces irregular break through bleeding or amenorrhea in some women. There is also the risk of reduction in bone mineral density. GNRH analogues may be given in women with fibroids prior to surgery or UAE for 3 to 6 months. It has side effects of menopausal symptoms and osteoporosis. Treatment should be stopped once surgery is scheduled.

Endometrial ablation is a conservative surgical approach to women with heavy menstrual loss , with a normal size uterus and completed family. It should be an informed choice after discussing advantages and disadvantages of other treatment options . Histological and structural abnormalities should be ruled out prior to decision. When compared to hysterectomy, it has less morbidity and mortality and good patient satisfaction rates. There is no compromise in ovarian function and hence the women should continue to use contraception. Amenorrhoea cannot be guaranteed. If uterine size is less than 10 weeks , fibroids less than 3 cm, no desire for fertility, ablation is a choice. Second generation ablative techniques like Impedance controlled radiofrequency ablation, ballon ablation, microwave ablation should be used as first line. The advantage is that it is done as a day case and carries less post op complications. Women should be willing to undergo hysterectomy in case of failed procedure.
Posted by Parveen  Q.
Wed Aug 8, 2007 01:14 am
The non hormonal treatment options are tranexamic acid and NSAIDS like mefenamic acid. Tranexamic acid is effective in reducing blood loss by about 50%. It is more effective than mefenamic acid. The side effects are nausea, vomitting, abdominal cramps, serious ,but uncommon side effects like intracranial thrombosis and reduced colour vision. These side effects are dose related, which can be limited by taking it during the first 3 to 4days of the period. NSAID are cheaper, very commonly used, it reduces the blood loss by 25%. It has better side effect profile compared to tranaexamic acid.

There many hormonal treatment options with different efficacy and side effect profile. Progestogens like norethisterone is ineffecetive if given for 5 to 10days in the luteal phase, but with increasing dose like 5mg thrice daily from D5 to D26 will reduce the blood loss significantly. It has side effects like fluid retention and mood changes and it is not a contraceptive. Depo medroxy progesterone given intramuscularly once in 12weeks acts as a effective contraception. It induces amenorrhoea in 30%. It has side effects like weight gain, irregular menstruation, and delay in return to fertility after stopping the treatment. Levonorgestrel intrauterine contraceptive system(mirena) is a popular choice . It reduces blood loss by 80% within 3months and by 1year blood loss is reduced by 97%. It is a very effective contraceptive, licensed for use for 5years and return to feritility once the device is removed. It is an acceptable alternative to hysterectomy to some women. Though the intial cost is high it is cost effective in 5years. The main side effect is the irregular bleeding in the first 3months. There are other options like GnRH analogue which can be used in intractable menorrhagia, but it cannot used longer than 6months due to hypooestrogenic effects and reduced bone mineral density. The mode of administration is monthly injections or nasal spray which may not be acceptable to some. Danazol, which is a synthetic androgen with antioestrogenic, anti progestogenic activity, which direcly suppresses the endometrium. It has many androgenic side effects like hot flushes, hirsutism, breast atrophy, which can be reversible on stopping the medication, but the voice change remains irreversible. Contraception has to advised along with danazol, due to virilisation of female foetus if pregnancy occurs. Gestrinone, reduces blood loss significantly, but not used as a first line of treatment. It has androgenic side effects like danazol and contraception is advised for similar reasons as danazol.

Endometrial ablation is the treatment option if the medical and IU system has failed or refused by the patient. There are different techniques with different risk, efficacy and cost . First generations are TCER, diathermy or laser ablation, and radiofrequency ablation, the second regenerations are thermal ballon ablation, microwave thermal ablation. It is done as the day case procedure , the hospital stay is less, and is cost effective. The post operative recovery is rapid. The amennorrhoea rate is 30%, patient satisfaction ranges from 55% to 90%. and the reopearation rate in 3years is 38%. It is suitable for somebody who has completed their family and willing to undergo hysterectomy if necessity arises. It is not suitable for somebody who considers total amennorhoea and cure from premenstrual tension or dysmennorrhoea. When compared to medical treatment or MIRENA , future pregnacy is contraindicated and patient has to be given contraceptive advise. There is risk of uterine perforation and fluid overload. In comparison to hysterectomy , endometrial ablation avoids complication of major surgery, and amennorrhoea rate is 20 to 40% when it is 100% in hystrectomy. Patient has to be informed that she will have vaginal discharge for 3weeeks, and abdominal cramps for few days. In a suitably motivated patient, especially in a case of DUB , in the end of reproductive life , endometrial ablation is the best option.
Posted by Natalia  N.
Wed Aug 8, 2007 11:22 am
A. Non-hormonal treatment is a first line therapy of menorrhagia, which of includes anti-fibrinolytic agent (tranexamic acid) and NSAIDs (mefenamic acid). Tranexamic acid decreases menstrual blood floow by 50%. It is cheap and easy to use. The disadvantages incude low efficacy and side-effects (nausea, vomitting, diarrhoea) and loss of color vision. It does not cause DVT. The latter is a indiction to cease tranexamic acid. The dose used is 1 g three times a day during the bleeding. Mefenamic acid decreases blood flow by 25%, it is also cheap and easy to use. It does have side-effects, gastrointestinal symptoms, asthma, ulcers.
Both above-mentioned medications are used in combination. Neither of the above-mentioned preparations have contraceptive effect, therefore, contrception should be advised. Both of these medications can be initiated at the primary level health service for treatment of menorrhagia, where uterine and cervical pathology have been excluded. The efficacy should be assessed in 3 months, and if it\'s not effective homonal therapy should be started.

B. Hormonal methods of treatment of menorrhagia include progesterone preparations (oral norethisterone, Depo (medroxyprogesterone acetate 150 mg, IM), Mirena IUD), gestrinone, danazol, GnRh analogues, cyclical HRT.
Oral progesterone taken short term in low dosage is not effective for treatment of menorrhagia. Norethisterone in highg dose (5 mg three times daily) taken for three out of 4 weeks of the menstrual cycle (day 5 to 26) is effective, cheap and easily available treatment of menorrhagia. It is an effective treatment in emergency situation of heavy menorrhagia. It has side effects of irregular bleeding, fluid retention, weight gain, depression, acne, gastointestinal problems. Depo Provera causes amenorrhoea in 30% of women after the first injection, and in 60% after the 2nd injection. It also provides contraception. It does need a specialist service to povide the treatment. It can be used for 5 years or longer in perimenopausal women. It has side-effects of irregular bleeding, depression, weight gain, bone mineral density loss is used for more than 5 years. Mirena IUD is effective treament, which is an IUD containing levonorgestrel released n small quantities in the uterus. It causes amenorrhoea in 80% of women by the end of the first year of use. It also provides contraception. It is cost-effective treatment of menorrhagia which avoids risk of surgery, e.g. hysterectomy with it\'s complications (infection, bleeding, injury to internal organs, DVT). About 10% of women will develop irregular bleeding, which is more common in the first 3-4 months. Women should be counselled appropriately regarding side-effects. Mirena requires a specialist service for insertion. The insertion could be difficult, and sometimes even require general anaesthesia. Uterine perforation, severe abdominal pain, PID (rare) are complication of Mirena. It also has some side-effects common for progesterone, e.g. depression, fluid retention.
Danazol is effective treatment, which has multiple troublesome side effects, e.g. acne, hirsutism, depression, mood swings, alopecia, loss of bone mineral density, irrevrsible change of voice. It shoudl be used for longer than 6 months due to side-effects profile, and symptoms usually return once the treatment was stopped. WOmen must use reliable contraception since danazol causes viriliasation of female fetus.
GnRH agonists is an effective treatment. However, it is expensive and has with multiple side -effects (hot flushes, dry skin, osteoporosis, gastrointestinal symptoms). Might be effective for treatment of menorrhagia in perimenopause, before surgery to shrink fibroids and decrease blood flow to improve Hb.
HRT can be successfuly used on perimenopausal women. It is effective and has other , but associated with teh side effects
The patient should be counselled regarding all the available options and the choice should be made depending on the patients wishes and clinical situation (desire for future fertility, need for contraception).

C. Endometrial ablation is a suitable treatment for this patient. The advantages of endometrial ablation is avoidance of major surgery (e.g. hysterectomy) and it\'s side effects, e.g. infection, bleeding, injury to internal organs, DVT. It is performed as a day procedure. Endometrial ablation causes amenorrhoae in 30% of the patient, and decreases the menstrual flow in up to 80%. It is not suitable for patients desiring future fertility, and for patients expecting permanent amanorrhoea. Endometrial malignancy, and premalignant cervical and uterine conditions condition, and pelvic infections shoudl be excluded prior to procedure. Uterine size should be less than 12 weeks. Endometrial ablation does not improve dysmenorrhoea, but there are some reports that it might be effective. It has side effects of fluid overload, uterine perforation, and infertility. Patient has to use contraception after the procedure. Pregnancy is contraindicated due to risk of uterine rupture. Special equipment (depending on a type of ablation, e.g. microvawe, high radio-frequency ablation, ballon ablation) and skilled operator is needed to perform the procedure.
Posted by Saad A.
Wed Aug 8, 2007 12:57 pm
The non-hormonal medical treatments are NSAIDS, and transmenaic acid. NSAIDS cause 20% decrease in menstrual flow, wheras transmenaic acid causes 50% reduction in menstrual flow. However it has been shown that transmenaic acid causes more side effects than NSAIDS. The side effects of trasmenaic acid are GI symptoms, central venous thrombosis and intraretinal thrombosis . NSAIDs also provide analgesic effects.
b. The hormonal treatments include COCP which is well tolerated, inexpensive , regulate menstrual cycle and makes the cycle less painful. It is 50% effective in reducing menstrual flow. It also provides contraception. It has side effects like breast tendereness, nausea, vomiting and risk of VTE, breast cancer, and hepatoxicity/cancer.The contraindications are breast cancer,focal migrane,and family /personal history of VTE . Progesteron when given for short term are not efective ,however when used for 5-25 days are efective . The side efects of progesteron are mood changes, fluid retention and weight gain. Progesteron does not provide contraception . LNG IUS cause 75% reduction in menstrual loss at 03 months and 97% reduction at 12 months. There are 35% chances of ammenorhea. It provides contraception. However the side efects is that it causes menstrual irregularity within 3-4 months. There is risk of ovarian cyst formation. There is risk of expulsion and perforation and there is difficulty in insertion in nulliparous. GnRH analouge are expensive . These drugs are given by injection/spray and not orally. It may be unacceptable to the patient because of the injectable mode of administration. It is associated with menopausal side-effects and there is risk of decreased bone mineral density when used for 06 months. Danazol are effective but associated with androgenic side effects . The effects on voice changes are irreversible.
c. Endometrial ablation is one of the surgical treatment options for DUB. It is a day case operative procedure associated with less operative time than hysterectomy . The operative morbidity is also less than hysterectomy. There is 80% satisfaction rate, 20-40% amenorrhea rate. However there is 38% re-operation rate within 03 years and 10-25% need hysterectomy within 05 years. The different ablation techniques are laser/diathermy ablation techniques , radiofrequency , thermal, balloon, and endometrial resection techniques. The procedure is undertaken under general anaesthesia however regional anaesthesia is possible. However it has been seen that hysterectomy is associated with more satisfactory rates and hysterectomy is the treatment of choice for those requiring permanent amenorrhea. There are risks associated with ablation techniques like perforation, bleeding and need of laproscopy/laprotomy if any complications develop and increase risk of water retention. However the risk associated with hysterectomy is more which include haemorrhage and risk of visceral injury, infection, VTE. Another disadvantage of endometrial ablation is that it doesnot relieve dysmenorrhea and PMS and there is need of endometrial sampling to exclude endometrial cancer before the procedure. There is also a requirement of contraception to be continued as there is risk of pregnancy complications like placenta accreta if pregnancy occurrs after ablation. Similarly the medical management including hormonal non hormonal should be used as first priority in patients with heavy menstrual bleeding and if no response then surgical intervention should be carried out . In surgical management endometrial ablation should be used in priority to hysterectomy in patients who donot require permanent amenorrhea.
Posted by Paul T.
Thu Aug 9, 2007 11:00 am
a) This patient has dysfunctional uterine bleeding and the non hormonal medical treatment are ferrous sulphate, tranexamic acid and mefenamic acid. Ferrous sulpate is cheap and effective in replacing iron lost during menstruation (1) . Its effectiveness is however not immediate and need to be taken regularly for prolonged periods and compliance is affected by nausea, abdominal cramps and constipation limitations not needed ? evaluate, NOT critically evaluate. You are wasting time & space . Tranexamic acid is cheap and effective (1) . It causes relief of menorrhagia in up to 50% of patients this is incorrect. There is ~50% reduction in menstrual blood loss but this is not = relief in 50% of patients . It does not increase the risk of thrombo embolic disease but compliance may be affected because of side effects of nausea,dizziness and abdominal cramps not needed . Mefenamic acid is less effective (1) and relieves menorrhagia in about 40% see above. How was this measured? By woman saying she is now happy with her loss or by a reduction in blood loss below 80ml per cycle? . It is more effective if pain accompany heavy periods and associated with the side effects of headache, dizziness and risk of peptic ulceration.

b) The hormonal methods include the combined pill.This is cheap and very effective in reducing menstrual blood loss (80-90%) Incorrect ? 80-90% reduction is too hgh . It has the additional advantage of providing effective contraception. It may however, not be appropriate in this age group especially if she smokes (1) , has raised BMI or risk factors for VTE. It also requires to be taking regularly which may affect compliance. The cyclical progestogen are not very effective reducing blood loss in less than 40% of the patients Suggest you read a different book if you obtained this information from a book. Women will be unable to make suitable comparisons if you quote % reduction in blood loss for one drug and % of patients improved for another . They are cheap but has to be taking regularly what does regularly mean? Every day? which may affect compliance. They are associated with side effects of irregular vaginal bleeding, breast tenderness and mood swings. DMPA are rarely used but effective how effective is it? It may be assumed that this is the best treatment because it is effective while the others are only 40-90% effective . It also provides effective contraception.It may be associated with irregular vaginal bleeding and sometimes amenorrhoea.The next progestogen is the IUS( Mirena coil). It is very effective in reducing menstrual blood loss by about 80% in 6/12 and up to 95% by 1year (1) . It is administered once every 5years and provides additional benefit of contraception if desired (1) . Although expensive it is more cost-effective in the long term and has reduced the need for surgery or hysterectomy. It is associated with the side effect of irregular vaginal bleeding in the first 6/12 and also cause acne, breast tenderness and the development of functional ovarian cyst not necessary . The GnRH analogue like zoladex or prostab do not use trade names are very effective and produce excellent results how effective is very effective? . They are however, very expensive and associated with side effects of menopausal symptons. They cannot be used for more than 6/12 except with add back therapy to prevent the risk of osteoporosis. Danazol is an alternative to GnRH analogue and also effective. It is no longer used because of its androgenic side effects of breast atrophy,acne and hirsutism.

c) The advantages of endometrial ablation in this 40 year old multiparous woman includes it avoids the complications associated with hysterectomy( bladder, bowel and ureteric injuries). It is usually performed as a day case procedure though overnight stay may be necessary for observation (1) .It is associated with increased cost effectiveness compared with hysterectomy and rapid post operative recovery (1) . The amenorrhoea rates varies from 10-75% is this an advantage? with satisfaction rates of about 55-90% depending on individual operator result (1) . The efficacy is improved with the pharmacological treatment of the endometrium with GnRH analogues.
The disadvantage is that the procedure may be complicated by haemorrhage requiring hysterectomy, perforation and fluid overload. This would be the best treatment for women with DUB at the latter end of reproductive life with a normal uterus, because the effectiveness decreases after the first year. It is essential to exclude endometrial pathology by sampling before treatment. In addition after treatment, menstrual blood loss may not alter or may remain unacceptable requiring further treatment what % of patients require further treatment? .
If contraception is desired why IF? Is there any reason why a 40 year old with menorrhagia will not require contraception unless she is trying for a pregnancy? she would need to continue contraception and the treatment does not relief dysmenorrhoea or premenstrual syndrome if present. This 40 year old multiparous women may have only short term benefit from endometrial ablation if her only sympton was menorrhagia with an increased need for re-operation . Therefore endometrial ablation may not be the most appropriate surgical option this is your opinion besed on your assessment of risks & benefits. The woman might come to a different conclusion. Are you suggesting that hysterectomy is the most appropriate surgical option for her? . I would provide her with an information leaflet on endometrial ablation.
Posted by Paul T.
Thu Aug 9, 2007 12:45 pm
a) Non hormonal medical treatment can be used and are beneficial in women who have heavy menstrual bleeding but want to conceive, whereas the hormonal treatments would be unsuitable in those women. It can also be used in women who do not want hormonal treatment or have contraindications. This form of treatment is also beneficial because they can be taken while doing any further investigations Not necessary ? this is a waste of your time and space. If you run out of time and do not answer one question, you will probably fail the entire exam . Non hormonal treatment options are tranexamic acid, non steroidal anti-inflammatory drugs and ethamsylate.
Tranexamic acid is an effective oral tablet . It is an antifibrinolytic drug. One gram is taken 3 to 4 times a day, from the onset of bleeding for 4 days. It reduces the menstrual bloss loss significantly by 50% (1) . It does not affect future fertility. However, it has limitations. It does not affect dysmenorrhea and does not regulate menstrual cycles. It has some sideeffects but they are not common such as indigestion and diarrhoea not necessary ? the question stated she had regular periods. The question does not require the limitations / side-effects .
Non steroidal inflammatory drugs such as Mefanamic Acid or Naproxen also reduce blood loss but not as effectively as Tranexamic acid (1) what is the % reduction in blood loss?. They are oral tablets that reduce blood loss by reducing the levels of prostaglandin. They are taken cyclically only at the onset of bleeding for a few days. They are also beneficial because they do not affect future fertility not necessary . There are side effects such as indigestion and diarrhoea.
Ethamsylate is not as effective as Tranexamic acid and NSAIDs at reducing blood loss. It reduces blood loss by only 13%. There is insufficient evidence to support its use.

b) The hormonal treatment options are levonorgestrel intrauterine system, combined oral contraceptive pill and progestagens. The LNG-IUS is the first line treatment option on what basis do you make this statement? for heavy bleeding. It is an intrauterine coil that contains a small dose of the progestagen levonorgestrel (20ug) is this what is contained in the coil or what is released per day? This information is not necessary for the answer and you lose marks if you get it wrong . It is effective and reduces blood loss by 71-96%. It is beneficial to women seeking a long term method of treatment is there a role for short-term treatment?? . It can remain in the uterus for 5 years before it needs to be removed or changed. It is also provides contraception and is useful in women that do not want to conceive (1) . It is also cost effective. The limitations are that it needs to be fitted. It requires equipment and someone with the skill of inserting it. Although it significantly reduces blood loss, the LNG-IUS may take 6 months to be effective not necessary
The COCP is a second line treatment why is this second line?? for heavy menstrual bleeding. It is an oral tablet that contains both estrogen and progestogen. It reduces proliferation of the uterus does it??? Again, such details are not necessary and if they are inaccurate, you lose marks .
It is effective in reducing blood how effective? loss but can also be used in women requesting contraception. It does have limitations. The first is compliance. It is not effective as contraceptive or reducing blood loss if they are not taken correctly and regularly. They can be used in women with a history of thromboembolism or migraines. It has sideeffects such as headaches, mood change and breast tenderness not necessary .
The progestogen only tablets are called norethisterone. This is the third line treatment option this is not a third line option. What if she does not want contraception? . The tablets have a dose of 15mg NO ? a dose of 5-10mg tds might suffice. Again, you do not need to write the dose and you lose marks if you get it wrong and are effective if taken from day 5 to day 26 of the menstrual cycle, reducing the blood loss by 83%. They function by reducing the proliferation of the endometrium. They are not effective if taken for 7 to 10 days during the luteal phase (1) . They are limited by sideeffects such as headache, acne, weight gain and breast tenderness not necessary .
Medroxyprogesterone is an injectable progestagen and used to provide contraception. It does produce amenorrhea but it is not licensed for treatment of HMB what is this? . It also affects long term fertility with ovulation being delayed further to stopping the injections.
Danazol is a synthetic steroid ? GnRH analogues . It reduces blood loss by 50% but its use is limited by severe androgenic sideeffects. The risks outweigh the benefits and therefore it should not be used.

c) Endometrial ablation is a surgical procedure that destroys the lining of the womb. There are different types, such as second generation balloon thermal and microwave ablation. They are also the first generation types such as rollerball and transcervical resection of the endometrium. It is the most appropriate method in some cases. If successful, it avoids a major operation and its inherent risks and complications. It is a day case procedure and therefore the patient has short stay in hospital and is cost-effective to the hospital (1) .
YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE
On the other hand, it is not always the most appropriate because it is associated with a failure rate and the bleeding may still be unacceptable to the patient. The patient may need further treatment. The procedure may need to be repeated or to have a hysterectomy. It can be argued that she may have been better off opting for hysterectomy in the first place. This method also is unsuitable for women who want to maintain their fertility and wish to conceive. Women must use an effective method of contraception. This may not be acceptable to some women. This procedure would be unsuitable for women with uterine pathology such as endometrial cancer. Oncology treatment and further investigations would be required. A biopsy should be performed prior to the endometrial ablation. It is also unsuitable in women with structural abnormalities such as large fibroids greater than 3 cm. In these women the procedure will be unsuccessful. It has recognised risks such as infection and uterine perforation, although this is uncommon. It is not a suitable method in women who have had previous uterine surgeries such as caesarean section. Some women may have vaginal discharge and increased dysmenorrhoea postoperatively and may find it unsatisfactory.
Posted by Paul T.
Thu Aug 9, 2007 12:55 pm
a- Non-hormonal medical treatment options include mefenamic acid and tranxaemic acid .
Mefenamic acid (1) is a non-steroidal anti-inflammatory that is associated with ~40%reduction in the menstrual blood loss (1) .It also releives dysmenorrhea.
Tranxaemic acid IS associated with 40%-50% reduction in the menstrual blood loss (1) more effective than mefenamic acid and this is not obvious from your answer .nO evidence to support that it increases the risk of thromboembolism.

b-hormonal treatment options :
Combined oral contraceptive pills (cocp) are associated with 50%-60% reduction in the menstrual blood loss (1) and it releives dysmenorrhea. It is relatively cheap and provides a reliable method for conteaception if patient wishes (1) .

Progestogens are effective in treatment6 of menorrhagia but should be used for 16 days to be effective ? days 5-25 = 20 days.

Danazol is an androgenic drug that is effective in reducing menstrual blood flow but its use is restricted by its androgenic side effects.

Gonadotrophin releasing hormone antagonists (GnRHa)are relatively expensive drugs taht are effective in treatment of menorrhagia .they have menopausal symptoms so can be used for 6 months while treating anaemia or waiting for surgical intervention (1) .

Levonorgestrel releasing intrauterine system (LNG-IUS) that releases locally 20ug levonorgestrel daily.It is associated with ~97%reduction of menstrual flow at one year of use (1) and most women get their periods as spots. It releives dysmenorrhea,premenstrual tension, and reduce ectopic pregnancy as compared to non users of contraceptives .It provides reliable contraception for 5 years (1) .It is associated with high patient satisfaction and reduced the need for hysterectomy.



c-Endometrial ablation is the destruction of the endometrial lininig for treatment of menorrhagia.It can be done using diathermy ,laser or heated balloon.It has the advantage of avoiding major surgical procedure with its complications (1) . It gives results comparable to hysterectomy on the short term 100% of women will be amenorrhoeic 1 month after hysterectomy ? is this so for endometrial ablation? (-1) but on long term is associated with less satisfaction with ~50%of patients requiring surgical intervention (1) and it did not reduce the rate of hysterectomy.Endometrial ablation can lead to hemorrhage ,uterine perforation and infection.It is not
suitable for patients withenlarged uterus (12 weeks or more),women requiring amenorrhea or suffering from dysmenorrhea.It does not provide contraception and a contraceptive should be used (1) ,. The effect of endometrial ablation on fertility and pregnancy outcome need to be evaluated so, it is not suitable if the patient is wishing to preserve her fertility.

It is the patient\'s choice after proper counselling (1) about different options and providing written information leaflets to decide the mode of treatment.

Posted by Paul T.
Thu Aug 9, 2007 03:28 pm
The non hormonal options include tranexamic acid, mefanamic acid and other Nsaids.Tranexamic acid is cheap, easy to take and has no major side effects (1) .It is effective in reducing flow in upto 70-80% of women what is the % reduction in blood loss? This is the appropriate figure to quote .It does not affect fertility.It only needs to be taken during a period hence is practical.However contraception is still needed.

Mefenamic acid and other Nsaids such as diclofenac also reduce blood loss, though less then tranexamic acid (1) what is less? 5% reduction? . They will also help dysmenorrhoea if present.However they cannot be used in the presence of peptic ulcers or gastritis.They are easy to take and only need to be taken during a period.

The hormonal options include the combined oral contracetive pill (COC), progestogens such as depo provera,norethisterone and Mirena IUS.Danazol and GnRH analogues are also available not necessary .

The COC is cheap,easy to take and also provides contraception if required (1) .It is effective at reducing menorrhagia what does this mean? How effective is it? and can also help dysmenorrhoea if present.It is protective against endometrial and ovarian cancer but can increase the incidence of thromboembolism, breast cancer and cervical cancer.Hence if this lady smokes or has a high BMI, the COC will be contraindicated.

Depo provera will reduce the blood flow and may render her amenorrhoeic.It will also provide adequate contraception.It does require repeat injections every 12 weeks and this may not be acceptable to the patient not licensed for the treatment of DUB . It is associated with bone density loss with prolonged use, irregular vaginal bleeding and weight gain, side effects which may not be acceptable. not necessary

Norethisterone taken in the luteal phase or day1-21 will be unhelpful in this lady as her periods are regular. It will not help heavy bleeding this is incorrect on two counts. Firstly, the typical duration of use is days 5-25. If administered from day 1, ovulation might be inhibited. Secondly, used from D5-25, it is effective in DUB .

Danazol is an anti oestrogen which may cause reduce blood loss and cessation of periods ? GnRH analogues . However there is a risk of virilisation, voice changes, breast atrophy and acne.

The mirena IUS is an option. It reduces blood flow in women after about 6 months of insertion (1) ? % reduction .It is expensive but effective in reducing blood loss. It is easy to insert, can be done under local anaesthetic and also acts as contraception if required.There is a small risk of pelvic infection around the time of insertion.Side effects from the progestogen is minimal but women may complain of bloating, mood swings and loss of libido.

GnRH analogues may be considered and are effective at reducing blood loss. However they can only be used for 6 months (1) and render the patient menopausal causing vasomotor side effects.They can also cause osteoporosis if used for more than 6 months.

The advantages of endometrial ablation are avoiding major operation of hysterectomy and risk factors associated such as visceral damage.The patient recovery is shorter as is the hopital stay (1) since it is mostly a day case procedure.The cost compared to hysterectomy is cheaper.The anaesthetic time is also shorter.The patient satisfaction rate for bleeding is upto 80% (1) .It is also safer in patients who have had multiple laparotomies ( not involving uterus) where a hysterectomy will be dificult due to adhesions.

The disadvantages are that a skilled trained operator is required for the procedure especially for TCREs is a skilled operator not required for other operations? .It cannot be performed for women with a classical caesarean section.The hospital has to have the necessary equipment which is expensive.It is not suitable for women who wish to become amenorrheic. Contraception is still needed after the procedure (1) . Some women will still need a hysterectomy for their menorrhagia afterwards hence increasing the costs what is the re-operation rate? .

Endometrial ablation is a very good option provided the patient is selected carefully and fully counselled and adequate equipment and operative skills are available.
Posted by Sabahat S.
Thu Aug 9, 2007 08:19 pm
a) Non hormonal medical options are mefanamic acid, tranexamic acid and iron therapy.
Mefanamic acid reduces the blood loss by 25-30 % and also alleviates dysmenorrhoea, if present. GI sideeffects may limit its efficacy. It is a cheap and effective method for treatment of menorrhoea.
Tranexamic acid reduces menstrual blood loss by more than 50 %. It is more efficacious than mefanamic acid in treatment of menorrhogia. It does not increase the risk of VTE.
Oral / parenteral iron therapy may be given to treat the anaemia.
b) Combined oral contraceptive pills reduced the cyclical ( withdrawal bleed ) blood loss by 25 ? 50 %. They provide added contraceptive benefits. However in a 40 yrs old, if she smokes and / or is obese, they may not be applicable and will increase her thromboembolic risks.
Oral progesterone ( norethisterone ) 5 ? 10 gms/ d from day 5 ? 25 of the cycle may reduce menstrual blood loss by 50 %. Injectible depot preparations (DMPA) may also be used, but may cause menstrual irregularity. Weight gain, bloating, breast tenderness may limit compliance.
Mirena IUS is an innovative method of progesterone delivery directly to the endometrim. It reduces menstrual blood loss by 97 % at 1 year(30% of the patients become ammenorric) & it significantly reduces the number of patients who may require hysterectomy for menorrhogia. It has added contraceptive benefits ( 5 yrs ) it proves to be cost effective in the long run.
Danazol reduces menstrual blood loss, but androgenic side effects limits it use.
GnRHa were used to induce amenorrhoea in severe cases, it is limited by its severe hypoestrogenic side affects ( bone loss, hot flushes, amenorrhoea )
c) Endometrial ablation resects or destroys the endometrial lining which was the cause of heavy menses. Various methods are used e g ? Diathermy loop resection, roller ball, microwave, radiofrequency,thermal ballon.
It may be done as a day case, avoiding long hospital stay, and an earlier return to work. The significant risk to surrounding organs (as in hysterectomy ) is avoided along with less analgesic requirement & less thromboembolic risk. There is intraoperative risk of haemorrhage, perforation, infection & fliud overload.It reduces menstrual blood loss by about 70 %,.Induces amenorrhoea in 20 ? 40 % patients, reduces blood loss in 40 % with no change in menstrual loss in 20 %.It will not cure dysmenorrhoea & premenstrual syndrome so if these are present, the patient may not be cured.
Endometrial ablation should only be undertaken, if the patient has completed her family & is ready to use a reliable method of contraception till her natural menopause. Pregnancy after endometrial resection is contraindicated. She may end up requiring hysterectomy ( 35 % over3yrs ) overall patient satisfaqction rate is 80 %.
10 ? 25 % of the patients may require a repeat procedure. Overall it has proven itself to be a cost effective tratment for DUB. But the efficacy largely depends on the patients preferences, her fertility options, other associated symptoms & her readiness to use a reliable contraceptive method.

Posted by Paul T.
Fri Aug 10, 2007 01:12 am
Metfomin IS THIS USED TO TREAT MENORRHAGIA??? (-1) is nonhormonal medicine of first choice, it is non steroidal anti inflammatory drug with anti prostaglandin activity on endometrium ,it reduce menstrual loss by 25% it has to be taken with menstruation ,complication include peptic ulcer and exacerbation of asthma,it confer no contraception
Antifibrinilytic agents(tranexamic acid) (1) reduce menstrual loss by 50% (1) .
It does not induce thromboembolic phenomenon ,it has to be taken durig mensis.it does not work as contraceptives.nausea ,dyspepsia abdominal pain are unwanted effects.visual disturbance warn for discontinuation.
b)Combine oral contraceptive pills reduce menstrual loss by 50% (1) ,it also cover her contraceptive wishes (1) .there are many contraindication which should be screen in history.
Oral Progesteron(norethisteron) effective only in high dose,when taken from day5 of cycle for 21 days to reduce menstrual loss (1) ,
Depoprovera is injectable progesterone it reduce menstrual loss by 80% in 3-6 month and 90% in 0ne year. It is not licensed for menorrhagia (1) . It also provide contraception which may not her need.there are incidence of break through bleeding.in 25-50%of subjects.
Levenorgesterone containing intrauterine device (1) release progesterone locally bring menstrual reduction in 75% of women you quoted % reduction in blood loss for other treatments but here, you quote % of women in whom blood loss is reduced?? in 3 months.it cause benign ovarian cyst. It is licensed for menorrhagia.
Danazole is another option it has more androgenic activity(acne ,hirsutism,oily skin) use only for short term basis what is the reasoning behind short-term use of danazol? ,which are reversible except deepening of voice.it warn discotinuation .
Gestrinon is less androgenic then danazole.Gonadotrophin releasing hormones cause reduction in mensis and amenorrhea but its prolong use lead to osteoporosis (1) .
C)Endometrial ablation cause destruction of endomtrium till its basal layer,Although amenorrhea in 40% of women but satisfaction achieve in 75%of subject why do you refer to women / patients as SUBJECTS? ,It avoid hysterectomy and its morbidities (1) . It has been seen in 38% of women who return to seek another treatment after 3 year. ? meaning?? Poor English. Is this supposed to be an argument in favour of or against ablation?
It is cheaper then hysterectomy,it can be perform as day care procedure (1) ,
Selection of women for uterine ablation can avoid complication .
women who expect amenorrhea should be council,she should avoid pregnancy by using contraception as there is possibility of pregnancy, which may associate with complications.Ablation should also be avoid in women with PID,adenomyosis.
Procedure related risks are more with first generation technique (TCRE,REA) it require hysteroscopy and distention water, Excessive absorption of water is a complication.
Second generation(thermachoice,microwave) does not require expertise are you implying that no training is required?? as first generation ,it is a blind procedure do not need hysteroscopy or distention media ,
Therefore endometrial ablation is good option for well selected women.with no fertility intention.
You were asked to debate. You should present the arguments in favour followed by the arguments against and these should be clearly distinguishable. If the examiner cannot decide whether a particular argument is in favour or against the proposition, you will get no marks.
Posted by Paul T.
Fri Aug 10, 2007 01:33 am
The non hormonal treatment options are tranexamic acid and nonsteroidal anti inflammatory drugs, especially mefenamic acid. These are suitable for women with regular heavy menstrual loss without structural or histological abnormality. These can be started in primary health care prior to physical examination and imaging if the history suggests no histological or structural abnormality not necessary ? you have already been told that there is no abnormality and you are not in primary care. Are you suggesting that a GP should start a woman on these treatments WITHOUT A PHYSICAL EXAMINATION? (-1) . Tranexamic acid (1) 1 to 4 g per day in divided doses reduces menstrual blood loss by 50% (1) . It has few side effects like headache, vomiting and indigestion. If menorrhagia is associated with dysmenorrhoea, NSAIDs would be the first line treatment and reduces blood loss by 25 to 50% (1) the question did not state that she had dysmenorrhoea. What if she has PMS?. You could have an endless number of ifs . Side effects are vomiting, worsening of peptic ulcer and bronchial asthma. If no improvement is noted in 3 cycles, non hormonal treatment should be stopped.

The hormonal treatment is especially useful in women with heavy menstrual loss with failed non hormonal treatment and in those whorequire contraception. The options are LNG- IUS (Mirena), COCP, norethisterone, injectable progesterone and GnRH analogues. Mirena (1) is the first choice in women who are willing for long term contraception. However, irregular bleeding is a side effect and women should be clearly advised on this and asked to persevere for 6 months. At 12 months of use, 97% report reduction in menstrual loss this is incorrect ? there is a 97% reduction in loss. This does not mean that 97% of women report a reduction . Low dose combined OC pills provide contraception and significant reduction (1) what is ?significant?? A 5% reduction could be statistically significant in blood loss with regular cycles. Norethisterone should be given 15 mg from day 5 to 26 of cycle (1) , there is no role of luteal phase treatment alone. Injectable progesterone DMPA given at dose of 150 mg every 3 months , reduces blood loss not licensed for treatment of menorrhagia but produces irregular break through bleeding or amenorrhea in some women. There is also the risk of reduction in bone mineral density. GNRH analogues may be given in women with fibroids the woman in question does not have fibroids ? you should answer the specific question asked prior to surgery or UAE for 3 to 6 months. It has side effects of menopausal symptoms and osteoporosis. Treatment should be stopped once surgery is scheduled.

Endometrial ablation is a conservative surgical approach to women with heavy menstrual loss , with a normal size uterus and completed family. It should be an informed choice after discussing advantages and disadvantages of other treatment options . Histological and structural abnormalities should be ruled out prior to decision this is not a debate. Are these arguments for or against? . When compared to hysterectomy, it has less morbidity and mortality and good patient satisfaction rates (1) what does ?good? mean? . There is no compromise in ovarian function and hence the women should continue to use contraception does the Cu IUCD compromise ovarian function? Is it an effective contraceptive?? . Amenorrhoea cannot be guaranteed is this an argument in favour or against? . If uterine size is less than 10 weeks , fibroids less than 3 cm, no desire for fertility, ablation is a choice. Second generation ablative techniques like Impedance controlled radiofrequency ablation, ballon ablation, microwave ablation should be used as first line why should these be first line? Do you have long-term outcome data? . The advantage is that it is done as a day case and carries less post op complications. Women should be willing to undergo hysterectomy in case of failed procedure.
In a debate, you should present arguments in favour and arguments against the premise. These must be presented separately and clearly identifiable. You do not get any marks if it is not obvious whether an argument is in favour or against the proposition
Posted by Paul T.
Fri Aug 10, 2007 01:51 am
The non hormonal treatment options are tranexamic acid and NSAIDS like mefenamic acid. Tranexamic acid (1) is effective in reducing blood loss by about 50% (1) . It is more effective than mefenamic acid. The side effects are nausea, vomitting, abdominal cramps, serious ,but uncommon side effects like intracranial thrombosis and reduced colour vision. These side effects are dose related, which can be limited by taking it during the first 3 to 4days of the period. NSAID are cheaper, very commonly used, it reduces the blood loss by 25% (1) . It has better side effect profile compared to tranaexamic acid (1) .

There many hormonal treatment options with different efficacy and side effect profile. Progestogens like norethisterone is ineffecetive if given for 5 to 10days in the luteal phase, but with increasing dose like 5mg thrice daily from D5 to D26 will reduce the blood loss significantly (1) . It has side effects like fluid retention and mood changes and it is not a contraceptive not necessary . Depo medroxy progesterone given intramuscularly once in 12weeks acts as a effective contraception. It induces amenorrhoea in 30%. It has side effects like weight gain, irregular menstruation, and delay in return to fertility after stopping the treatment not licensed for treatment of DUB . Levonorgestrel intrauterine contraceptive system(mirena) is a popular choice . It reduces blood loss by 80% within 3months and by 1year blood loss is reduced by 97% (1) . It is a very effective contraceptive (1) , licensed for use for 5years and return to feritility once the device is removed. It is an acceptable alternative to hysterectomy to some women. Though the intial cost is high it is cost effective in 5years. The main side effect is the irregular bleeding in the first 3months this is not the VALUE of the treatment. You were asked to EVALUATE = attach value to . There are other options like GnRH analogue which can be used in intractable menorrhagia, but it cannot used longer than 6months due to hypooestrogenic effects and reduced bone mineral density. The mode of administration is monthly injections or nasal spray which may not be acceptable to some. Danazol, which is a synthetic androgen with antioestrogenic, anti progestogenic activity, which direcly suppresses the endometrium (1) . It has many androgenic side effects like hot flushes, hirsutism, breast atrophy, which can be reversible on stopping the medication, but the voice change remains irreversible. Contraception has to advised along with danazol, due to virilisation of female foetus if pregnancy occurs. Gestrinone, reduces blood loss significantly, but not used as a first line of treatment. It has androgenic side effects like danazol and contraception is advised for similar reasons as danazol.

Endometrial ablation is the treatment option if the medical and IU system has failed or refused by the patient patients do not refuse treatment ? they simply select an option that is best for them . There are different techniques with different risk, efficacy and cost . First generations are TCER, diathermy or laser ablation, and radiofrequency ablation, the second regenerations are thermal ballon ablation, microwave thermal ablation. It is done as the day case procedure , the hospital stay is less, and is cost effective (1) . The post operative recovery is rapid. The amennorrhoea rate is 30%, patient satisfaction ranges from 55% to 90% (1) . and the reopearation rate in 3years is 38% is this an argument in favour??? . It is suitable for somebody who has completed their family and willing to undergo hysterectomy if necessity arises. It is not suitable for somebody who considers total amennorhoea and cure from premenstrual tension or dysmennorrhoea. When compared to medical treatment or MIRENA , future pregnacy is contraindicated and patient has to be given contraceptive advise the debate was about SURGICAL OPTIONS . There is risk of uterine perforation and fluid overload. In comparison to hysterectomy , endometrial ablation avoids complication of major surgery, and amennorrhoea rate is 20 to 40% when it is 100% in hystrectomy. Patient has to be informed that she will have vaginal discharge for 3weeeks, and abdominal cramps for few days. In a suitably motivated patient, especially in a case of DUB , in the end of reproductive life , endometrial ablation is the best option.
You have not presented a debate. There should be arguments FOR, and arguments AGAINST the proposition and these should be presented separately and clearly identifiable
Posted by Paul T.
Fri Aug 10, 2007 02:04 am
A. Non-hormonal treatment is a first line therapy of menorrhagia, which of includes anti-fibrinolytic agent (tranexamic acid) and NSAIDs (mefenamic acid). Tranexamic acid (1) decreases menstrual blood floow by 50% (1) . It is cheap and easy to use. The disadvantages incude low efficacy and side-effects (nausea, vomitting, diarrhoea) and loss of color vision. It does not cause DVT. The latter is a indiction to cease tranexamic acid. The dose used is 1 g three times a day during the bleeding. Mefenamic acid (1) decreases blood flow by 25% (1) , it is also cheap and easy to use. It does have side-effects, gastrointestinal symptoms, asthma, ulcers.
Both above-mentioned medications are used in combination. Neither of the above-mentioned preparations have contraceptive effect, therefore, contrception should be advised. Both of these medications can be initiated at the primary level health service for treatment of menorrhagia, where uterine and cervical pathology have been excluded. The efficacy should be assessed in 3 months, and if it\'s not effective homonal therapy should be started.

B. Hormonal methods of treatment of menorrhagia include progesterone preparations (oral norethisterone, Depo (medroxyprogesterone acetate 150 mg, IM), Mirena IUD), gestrinone, danazol, GnRh analogues, cyclical HRT this is a waste of time & space as you will not get any marks for a list .
Oral progesterone taken short term in low dosage is not effective for treatment of menorrhagia. Norethisterone in highg dose (5 mg three times daily) taken for three out of 4 weeks of the menstrual cycle (day 5 to 26) is effective (1) , cheap and easily available treatment of menorrhagia. It is an effective treatment in emergency situation of heavy menorrhagia. It has side effects of irregular bleeding, fluid retention, weight gain, depression, acne, gastointestinal problems not necessary . Depo Provera causes amenorrhoea in 30% of women after the first injection, and in 60% after the 2nd injection. It also provides contraception. It does need a specialist service to povide the treatment ? meaning?? Not licensed for treatment of DUB . It can be used for 5 years or longer in perimenopausal women. It has side-effects of irregular bleeding, depression, weight gain, bone mineral density loss is used for more than 5 years not necessary . Mirena IUD (1) is effective treament, which is an IUD containing levonorgestrel released n small quantities in the uterus. It causes amenorrhoea in 80% of women by the end of the first year of use. It also provides contraception (1) . It is cost-effective treatment of menorrhagia which avoids risk of surgery, e.g. hysterectomy with it\'s complications (infection, bleeding, injury to internal organs, DVT). About 10% of women will develop irregular bleeding, which is more common in the first 3-4 months. Women should be counselled appropriately regarding side-effects. Mirena requires a specialist service for insertion. The insertion could be difficult, and sometimes even require general anaesthesia. Uterine perforation, severe abdominal pain, PID (rare) are complication of Mirena. It also has some side-effects common for progesterone, e.g. depression, fluid retention. not necessary
Danazol is effective treatment, which has multiple troublesome side effects, e.g. acne, hirsutism, depression, mood swings, alopecia, loss of bone mineral density, irrevrsible change of voice. It shoudl be used for longer than 6 months due to side-effects profile, and symptoms usually return once the treatment was stopped. WOmen must use reliable contraception since danazol causes viriliasation of female fetus.
GnRH agonists is an effective treatment (1) . However, it is expensive and has with multiple side -effects (hot flushes, dry skin, osteoporosis, gastrointestinal symptoms). Might be effective for treatment of menorrhagia in perimenopause, before surgery to shrink fibroids and decrease blood flow to improve Hb.
HRT can be successfuly used on perimenopausal women is the woman in question perimenopausal? . It is effective and has other , but associated with teh side effects
The patient should be counselled regarding all the available options and the choice should be made depending on the patients wishes and clinical situation (desire for future fertility, need for contraception).

C. Endometrial ablation is a suitable treatment for this patient. The advantages of endometrial ablation is avoidance of major surgery (1) (e.g. hysterectomy) and it\'s side effects, e.g. infection, bleeding, injury to internal organs, DVT. It is performed as a day procedure. Endometrial ablation causes amenorrhoae in 30% of the patient, and decreases the menstrual flow in up to 80% (1) . It is not suitable for patients desiring future fertility, and for patients expecting permanent amanorrhoea is this an argument in favour OR against? . Endometrial malignancy, and premalignant cervical and uterine conditions condition, and pelvic infections shoudl be excluded prior to procedure.
YOU WOULD HAVE RUN OUT OF TIME / SPACE HERE
Uterine size should be less than 12 weeks. Endometrial ablation does not improve dysmenorrhoea, but there are some reports that it might be effective. It has side effects of fluid overload, uterine perforation, and infertility. Patient has to use contraception after the procedure. Pregnancy is contraindicated due to risk of uterine rupture. Special equipment (depending on a type of ablation, e.g. microvawe, high radio-frequency ablation, ballon ablation) and skilled operator is needed to perform the procedure.
Posted by Paul T.
Fri Aug 10, 2007 01:57 pm
The non-hormonal medical treatments are NSAIDS, and transmenaic acid . NSAIDS (1) cause 20% decrease in menstrual flow, wheras transmenaic acid causes 50% reduction in menstrual flow. However it has been shown that transmenaic acid causes more side effects than NSAIDS. The side effects of trasmenaic acid one incorrect spelling is a mistake. Four consistently wrong spellings suggest you do not know the drug are GI symptoms, central venous thrombosis and intraretinal thrombosis . NSAIDs also provide analgesic effects.
b. The hormonal treatments include COCP which is well tolerated, inexpensive , regulate menstrual cycle and makes the cycle less painful. It is 50% effective what does 50% effective mean? Does it work in 50% of patients, reduce blood loss by 50%?? in reducing menstrual flow. It also provides contraception (1) . It has side effects like breast tendereness, nausea, vomiting and risk of VTE, breast cancer, and hepatoxicity/cancer.The contraindications are breast cancer,focal migrane,and family /personal history of VTE not necessary . Progesteron progesterone is not used therapeutically ? progestogens are used when given for short term are not efective ,however when used for 5-25 days are efective . The side efects of progesteron are mood changes, fluid retention and weight gain. Progesteron does not provide contraception not necessary . LNG IUS cause 75% reduction in menstrual loss at 03 months and 97% reduction at 12 months (1) . There are 35% chances of ammenorhea. It provides contraception (1) . However the side efects is that it causes menstrual irregularity within 3-4 months. There is risk of ovarian cyst formation. There is risk of expulsion and perforation and there is difficulty in insertion in nulliparous not necessary . GnRH analouge are expensive . These drugs are given by injection/spray and not orally. It may be unacceptable to the patient because of the injectable mode of administration. It is associated with menopausal side-effects and there is risk of decreased bone mineral density when used for 06 months. Danazol (1) are effective but associated with androgenic side effects . The effects on voice changes are irreversible.
c. Endometrial ablation is one of the surgical treatment options for DUB. It is a day case operative procedure associated with less operative time than hysterectomy . The operative morbidity is also less than hysterectomy (1) . There is 80% satisfaction rate (1) , 20-40% amenorrhea rate. However there is 38% re-operation rate within 03 years and 10-25% need hysterectomy within 05 years (1) . The different ablation techniques are laser/diathermy ablation techniques , radiofrequency , thermal, balloon, and endometrial resection techniques. The procedure is undertaken under general anaesthesia however regional anaesthesia is possible. However it has been seen that hysterectomy is associated with more satisfactory rates and hysterectomy is the treatment of choice for those requiring permanent amenorrhea. There are risks associated with ablation techniques like perforation, bleeding and need of laproscopy/laprotomy if any complications develop and increase risk of water retention. However the risk associated with hysterectomy is more you have discussed this earlier which include haemorrhage and risk of visceral injury, infection, VTE. Another disadvantage of endometrial ablation is that it doesnot relieve dysmenorrhea and PMS and there is need of endometrial sampling to exclude endometrial cancer before the procedure. There is also a requirement of contraception to be continued (1) as there is risk of pregnancy complications like placenta accreta if pregnancy occurrs after ablation. Similarly the medical management the debate was about surgical options including hormonal non hormonal should be used as first priority in patients with heavy menstrual bleeding and if no response then surgical intervention should be carried out . In surgical management endometrial ablation should be used in priority to hysterectomy in patients who donot require permanent amenorrhea.
you have not presented a clear debate. You should present arguments for and arguments against and these should be distinguishable. Your answer contains a random mixture of arguments for & against
Posted by Paul T.
Fri Aug 10, 2007 02:35 pm
a) Non hormonal medical options are mefanamic acid, tranexamic acid and iron therapy.
Mefanamic acid (1) reduces the blood loss by 25-30 % (1) and also alleviates dysmenorrhoea, if present. GI sideeffects may limit its efficacy. It is a cheap and effective method for treatment of menorrhoea.
Tranexamic acid (1) reduces menstrual blood loss by more than 50 %. It is more efficacious (1) than mefanamic acid in treatment of menorrhogia. It does not increase the risk of VTE.
Oral / parenteral iron (1) therapy may be given to treat the anaemia.
b) Combined oral contraceptive pills reduced the cyclical ( withdrawal bleed ) blood loss by 25 ? 50 % (1) . They provide added contraceptive benefits (1) . However in a 40 yrs old, if she smokes and / or is obese, they may not be applicable and will increase her thromboembolic risks.
Oral progesterone ( norethisterone ) 5 ? 10 gms/ d from day 5 ? 25 of the cycle may reduce menstrual blood loss by 50 % (1) . Injectible depot preparations (DMPA) may also be used, but may cause menstrual irregularity. Weight gain, bloating, breast tenderness may limit compliance not licensed .
Mirena IUS is an innovative method of progesterone progestogen delivery directly to the endometrim. It reduces menstrual blood loss by 97 % at 1 year (1) (30% of the patients become ammenorric) & it significantly reduces the number of patients who may require hysterectomy for menorrhogia. It has added contraceptive benefits (1) ( 5 yrs ) it proves to be cost effective in the long run.
Danazol reduces menstrual blood loss, but androgenic side effects limits it use.
GnRHa (1) were used to induce amenorrhoea in severe cases, it is limited by its severe hypoestrogenic side affects ( bone loss, hot flushes, amenorrhoea )
c) Endometrial ablation resects or destroys the endometrial lining which was the cause of heavy menses. Various methods are used e g ? Diathermy loop resection, roller ball, microwave, radiofrequency,thermal ballon.
It may be done as a day case, avoiding long hospital stay (1) , and an earlier return to work. The significant risk to surrounding organs (as in hysterectomy ) is avoided along with less analgesic requirement & less thromboembolic risk. There is intraoperative risk of haemorrhage, perforation, infection & fliud overload. is this an argument in favour or against?? It reduces menstrual blood loss by about 70 %,.Induces amenorrhoea in 20 ? 40 % patients, reduces blood loss in 40 % with no change in menstrual loss in 20 % is this an argument in favour of or against endometrial ablation? .It will not cure dysmenorrhoea & premenstrual syndrome so if these are present, the patient may not be cured.
Endometrial ablation should only be undertaken, if the patient has completed her family & is ready to use a reliable method of contraception till her natural menopause. Pregnancy after endometrial resection is contraindicated. She may end up requiring hysterectomy ( 35 % over3yrs ) overall patient satisfaqction rate is 80 %.
10 ? 25 % of the patients may require a repeat procedure. Overall it has proven itself to be a cost effective tratment for DUB. But the efficacy largely depends on the patients preferences, her fertility options, other associated symptoms & her readiness to use a reliable contraceptive method.

In a debate, one person presents the case for, and someone else the case against. When asked to debate, you should present the case for separate from the case against. It should be clear whether a particular argument is in favour or against the proposition. Your answer is a random mixture of arguments in favour and against and as such is not a debate
Posted by Natalie P C.
Fri Aug 10, 2007 06:59 pm
A
Non hormonal medical treatment includes Tranexamic acid (TA) and NSAIDS like Mefenamic acid (MA). These are non-contraceptive. TA has a reported 60% reduction in menses with few side effects. It is an anti fibrinolytic. It is not associated with increased risk of venous or arterial thombosis. It is the non ?hormonal drug with the best efficacy.

NSAIDs like mefenamic acid have a 50% reduction in menstrual loss. Their other benefit is relief of dysmenorrhoea which can often accompany heavy menstrual bleeding. They work by inhibiting prostaglandin synthesis via inhibition of cycloxygenase COX. Side effects include gastric irritation and peptic ulcer disease. There are some COX 2 inhibitors that have been used which have similar efficacy to NSAIDs with a reduced side effect profile regarding gastric irritation.

B
Hormonal therapies include Mirena (levonorgestrel Intraterine system LNG IUS), progestogens (cyclical, injectable and implants) and the combined oral contraceptive pill and these are contraceptive. NICE guidelines suggest that if a woman needs contraception for at lease 12 months that first line management offered should be the LNG IUS. This produces a 95% reduction in menstrual loss with many women becoming amenorrhoeic. Side effect are main at the time of insertion and include uterine perforation, infection and expulsion. The other main side effect is irregular vaginal bleeding for the first 4-6 months.

Progestogens like medroxyprogesterone acetate orally produce a 85% redction in menstral loss. They must be taken day 5 to 26 cyclically. Side effects inclusde bloating, fluid retention, breast tenderness and weight gain. Injectables and implants produce amenorrhoea in over 90% women with a similar side effect profile. These prodce longer term contraception with may be preferable for a woman at age 40 with 3 children.

The combined contraceptive pill produces a 40% reduction in menstrual blood loss. Even if she is a non-smoker and well with a normal BMI the COCP is a relative contraindication due to it?s increased risk or venous and arterial thromboembolism.

C
Endometrial ablation has many benefits over hysterectomy. It has a high success rate of oligomenorrhoa (90%) with 40% amenorrhoea rates. Complication rates are low with risks like uterine perforation, bleeding and infection. It avoids major pelvic surgery with its associated complications like prolapse, bladder and bowel injury and dysfunction and venous thromboembolism. It can be done under local anaesthetic for many women avoiding the need for general aneathesia and risks of aspiration and hypoxia. The cost is also less even when considering that some of these women (20%) still end p having a hysterectomy.

Hysterectomy though sorts the problem out in one go. The 20% of women who have a hysterectomy anyway end up having 2 procedures. Some endometraial ablation techniques are not suitable for some patients like women with sub mucosal fibroids or other reasons for distortion of the uterine cavity. Also if they have other symptoms like pain or pressure symptoms due to fibroids or endometriosis, hysterectomy is the better option.

Overall I do believe that endometrial ablation in the properly selected patient is the better option.
Posted by saima gulzar S.
Sun Aug 12, 2007 09:17 pm
Treatment of anaemia with Iron(ferrous sulphate) due to heavy menstrual blood loss is effective and cheap to restore haemoglobin & ferritin level.NSAIDs(mefanimic acid) is effective in reducing menstrual blood loss upto 20% with an added advantage of analgesic effect in coexistant dysmenorrhoea.Tranexamic acid reduces blood loss upto 50% & not associated with increase in risk of VTE.
In hormonal treatment COCP is effective in reducing 50% menstrual blood loss & also provides contraception.It is well tolerated ,cheap and provide relief in dysmenorrhoea.Progestogens ,if use in high dose from Day5-25 are effective in treatment of DUB but short cycle from day15-25 are not effective.Medroxyprogesterone is effective in reducing blood loss and causing amenorrhoea but not licenced for treatment of DUB.Danazol helps in reducing blood loss in menorrhagia but not well tolerated because of its androgenic side effects.GnRH Analogues causes amenorrhoea and improve anaemia but associated with menopausal symptoms & loss of bone density if used for more than 6 months(need add back therapy).However use before endometrial ablation for thinning of endometrium provides better results in ablation. Levonorgestrel intrauterine system reduces 75% blood loss after 3 months of use and 97% reduction in blodd loss after 1 year.It provides effective contraception for 5 years.It is expensive as a contraceptive but cost effecive if associated benign gynaecological diseases such as menorrhagia due to DUB are present as it reduces the need for surgical interventions.
Endometrial ablation is surgical destruction of endometrial lining by use of laser, microwave ,balloon or thermal.It has many advantages as well as disadvantages over hysterectomy.The advantages are easy to perform ,effective and reduced complications and morbidity. There is avoidance of major surgery(hysterectomy) with its inherent risk of associated injuries to bowel ,bladder and ureter.It is associated with reduced operation and anaesthesia time and reduced analgesia requirement .It is usually done as a day case so reduced hospital stay and reduced complications of thromboembolism & rapid postopeartive recovery and early return to normal activities.Patient satisfaction rates upto 80% has been reported.
The disadvantages are need of contraception after the procedure & need for re operation in 38% of patients after 3 yrears. Hysterectomy may be needed in 10-25% after 3 years.Endometrial ablation is associated with complication of uterine perforation which may need laparotomy or hysterectomy.There is no relief of dysmenorrhoea or premenstrual syndrome .Endometrial pathology need to be excluded before enometrial resection .
Patient should be given all the information on all available methods of treatment in verbal as as well as in written form and she should give informed choice.
Posted by Paul T.
Sun Aug 12, 2007 11:32 pm
A
Non hormonal medical treatment includes Tranexamic acid (TA) and NSAIDS like Mefenamic acid (MA). These are non-contraceptive. TA (1) has a reported 60% (1) reduction in menses with few side effects. It is an anti fibrinolytic. It is not associated with increased risk of venous or arterial thombosis. It is the non ?hormonal drug with the best efficacy.

NSAIDs (1) like mefenamic acid have a 50% reduction in menstrual loss (1) 50% seems generous ? accepted figures are ~50% for TA and 35% for mefenamic acid . Their other benefit is relief of dysmenorrhoea which can often accompany heavy menstrual bleeding. They work by inhibiting prostaglandin synthesis via inhibition of cycloxygenase COX. Side effects include gastric irritation and peptic ulcer disease. There are some COX 2 inhibitors that have been used which have similar efficacy to NSAIDs with a reduced side effect profile regarding gastric irritation.

B
Hormonal therapies include Mirena (levonorgestrel Intraterine system LNG IUS), progestogens (cyclical, injectable and implants) and the combined oral contraceptive pill and these are contraceptive writing a list of the options then going on to discuss each in detail is a waste of your time and space. The list should be in your answer plan . NICE guidelines suggest that if a woman needs contraception for at lease 12 months that first line management offered should be the LNG IUS (1) none of these treatments can be considered ?first line? as women have a range of reasons for selecting specific treatmernts. All available options should be discussed . This produces a 95% reduction in menstrual loss ? after 1 month?? with many women becoming amenorrhoeic. Side effect are main at the time of insertion and include uterine perforation, infection and expulsion. The other main side effect is irregular vaginal bleeding for the first 4-6 months.

Progestogens like medroxyprogesterone acetate orally produce a 85% redction in menstral loss this is an over-estimate, almost equivalent to the IUS. To achieve this, a significant % of women will need to be amenorrhoeic and this does not occur with cyclical progestogens . They must be taken day 5 to 26 cyclically. Side effects inclusde bloating, fluid retention, breast tenderness and weight gain. Injectables and implants produce amenorrhoea in over 90% women If you said this to a patient, will she be wrong to expect that in 1-2 months, she should become amenorrhoeic? ?? time scale. Which implant are you referring to? Implanon?? Is it associated with 90% amenorrhoea? with a similar side effect profile. These prodce longer term contraception with may be preferable for a woman at age 40 with 3 children.

The combined contraceptive pill produces a 40% reduction (1) in menstrual blood loss. Even if she is a non-smoker and well with a normal BMI the COCP is a relative contraindication due to it?s increased risk or venous and arterial thromboembolism NO ? this is incorrect and is a misconception. Age in its own right is NOT a relative contra-indication to COCP use ? see notes on COCP .

C
Endometrial ablation has many benefits over hysterectomy. It has a high success rate of oligomenorrhoa (90%) with 40% amenorrhoea rates (1) . Complication rates are low with risks like uterine perforation, bleeding and infection. It avoids major pelvic surgery with its associated complications (1) like prolapse, bladder and bowel injury and dysfunction and venous thromboembolism. It can be done under local anaesthetic for many women avoiding the need for general aneathesia and risks of aspiration and hypoxia. The cost is also less (1) even when considering that some of these women (20%) still end p having a hysterectomy.

Hysterectomy though sorts the problem out in one go. The 20% of women who have a hysterectomy anyway end up having 2 procedures. Some endometraial ablation techniques are not suitable for some patients like women with sub mucosal fibroids or other reasons for distortion of the uterine cavity. Also if they have other symptoms like pain or pressure symptoms due to fibroids or endometriosis, hysterectomy is the better option the advantages of hysterectomy are not the disadvantages of endometrial resection. Your second part should be the disadvantages of resection, not the benefits of hysterectomy.

Overall I do believe that endometrial ablation in the properly selected patient is the better option this is not the conclusion the examiner is looking for as your belief is not relevant. Women should be given information on the benefits and limitations of endometrial resection to enable them make an informed choice .
Posted by Paul T.
Sun Aug 12, 2007 11:44 pm
Treatment of anaemia (1) with Iron(ferrous sulphate) due to heavy menstrual blood loss is effective in relieving symptoms of anaemia and cheap to restore haemoglobin & ferritin level.NSAIDs(mefanimic acid) (1) is effective in reducing menstrual blood loss upto 20% (1) with an added advantage of analgesic effect in coexistant dysmenorrhoea.Tranexamic acid (1) reduces blood loss upto 50% (1) & not associated with increase in risk of VTE.
In hormonal treatment COCP is effective in reducing 50% (1) menstrual blood loss & also provides contraception (1) .It is well tolerated ,cheap and provide relief in dysmenorrhoea.Progestogens ,if use in high dose from Day5-25 are effective in treatment of DUB but short cycle from day15-25 are not effective (1) . Medroxyprogesterone ? oral?? is effective in reducing blood loss and causing amenorrhoea but not licenced for treatment of DUB.Danazol helps in reducing blood loss in menorrhagia but not well tolerated because of its androgenic side effects.GnRH Analogues causes amenorrhoea and improve anaemia but associated with menopausal symptoms & loss of bone density if used for more than 6 months(need add back therapy) (1) .However use before endometrial ablation for thinning of endometrium provides better results in ablation. Levonorgestrel intrauterine system (1) reduces 75% blood loss after 3 months of use and 97% reduction in blodd loss after 1 year .It provides effective contraception for 5 years (1) .It is expensive as a contraceptive but cost effecive if associated benign gynaecological diseases such as menorrhagia due to DUB are present as it reduces the need for surgical interventions.
Endometrial ablation is surgical destruction of endometrial lining by use of laser, microwave ,balloon or thermal.It has many advantages as well as disadvantages over hysterectomy.The advantages are easy to perform ,effective and reduced complications and morbidity (1) . There is avoidance of major surgery(hysterectomy) with its inherent risk of associated injuries to bowel ,bladder and ureter.It is associated with reduced operation and anaesthesia time and reduced analgesia requirement .It is usually done as a day case so reduced hospital stay (1) and reduced complications of thromboembolism & rapid postopeartive recovery and early return to normal activities.Patient satisfaction rates upto 80% (1) has been reported.
The disadvantages are need of contraception after the procedure (1) & need for re operation in 38% of patients after 3 yrears (1) . Hysterectomy may be needed in 10-25% after 3 years.Endometrial ablation is associated with complication of uterine perforation which may need laparotomy or hysterectomy.There is no relief of dysmenorrhoea or premenstrual syndrome .Endometrial pathology need to be excluded before enometrial resection .
Patient should be given all the information on all available methods of treatment in verbal as as well as in written form and she should give informed choice (1)

Very good answer
.
Posted by Paul T.
Sun Aug 12, 2007 11:48 pm
(a) A good candidate should evaluate the following options

? Tranexamic acid ? anti-fibrinolytic agent - reduces menstrual loss by ~50% and is more effective than NSAIDS (2)

? NSAIDS - mefenamic acid commonly used, reduces menstrual loss by ~25%. Have a better side-effect profile compared to tranexamic acid (2) .

? Treatment of anaemia might result in symptomatic improvement (1)

(b) With respect to hormonal treatment options

? COCP ? effective in reducing menstrual blood loss by ~35% with good side-effect profile and also provide contraception . Not suitable if she smokes (2) .

? Long-cycle progestogens (days 5-25) effective in reducing menstrual blood loss but luteal phase progestogens are ineffective (1)

? Depo-medroxyprogesterone acetate is not licensed for the treatment of menorrhagia. Amenorrhoea rates are 30% after first dose and 55% after 4th dose (1) .

? MIRENA IUS results in up to 97% reduction in menstrual blood loss at 12 months. Provides effective contraception (2)

? Other medical treatments like danazol, GnRH analogues have poor side-effect profile and are unsuitable for long-term treatment (1)

(c ) With respect to endometrial ablation / resection

? Endometrial ablative procedures are effective in treating menorrhagia with amenorrhoea rates 20-40% and patient satisfaction rates of ~80%. Cost-effective compared to hysterectomy (2)

? Day case procedure with lower morbidity and quicker recovery compared to hysterectomy. Newer ablative techniques may be undertaken as office procedures (2)

? However, does not guarantee amenorrhoea and this may be unacceptable to some women (1)

? Significant re-operation rates with 10-25% of women requiring hysterectomy over 3-4 years (1)

? Not contraceptive therefore woman will need contraception (1)

? Ultimately, women should decide which treatment is most appropriate for them. (1)