A 30 yrs woman 2+0, hypertension have menorrhagia. Which is the best treatment for her -

Ans. is 'b' i.e., MIRENA * The question does not give any clue regarding the etiology of menorrhagia, so most probably the women are havingD.U.B. i.e., dysfunctional uterine bleeding. When a woman present with menorrhagia, consideration must first be given to diagnosis.This requires an appropriate history and clinical examination completed by the suitable investigation.Anemia should be detected by full blood count and iron studies.Ultrasonography, sonohysterography, and hysteroscopy are additional investigations that may diagnose a structural problem and should be utilized depending on their availability and the experience of the surgeon.Common causes of menorrhagia include local pathologies such as fibroids, polyps, adenomyosis or infection.Rarer, but important causes include genital malignancy (cervical, endometrial or myometrial) and systemic disorders such as thyroid disease and bleeding disorders.In over 50% cases no cause is found and the diagnosis of dysfunctional uterine bleeding is made.Dysfunctional uterine bleeding requires the following criteria: -Complaint of excessive menstrual blood loss (menorrhagia).Adequate exclusion of pathology that may otherwise cause menorrhagia.Dysfunctional uterine bleeding may be ovulatory or nonovulatory.Anovulatory cycles result in menorrhagia with regular cycles were asOvulatory cycles result in menorrhagia with irregular cycles.Most of the cases of dysfunctional uterine bleeding are secondary to anovulation.Without ovulation, the corpus luteum fails to form resulting in no progesterone secretion.In the absence of progesterone, there is no lateral phase or the secretory phase.The anovulatory woman is always in the follicular phase of the ovarian cycle and in the proliferative phase of the endometrial cycle.The only ovarian steroidal signal the endometrium receives is through estrogen.Continuous stimulation of endometrium by estrogen produces a proliferation of the endometrium to abnormal levels where it becomes fragile without the growth limiting and organizing effect of progesterone.The endometrium finally outgrows its blood supply and degenerates. The end result is an asynchronous breakdown of the endometrial lining at different levels.We can conclude that bleeding in anovulatory cycle occurs due to unopposed action of estrogen in the absence of progesterone.Anovulatory menstrual cycle gives rise to irregular bleeding.On the other hand, ovulatory cycles give rise to regular menstrual bleeding.These patients ovulate regularly. These patients have both the phases of menstrual cycle i.e., follicular phase and the secretory phase.Research has shown that several abnormalities can occur in the endometrium of women with DUB's ovulary cycles, for example, increased fibrinolytic activity and increased production of prostaglandins.These observations provide the rational basis for treatment in these women i.e.,Antifibrinolytic Tranexamic acidProstaglandin inhibitor acidManagement of dysfunctional uterine bleeding.In D.U.B's there is no specific abnormality present, therefore, the choice of t/t must be considered in relation to several factors: -Factors influencing t/tPresence of ovulatory or anovulatory cycles.Need for contraceptionPatient preferenceContraindication to t/tHeavy periods |Require contraceptionYes -Combined oral contraceptive or levonorgestrel-releasing intrauterine systemNo |Regular cyclesNo-Combined oral contraceptives or cyclical progestinsYes |Dysmenorrhea significant symptomsYes-Non-steroidal anti-inflammatory drugsNo | Tranexamic acid Medical treatment can be conveniently divided into hormonal and non hormonal: -As there is no hormonal defect the use of hormonal therapy does not correct an underlying disorder but merely imposes an external control of the cycle.The two main first-line t/t for menorrhagias associated with ovulatory cycles are nonhormonal as the ovulatory cycles usually have no defect in the menstrual cycle.They have normal menstruation and regular cycle the abnormality usually lies in increased fibrinolysis and increased production of prostaglandin.First line drugs in ovulatory cycles (menorrhagia with regular cycles)Antifibrinolytic Q (Tranexamic acid)NSAIDSTranexamic acid reduces menstrual loss by half and NSAID reduces it by one third.Both have the advantages of only being taken during menstruation, and aid to compliance and are particularly useful in those women who either do not require contraception or do not wish to use a hormonal therapy.They are also of value in treating excessive menstrual blood loss associated with the use of the nonhormonal intrauterine contraceptive device.Hormonal therapy Progesterone Traditionally hormonal therapy for menorrhagia has been progesterone given during luteal phase of the cycle.Normally progesterone therapy will control anovulatory bleeding once uterine pathology is excluded.In women who do not ovulate but are more frankly hypogonadal cyclic progesterone therapy restores the normal sequence of steroid hormone stimulation, estrogen followed by estrogen plus progesterone followed by withdrawal bleeding.Progestins are usually not effective.Despite this, they remain the first choice of many general practitioners and gynecologists.Progesterone's are effective when given for 21 days in each cycle but the side effects are such that patient may not choose to continue with the t/t.Although progestins have the contraceptive effect they are not the best choice when contraception required. Combined contraceptive pillThey are popular first-line drugs for women who desire contraception.OCP's suppress pituitary gonadotropin release preventing ovulation.Like cyclical progestins, they are useful for anovulatory bleeding as they impose a cycle.Levonorgestrel intrauterine system (MIRENA)It is a T shaped intrauterine device which releases levonorgestrel at the rate of 20 mcg daily.This low hormone minimizes the systemic progestin side effects and more patients will continue this therapy than cyclic progesterone's.It exerts its clinical effect by preventing endometrial proliferation and consequently reduces both the duration of bleeding and the amount of menstrual loss.The levonorgestrel-releasing system is also advocated as an alternative to surgery. Endometrial ablation Vs Levonorgestrel IVDFor women who wish to stop using chronic medical therapy or have contraindications to medications, minimally invasive options include the LNG-IUD or endometrial ablation.A systematic review of six randomized trials and a subsequent randomized trial found that women with menorrhagia who were treated with either the LNG-IUD or endometrial ablation had similar reductions in menstrual blood loss at 6, 12, and 24 months, as well as similar improvements in quality of life.A meta-analysis of four randomized trials found that rates of dissatisfaction were similar for women treated with the LNG-IUD (17 percent) compared with endometrial ablation (18 percent) (OR 0.9, 95% Cl 0.5-1.8).The decision to use the LNG-IUD or endometrial ablation depends upon a patient's preferences regarding treatment at 6, 12, and 24 months, as well as similar improvements in quality of life.factors such as plans for fertility and contraception, convenience, and risks of anesthesia.- The LNG-IUD is a reversible contraceptive. - Pregnancy is contraindicated after endometrial ablation. but the procedure does not prevent pregnancy: thus. women will need to continue to use contraception following ablation. The LNG-IUD can be placed in an office setting for all women and requires no or local anesthesia.Endometrial ablation can also be done in an office by surgeons who are appropriately equipped but is often performed in an operating room under general anesthesia.If successful, endometrial ablation is performed once, while the LNG-IUD needs to be replaced every five.