Which of the following is not indicated in menorrhagia:

Ans. is b, i.e. ClomipheneRef: Dewhurst's Textbook of Obs. & Gynae. 7th/ed, p401; Gyanaecology by Soutter - Stanton 2nd/ed, p435; Shaw 12th/ed, p242Medical Management of Menorrhagia:A. Prostaglandin synthetase inhibitorB. AntifibrinolyticC. Hormones* Mefenamic Acid* Tranexamic acid* Progesterones* Estrogen* OCP's* Danazol/Gestrinone (androgen)* GNRH analoguesNSAID's* Rationale: Its use stems from the suspected role of prostaglandins in the pathogenesis of DUB.* Advantages:- It is required only during menstruation- It provides relief from dysmenorrhea* Tranexamic acid: It is an antifibrinolytic drug which exerts its effects by reversibly blocking lysine binding sites on plasminogen. The resulting decreased plasmin levels diminish fibrinolytic activity within endometrial vessels to prevent bleeding."Clinically, the drug has been shown effective to reduce bleeding in upto half of the women with DUB related to menorrhagia." - Ref Williams Gynae 1st/ed, p187According to latest RCOG guidelines tranexamic acid is the first line DOC for menorrhagiaProgesterone's"With the introduction of potent orally active progestins, they became the mainstay in the management of DUB in all age groups and practically replaced the isolated use of oestrogens and androgens." - Ref Dutta Gynae 5th/ed, p187Estrogen: High dose estrogen therapy may be useful in controlling acute bleeding episodes because it promotes rapid endometrial growth to cover denuded surface. Conjugated equine estrogens are administered orally at dosages up to 10mg daily given in four divided doses. Similarly the drug can be given intravenously in 25mg doses every 4 hours for up to 3 doses. Once bleeding has slowed, patients can be transitioned to an oral taper using COCs.Androgens - Danazol - It is suitable for recurrent symptoms and in patients waiting for hysterectomy. A smaller dose tends to minimize the blood loss and higher dose produces amenorrhea.Gestrinone - can also be used like Danazol.Mifepristone - It is an antiprogesterone. It inhibits ovulation and induces amenorrhea but is not commonly used for DUB (this drug is not mentioned in Williams Gynae for management of DUB)Gonadotropin Releasing hormone agonists (GnRH agonist) - Its subtherapeutic doses decrease the blood loss whereas therapeutic doses produce amenorrhea.It is valuable for short term use in severe DUB, particularly if the woman is infertile and wants pregnancy.* As far as ethamsylate is concerned:- It is an hemostatic agent but its action and efficacy is inconsistent.- Though in some books it is given ethamsylate may be used but Williams Gynae. specifically says:"Because of its inconsistent efficacy, in United States ethamsylate doesnot have a clinical role the treatment of menorrhagia." - Ref Williams Gynae 1st/ed, p187