A 30 yrs woman 2+0, hypeension have menorrhagia. Which is best treatment for her aEUR'

MIRENA [Ref- Dewhurst text book of Gynae & Obs 7/e p. 399-404; A Comprehensive textbook of Ohs & Gynae Saillma Gupta 140, 141, 1421 The question does not give any clue regarding the aetiology of menorrhagia, so most probably the women is having D.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 cotnplented by 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 pathology such as fibroids, polyps, adenomyosis or infection. Rarer, hut impoant 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 :- i) Complaint of excessive menstrual blood loss (menorrhgia). ii) Adequate exlusion of pathology that may otherwise cause menorrhagia. Dysfunctional uterine bleeding may be ovulatory or nonovulatory. - Anovulatory cycles results in menorrhagia with regular cycles where as - Ovulatory cycles results 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 secretor), phase. - The anovulatory woman is always in the follicular phase of the ovarian cycle and in the proliferative phase of endometrial cycle. - The only ovarian steroidal signal the endometrium receives is through estrogen. - Continuous stimulation of endometrium by estrogen produces 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 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 observation provide the rational basis for treatment in these women i.e., - Antifibrinolytics Trenaximic acid - Prostaglandin inhibitor acid Management 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 tit -Presence of ovulatory or anovulatory cycles. - Need ,for contraception - Patient preference - Contraindication to t/t Heavy periods Require contraception No Regular cycles Yes .L Dysmenorrhoea significant symptoms No.L Tranexanic acid Yes No Yes Combined oral contraceptive or levonorgestral releasing intrauterine system Combined oral contraceptives or cyclical progestins Non steroidal anti inflammatory drugs Medical treatment can be conveniently divided into hormonal and nonhormonal : ? -As there is no hormonal defect the use of hormonal therapy does not correct an underlying disorder but merely imposes and external control of the cycle. - The two main first line t/t for menorrhagias associated with ovulatory cycles are non hormonal as the ovulatory cycles usually have no defect in 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) - Antifibrinolytice (Trenaxamic acid) - NSAIDSQ Trenaxamic 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 paicularly 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 non hormonal 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 practioners and gynaecologists. Progesterones 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 contraceptive effect but they are not the best choice when contraception required. Combined contraceptive pill They 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. Levonorgesteral intrauterine system (MIRENA) It is a T shaped intrauterine device which releases levornorgestral at the rate of 20 mcg daily. This low hormone minimizes the systemic progestinic side effects and more patients will continue this therapy than cyclic progesterones. It exes its clinical effect by preventing endometrial proliferation and consequently reduces both the duration of bleeding and the amount of menstrual loss. The levonorgestral releasing system is also advocated as an alternative to surgery. Levonorgestrel-IUD versus surgical treatments A cost-utility model study from Hong Kong repoed that over a period of five years, treatment with the LNG-IUD compared with oral medical treatment, endometrial ablation, or hysterectomy was less expensive and accrued more quality adjusted life years. It is impoant to note that cost-utility calculations may vary in different health care settings. Endometrial ablation Vs Levonorgestrol IVD For 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% CI 0.5-1.8). The decision to use the LNG-IUD or endometrial ablation depends upon a patient's preferences regarding treatment factors such as plans:for:feility 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 live.