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Fifth stage
Gynecology
Lec-
Dr. asmaa
28/11/2016
Abnormal uterine bleeding… (cont.)
Treatments
For some women, the demonstration that their blood loss is in fact ‘normal’ may be
sufficient to reassure them and make further treatment unnecessary.
For others, there are a number of different treatments for HMB.The effectiveness of
medical treatments is often temporary, while surgical treatments are mostly incompatible
with desired fertility.
When selecting appropriate management for the patient, it is important to consider and
discuss:
the patient’s preference of treatment;
risks/benefits of each option;
contraceptive requirements
family complete?
current contraception?
past medical history:
any contraindications to medical therapies for HMB?
suitability for an anaesthetic . Previous surgical
history?
Each treatment option is associated with a different array of side effects, which may be
acceptable to some women but not others. For these reasons, and since menorrhagia is
rarely life threatening but has an adverse impact on the woman's quality of life, it is
essential that the treatment plan is determined in collaboration with the patient.
In treatment of abnormal uterine bleeding, Consider:
• 1.Age group.
• 2.Amount and pattern of bleeding.
Non hormonal treatment
1.Antifibrinolytics
• Antifibrinolytics, such as tranexamic acid, reduce blood loss by up to 50% by
inhibiting endometrial fibrinolysis, Side effects are rare but include gastrointestinal
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symptoms. Antifibrinolytic agents can be used to stabilize clots in uterine arterioles
or capillaries of women who may have excessive fibrinolytic activity. Successive clots
formed in the vessels feeding the endometrium are lysed in these women, and
antifibrinolytic therapy can reduce blood loss .
These agents should not be combined with estrogen-containing medications.
theoretical concerns have been raised that tranexamic acid may be associated with an
increased risk of venous thrombosis.
Benefits: Only requires to be taken on days when
the bleeding is particularly heavy.
It is compatible with ongoing attempts at conception.
Recommended dose: 1 g p.o. qds to be taken when menstruating heavily.
• Mefenamic acid and other non-steroidal anti-inflammatory drugs
Mefenamic acid and other non-steroidal anti –inflammatory drugs (NSAIDs),
Prostaglandin synthetase inhibitors inhibit endometrial prostaglandin production,
leading to a reduction in menstrual blood loss.
The drug is taken during menstruation and has the are associated with a reduction in
mean menstrual blood loss of 20–25 percent. This may be sufficient in some women
to restore menstrual blood loss either to normal or to a level which is compatible
with a reasonable quality of life.
• Women with heavy bleeding have an imbalance of prostaglandins. For example,
levels of vasodilating prostaglandin E2 (PGE2) may exceed levels of vasoconstricting
PGF2α, or there may be excessive numbers of receptors for PGE2 compared with
those for PGF2α. An increased PGE2/PGF2α ratio is more common among an
ovulatory women. NSAIDs taken in higher doses alter the prostaglandin ratios, but
correct dosing and timing is needed to avoid interfering with platelet function. This
therapy reduces blood loss by 20-30% and can be combined with hormonal
therapies.
• other advantage of NSAID use, it containing analgesic properties.
However, NSAIDs are associated with
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--gastro-intestinal side effects.
--isolated reports of NSAID-associated reversible female infertility , and the probable
mechanism
is ovulatory failure due to non-rupture of mature follicles. If a woman presents with
infertility and is found to be taking a NSAID for HMB, this potential cause should be
considered.
• Recommended dose: 500 mg p.o. tds to be taken when menstruation is particularly
heavy or painful.
HORMONAL THERAPY
• First-line drugs:
• Combined oral contraceptive pills
• cyclical combined oral contraceptive pill (COCP) is generally considered to be
effective in the management of HMB . Furthermore, as amenorrhoea becomes more
acceptable, many women use the COCP continuously for periods of between 3 and
6 months to avoid menstruation altogether . Evidence from one randomized
controlled trial (RCT) of the COCP (ethinyl oestradiol mcg and levonorgestrel 150mcg
for 21 days) found a reduction in blood loss of 43%.
•
Risks of COCP treatment include thromboembolic disease and migraine (increased in
the older woman, particularly if she is a smoker
).
COCP benefits are :
effective in reducing menstrual bleeding, controlling cycle irregularities .
relieving menstrual pain (dysmenorrhoea)
provide contraception or for women whom hormonal agents are acceptable.
It helps to prevent the risks associated with prolonged unopposed estrogen
stimulation of the endometrium
Progestogen therapy:
A.Oral progesterone therapy :
1-Whole cycle progestins used for treatment of HMB
Treatment with cyclic progestins is preferred when COCP use is contraindicated, such as in
smokers over age 35 and women at risk for thromboembolism.
it’s an effective treatment for menorrhagia(HMB) when given at high Doses between days
5 and 26 of cycle. And Treatment can be continued for 6-9 months.
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Norethisterone acetate (primolut-N ) 5mg tid for 21days out of 28 .
Or Medroxy progestrone acetate (Provera) 10 mg tid
Side effects include weight gain, headache and bloatedness.
• withdrawal bleeding occur 3-5 days after completion of the course.
2.Arrest of sever bleeding.
Norethisterone acetate (primolut-N ) 20-30 mg daily until bleeding stops usually in 24-48
hours and for not more than 3days and may continued in lower dose for up to 21 days.
Once she stopped , withdrawal bleeding will occur in a few days later
3.Luteal phase insufficiency treatment
• Luteal phase treatment in second half of cycle (from 15th to 26th day) indicated
when corpus luteum insuffiency has been diagnosed particularly in premenstrual
spotting. Treatment continued for 6-9 months.
• Norethisterone acetate (primolut-N) 5mg tid (three times a day)Or
Medroxy progestrone acetate (Provera) 10 mg tid.
luteal phase treatment is not so effective in treating menorrhagia.
B-Long acting high dose progestogens .
(Depo-Provera) may be used to induce amenorrhoea but it’s use is limited by side effects.
Progestogen-releasing intrauterine system:
Levonorgestrel-releasing intrauterine system (LNG-IUS) used to relief Menorrhagia as it
induce progressive endometrial atrophy.
Mean reductions in MBL of around 95 per cent by 1 year after LNG-IUS insertion have been
demonstrated, similar to those for the surgical procedure en As its action is local,
progestogen related side effects are much less than with oral agents . The LNG-IUS may be
inserted in the outpatient setting and requires change every 5 years
GnRHa ; Gonadotrophin-releasing hormone analogue
Act by downregulating the HPO axis and induce ovarian suppression,leading to
amenorrhoea.
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Unfortunately, their beneficial effect does not continue after stopping treatment and their
adverse effect on bone density limit their use beyond 6 months. If used for over 6 months,
the addition of ‘add-back’ hormone replacement therapy (HRT) is recommended.
Estrogen therapy
Alone used rarely in DUB treatment. Used in atrophic endometrium and in cases of DUB
secondary to depot progestogen.
Second line hormonal therapy
Gonadotropin-releasing hormone agonists (GnRH analogue)
GnRHa act by downregulating the HPO axis and induce ovarian suppression,
leading to amenorrhoea. Unfortunately, their beneficial effect does not continue after
stopping treatment and their adverse effect on bone density limit their use beyond 6
months.
They produce a profound hypoestrogenic state similar to menopause (They induce medical
menopause by suppressing gonadotrophions).
Side effects include menopausal symptoms and bone loss with long-term use so it should
not prescribed for longer than 6 months because the risk of osteoporosis. If used for over 6
months, the addition of ‘add-back’ hormone replacement therapy (HRT) is recommended.
Danazole
Treatment with danazol for 2-3 months is associated with a mean reduction in MBL in the
order of 100 ml.However,
danazol is associated with androgenic Side effects such as weight gain, acne, hirsutism and
Voice changes .
Although the majority of these (with the exception of voice changes) are reversible on
cessation of treatment, the fact that they can occur is enough to prevent most women with
menorrhagia from opting for danazol treatment.
Gestrinone
Gestrinone is a 19-testosterone derivative which has anti-progestogenic, anti-oestrogenic
and androgenic activity.it reduce menstrual blood loss in menorrhagia. However, it also has
androgenic side effects
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Surgical treatment
• Surgical treatment is normally restricted to women for whom Medical treatments
have failed.
• should be certain that their family is complete. As she can be treated by
Hysterectomy, and endometrial ablation
other wise Women wishing to preserve their fertility for future attempts at
childbearing should therefore be advised to have the LNG-IUS rather than
endometrial ablation or hysterectomy.
• Surgical method:
1. Dilatation and curettage (D&C)
2. Endometrial resection and ablation.
3. Hysterectomy
Dilatation and curettage (D&C):
A D&C may be done for a woman with heavy bleeding used in acute situation (for
diagnostic and therapeutic purpose).
Endometrial ablation
All endometrial destructive procedures employ the principle that ablation of the
endometrial lining of the uterus to sufficient depth preventing regeneration of the
endometrium.
Indication:
• The technique is suitable for women with HMB who have completed their family
• all organic and structural causes of HMB have been excluded.
During normal menstruation, the upper functional layer of the endometrium is shed ,whilst
the basal 3 mm of the endometrium is retained.
In endometrial ablation, the basal endometrium is destroyed, and thus there is little or no
remaining endometrium from which functional endometrium can regenerate.
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First-generation techniques
Include hysteroscopic transcervical resection of the endometrium, using an :
-Electrical diathermy loop,
-Roller-ball ablation.
These techniques offer treatment for uterine cavities with Submucous fibroids.
Simpler, quicker second-generation alternatives have subsequently been developed for
smoother, smaller cavities.
These include :
- fluid-filled thermal balloon endometrial ablation (Thermachoice™),
-
microwave ablation(Microsulis™)
-
impedance-controlled endometrial ablation (Novasure™).
All these performed as day-care procedures, either under general anaesthetic or under
local anaesthetic in the outpatient setting.
Women who undergo this procedure should be advised to use long-term effective
contraception ( effects of endometrial ablation on future reproductive potential )..
Methods performed non-hysteroscopically
(i.e.without direct visualization of the
endometrial cavity at the time of the procedure)
• Thermal uterine balloon therapy
• Microwave ablation
• Heated saline
All the above operations are performed through the uterine cervix. Most take around 30-45
minutes to perform, and in the majority of cases the patient can return home that evening.
Postoperatively,
patients may complain of
-transient crampy abdominal pain and
-watery brown discharge for between 3 and 4 weeks.
Prophylactic antibiotic therapy is often used to reduce the risk of endometritis.
The mean reduction in MBL associated with endometrial ablation is around 90 %.
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Complication
• device failures at time of procedure,
• endometritis,
• haematometra,
• fluid overload due to absorption of distension medium (resection only),
• perforation and intra-abdominal injury (including visceral burn)
Around 4 per cent of women have some complications Associated with endometrial
ablation .
In 1 per cent of women, the complications arising during the procedure are sufficiently
serious to prompt either laparotomy or another unplanned surgical procedure.
Result of endometrial ablation:
Of all women undergoing endometrial ablation with a second-generation technique ,
44
–
54
%
will become amenorrhoeic,
44
–
64
%
will have markedly reduced menstrual loss
20% will have no difference in their bleeding.
Hysterectomy
Hysterectomy involves the removal of the uterus.
It is an extremely common surgical procedure,
20 per cent of women will have a hysterectomy at some point in their lives.
Hysterectomy can be :
• 'total', in which the uterine cervix is also removed,
• 'subtotal', in which the cervix is retained.
Hysterectomy is often accompanied by bilateral oophorectomy (removal of both ovaries).
The precise choice of operation should be determined after detailed discussion between
the doctor and patient.
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In terms of the treatment of menorrhagia,
it is Removal of the uterus that effects a cure, and'-thus removal of the cervix and/ or
ovaries is an 'optional extra'.
The main perceived advantage of oophorectomy is a reduced risk of ovarian cancer.
Additionally, Women with pelvic pain and/or severe premenstrual syndrome in addition to
their menorrhagia may find That hysterectomy and bilateral salpingo-ophorectomy is more
effective at treating their symptoms than hysterectomy alone.
with the adverse effects of oestrogen Loss on bone density for women who do not take
hormone replacement therapy (HRT) after oophorectomy.
Mode of hysterectomy
Total hysterectomy may be achieved using three
Main techniques:
• abdominal hysterectomy
• vaginal hysterectomy
• laparoscopically assisted hysterectomy
Other form is surgery for the underlying organic cause as :myomectomy ,uterine artery
embolization , polypectomy.