Modern Management

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					            Modern Management


               of Menorrhagia




July 2000          G.P. Downey
 “To study the indications for hysterectomy
 is to study the interface between medicine
                 and society”




                                 Coulter et al, 1986


July 2000          G.P. Downey
Perspectives


• In California, only 50% of women have
  their uterus at death.
• A gynaecologist in Saudi Arabia will
  perform only one hysterectomy a year.
• In the UK, 20% will have had a
  hysterectomy

July 2000         G.P. Downey
Local Variations
• Perceived excessive menstruation accounts for
  70% of hysterectomies whilst 25% will have
  pathology
• 70% of hysterectomy specimens at City
  Hospital have “Pathology”.
• 40% of hysterectomy specimens at Solihull
  Hospital have “Pathology.

            Balachandra et al, 1994 (unpublished data)

July 2000             G.P. Downey
A Structured Approach



•   Definition(s)
•   Assessment
•   Diagnosis
•   Management Options

July 2000       G.P. Downey
Definitions
• Objective
   – Menstrual Blood Loss > 80ml
• Clinical: Blood Flow Resulting In
   –   Flooding
   –   Clots
   –   Time off work
   –   Anaemia
• Practical
   – Any menstrual blood loss deemed to be excessive by
     the woman

July 2000                G.P. Downey
Assessment

• History
   – Regular Cycle suggests Ovulatory
   – Irregular Cycle suggests anovulation
   – Associated Pain; Dyspareunia; Intermenstrual
     Bleeding.
• Thyroid Dysfunction (Hypothyroidism)[RARE]
• Blood Dyscrasias [VERY RARE]



July 2000               G.P. Downey
Examination


•   Anaemia
•   Thyroid (Goitre; Signs of Hypothyroidism)
•   Abdominal Examination
•   Cervical Inspection
•   Uterus
•   Adnexal Masses


July 2000             G.P. Downey
Investigations

• Haematological: FBC, (Clotting, Profile,
    TFT’s)

• Pipelle Biopsy: (30% Endometrium Sampled)

• Ultrasound: PA and TV

• Hysteroscopy (10% will require this)

July 2000           G.P. Downey
Management in Primary Care

• Prostaglandin Synthetase Inhibitors
     Blood Loss by 20-50% (in 75% of women)
     Pain
    • Rx Mefenamic Acid 500mg tds during the period
• Antifibrinolytics
 Blood Loss by 50% in women with:
    •   Dysfunctional Uterine Bleeding
    •   Uterine Fibroids
    •   Coagulation Defects
         • Rx Tranexamic Acid, 3-6g Daily (N.B. side effects)
July 2000                   G.P. Downey
Management in Primary Care (Continued)

• Synthetic Progestagens
   – Of no benefit in ovulatory menorrhagia
    – Must be used from day 5-26 of the cycle
    – Variable efficacy
    – Rx Norethisterone, 5mg tds or
      Medroxyprogesterone Acetate 10mg tds
• Intrauterine Progestagens
     Blood loss (85% in 3 months; 97% at 12 months)
    • But Large bore, difficult insertion and cost


July 2000                 G.P. Downey
Management in Primary Care (more)


• Combined OCP: 50% reduction in blood loss
• Danazol: Useful but has adrogenic side effects
• GnRH Analogues ( Livial)
     – Synarel
     – Zoladex
     – Prostap



July 2000            G.P. Downey
Conservative Surgical Options

 Modality               Success at 2 and 3        Main
                             Years             Complications
 Endometrial                 72% (60%)       TURP Syndrome
 Resection                                   Perforation
 Endometrial Ablation
 Microwave                                   Ablation of pelvic
                                             organs, Fistulae
 Rollerball                  75% (36%)       TURP Syndrome
 NdYag Laser                 90% (82%)       TURP Syndrome
                                             Perforation
 Thermal Balloon             77%             Infection

July 2000                   G.P. Downey
Non-Conservative: Hysterectomy

  Subtotal                     Laparoscopic

                               Abdominal

  Total                         Vaginal


July 2000        G.P. Downey
When to Refer?
•   Age (> 40yrs)
•   Persistent IMB
•   Failed Medical management
•   Other or Associated Factors
     –      Abnormal Smear
     –      Post-coital bleeding
     –      Severe Pain
     –      Palpable Mass


July 2000                          G.P. Downey
Learning Points

• Regular Cycle Ovulation
    – Best Option Tranexamic Acid
    – Consider MIRENA
• Irregular CycleAnovulation
    – Still Best Option, Tranexamic Acid
    – Consider NET D5-D26
• Refer if Medical Rx Fails, PCB, IMB

July 2000                G.P. Downey

				
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