Gui Delines for the Managem Ent of Menor Rha Gia

8/14/2019 Gui Delines for the Managem Ent of Menor Rha Gia

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GUI DELINES FOR THEMANAGEM ENT OFMenor rha gia

Dr Mahdy El- Maz zahyDam iett a g eneral Hosp ital


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De fintio n (HMB ) is def inedsubjectiv ely asexces sive me nstr ualbleeding or objective lyas menst rual blood lossof 80 mls for t he wholeof a woman s per iod(Hallberg 1966).


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BACK GRO UN D Men orrhagi a is a si gni ficantheal thcare probl em in thedevel oped worl d. Two-thi rds o f the womenwi th menorrhagi a wi lldi spl ay iron- def iciencyanem ia. Men orrhagi a causesdecreased hemogl obi n,

hema tocri t, and serum iron


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BACK GRO UN D Surgi cal management o f thi sprobl em is c ommon and as a

resul t one i n five NewZeal and women wi ll have hada hysterecto my by the age of54 (Paul et al 1988).

Despi te widely avai labl eevi dence inapprop riatetreatments a re bei ng


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RECOMMENDATIONS


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Grade of

recommendation Grade A - based on

randomised controlled trials*

Grade B - based on robustexperimental or observationalstudies

Grade C - based on morelimited evidence but the advicerelies on expert opinion


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SO URC ES OFO URC ES OFGUI DEL INE SUI DEL INE S2. COCHRANE LIBRARY2. COCHRANE LIBRARY

3. NEW ZEALAND GUIDELINES3. NEW ZEALAND GUIDELINESGROUPGROUP

4. NATIONAL GUIDELINES4. NATIONAL GUIDELINESCLEARING HOUSECLEARING HOUSE


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Assessment Women who have a normal

haemoglobin level should beencouraged to chart their menstrual

blood loss by using a pictorial bloodloss assessment chart (Grade B).

Women with erratic menstrual

bleeding should be investigatedinvestigatedthroughlythroughlyas endometrial polypsand submucous fibroids are more

likely to be present (Grade B).


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Asse ssm ent Perimenopausal women with

irregular cycles but normal bloodloss do not require referral (Grade

C). An abdominal and pelvic

examination should be performed inwomen presenting with heavy

menstrual bleeding with the possibleexception of women under the age of20 as the likelihood of pathology issmall (Grade C).


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Asse ssm ent Women with an abnormal

pelvic examination, should have

an ultrasound to confirm thefindings (Grade C).

A full blood count should be

offered to all women presentingwith heavy menstrual bleeding

(Grade A).


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Asse ssm ent Thyroid function tests do

not need to be routinely

performed in women withheavy menstrual bleeding

unless the woman has

symptoms or signs ofhypothyroidism (Grade C).


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Asse ssm ent The following women with heavy

menstrual bleeding are recommended tohave a transvaginal ultrasound of theendometrium

- weight 90 kg- age 45 years old

- other risk factors for endometrialhyperplasia or carcinoma such as

infertility or nullipairty, familyhistory of colon or endometrial cancer,exposure to unopposed oestrogens(Grade B).


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Asse ssm ent If transvaginal ultrasound is not

available then an endometrial

sample should be taken (Grade C).

If the endometrial thickness on

TVS is 12 mm an endometrial

sample should be taken to exclude

endometrial hyperplasia (Grade A).


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Asse ssm ent Failure to obtain

sufficient material forhistological diagnosisdoes not require furtherinvestigation unless theendometrial thickness is12 mm (Grade B).


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Asse ssm ent Hysteroscopy and biopsy is

indicated for :-

1-women with erratic menstrualbleeding.

2- failed medical therapy.

3- transvaginal ultrasoundsuggestive of intrauterinepathology such as polyps orsubmucous fibroids (Grade B).


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AssessmentAssessment

Tests for coagulopathyTests for coagulopathyare only indicated inare only indicated inwomen who havewomen who havesuspicious features insuspicious features in

the history orthe history orexamination (Grade C).examination (Grade C).


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Me dical Ma nagementThe following treatments are

effective in reducing regularheavy menstrual bleeding:

Levonorgestrel intrauterinesystem

Tranexamic acid (menstruatingdays only)

Non-steroidal anti-inflammatory

agents (menstruating days only)


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Me dical Ma nagement Oral contraceptive pill (Day 5-

25)

Long course of high dose

norethisterone (Day 5-25)

Danazol (daily continuous)

(All Grade A)


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Revi ewer s' concl usi onsevi ewer s' concl usi ons (C O C H R A N E )

NSAI Ds reduce menorrh ag iaSAI Ds reduce menorrh ag iawhe n comp ared wi th plac ebohe n comp ared wi th plac ebobut are less ef fect ive thanut are less ef fect ive thanei ther tranexami c aci d ori ther tranexami c aci d ordanazol .anazol .

How ever, advers e event sow ever, advers e event s

NON STERO IDALON STERO IDALANTI- INFLAMMATO RYNTI- INFLAMMATO RYDRU GSRU GS (NSAI Ds)SAI Ds)


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Revi ewers' co nc lusi onsevi ewers' conc lusi ons( C OC HR A NE)

An tif ibrin olyt icn tif ibrin olyt icth era py cause s ah era py cause s agreater reduction inreater reduction inobjectivebjectivemeasurements ofeasurements of

menorrhagia wh enenorrhagia wh en

ANT IF IB RI NOL YTI CNT IF IB RI NOL YTI CDRU GSRU GS


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Danaz ol is effectiv eanaz ol is effectiv efor reduci ngor reduci ngmenor rhagi a butenor rhagi a butside eff ect s limit iti de eff ect s limit itto a second choiceo a second choicetherapy or shortherapy or short

DAN AZ OLAN AZ OL


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Me dical Ma nagement Progestogens (norethisterone

or medroxyprogesterone

acetate) given in the lutealphase (Day 12-26), are not

effective in reducing regular

heavy menstrual bleeding(Grade A).


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Me dical Ma nagement Emergency suppression of a

heavy prolonged menstrual

bleed can be achieved bynorethisterone 15 mg/day or

medroxyprogesterone acetate

30 mgs/day for 3 weeks (GradeC).


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There is no conclusive

evidence of theeffectiveness ofethamsylate for reducingheavy menstrual bleeding

(G rade A)

ETHAMSYLATETHAMSYLATE


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SurgicalurgicalManagemenanagement


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Surgical ManagementSurgical Management

Dilatation and curettage is not effective

for therapy in women with heavy

menstrual bleeding (Grade B).

The endometrium can be destroyed with

a variety of techniques but there may be a

40% reoperation rate after 5 years (Grade

A).


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Surgical ManagementSurgical Management

Women are more likely to be satisfied

with endometrial ablation than oral

medical therapy (Grade A).

There is a similar satisfaction rate and

efficacy with endometrial ablation and the

levonorgestrel intrauterine system (Grade

A).


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Surgical Management Vaginal

hysterectomy isassociated withreduced operating

time, earlierhospital dischargeand reduced costswhen compared

withlaparoscopicallyassisted vaginalhysterectomy

(Grade A).


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Surgical Management Endometrial

destruction techniques

and vaginal hysterectomy

are preferable to

abdominal hysterectomy(Grade B).


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Gui Delines for the Managem Ent of Menor Rha Gia

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