10 secrets of success of IUI Dr. Sharda Jain Programme Director.
LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti...
-
Upload
lifecare-centre -
Category
Documents
-
view
1.562 -
download
0
Transcript of LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti...
![Page 1: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/1.jpg)
LNG-IUS: heavy meNStrUaL bLeedING
What IS NeW???
![Page 2: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/2.jpg)
Dr. Sharda JainDr. Jyoti Agarwal Dr. Jyoti Bhaskar
![Page 3: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/3.jpg)
1 Int J Women’s Health. 2011;3: 207–21; 2. J Midlife Health. 2013;4(1):8–15; 3. Open Access J
Contracep. 2013; 4:21–28; 4 NICE 2007; 5. Drug safety 2004
Major impact on a woman’s quality of life
![Page 4: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/4.jpg)
Options AvailableOptions Available
Mirena / Endometrial Ablation
Drug therapyDrug therapy
Hysterectomy
![Page 5: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/5.jpg)
LNG-IUS first designed in Finland – 1990
• From the concept of contraception, the spectrum of indications broadened
• In sept 2009 , the US FDA approved
mirena as a treatment for heavy menstrual bleeding
Obstet gynecol 2009;1104-1116
![Page 6: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/6.jpg)
NatIoNaL eSSeNtIaL LISt of medIcINe (NeLm) 2011
Out of 348 drugs Govt . of India has inc luded LNG-IUS as hormonal IUD in NELM 2011
Source: Union Health Ministry of India
From Research to Practice – Long Way to Go
![Page 7: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/7.jpg)
• Progestin releasing intrauterine system
• T shaped polyethylene frame
• Contains 52 mg levonorgestrel
• Releases 20 µg LNG daily
What is Mirena - LNG IUS
![Page 8: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/8.jpg)
Mirena :‘Local is logical’
local mode of action • Prevents endometrial
proliferation• Thickens cervical mucus• Inhibits sperm motility
serum levels are 4 times lower than after oral ingestion
![Page 9: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/9.jpg)
usage
4CHALLENGES
![Page 10: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/10.jpg)
MOTIVATION INSERTION POST INSERTION COST
![Page 11: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/11.jpg)
Motivational Facts …….• Over 60% of women diagnosed with
HMB ended up having a hysterectomy within 5 years from the diagnosis
• About 1/3 rd of hysterectomies for HMB result in removal of anatomically normal uterus
![Page 12: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/12.jpg)
MOTIVATION
Your words can change their
world
![Page 13: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/13.jpg)
MIRENA
Inspired by : Prof.Osama Showki
Magic Stick
![Page 14: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/14.jpg)
International Guidelines recommend LNG-IUS as first line Rx in HMB
Data on file
![Page 15: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/15.jpg)
Recent guidelines place more emphasis on
improvement of QoL of the patient
![Page 16: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/16.jpg)
Data on file
![Page 17: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/17.jpg)
Efficacy of LNG - IUSEfficacy of LNG - IUS
“The results are in line with NICE recommendations 2007, as they show that women should be offered Mirena
first to avoid more invasive treatment”
![Page 18: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/18.jpg)
Efficacy of LNG IUS in Idiopathic Menorrhagia
![Page 19: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/19.jpg)
97% Reduction in Menstrual Blood Loss over 1 year of therapy
Significant increase in Hemoglobin and Serum Ferritin level
![Page 20: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/20.jpg)
Comparison of Rx Modalities Progesterone or LNG IUS
LNG IUS reduces menstrual blood loss more effectively and has a higher likelihood of treatment success than oral medroxyprogesterone acetate.
Obstet Gynecol. 2010
![Page 21: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/21.jpg)
Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing
Intrauterine System in Primary Care against Standard Treatment for
Menorrhagia (ECLIPSE) Trial
21
Improvements in MMAS scores were significantly greater (lesser score= more severity)
Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J for the ECLIPSE Trial Collaborative Group N Engl J Med 2013;368:128-37
Daily routine work, social and family life, and psychological and physical well-being Menorrhagia Multi-Attribute Scale (MMAS)
![Page 22: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/22.jpg)
COCs= Combined OC pills; LNG-IUS – Levonorgestrel Intrauterine System; GnRH – Gonadotrophin Releasing Hormone agonists
Finnish Survey:: Among 75 Obstericians/ gynaecologists
working at the Helsinki University Central Hospital (2013)
Pre congress course on heavy menstrual bleeding, 10‐ th Congress of European Society of Gynecologists, Brussels Belgium September 18-21 2013
In your opinion what is the most effective medical treatment for HMB?
![Page 23: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/23.jpg)
Finnish trial (multicentric RCT 236 pts)
• Mirena improves the quality of life as effectively as surgical treatment at 1 year.
• Women ranked their satisfaction with a mean score of 7 / 10.
• Less than 5% of women required subsequent operative treatment
• Mirena is more cost effective than hysterectomy in the short term
![Page 24: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/24.jpg)
LNG IUS versus Hysterectomy
24
When patients were given the option of mirena a significant percentage of women cancelled their hysterectomy
Pekka Lähteenmäki et al. 1998 316: 1122 (6)
![Page 25: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/25.jpg)
Objective: To evaluate the efficacy, acceptability, and possible side effects of a levonorgestrelreleasingintrauterine system for menorrhagia. Method : Sixty-three women with menorrhagiabut without uterine enlargement, endometrial hyperplasia, or endometrial carcinomawere enrolled in this prospective, open, nonrandomized clinical trial and LNG-IUS was inserter in post menstrual period to these womenResult : Menstrual pattern, number of bleeding days, and subjective and objectiveestimation of menstrual blood loss using a pictorial blood loss assessment chart (PBAC) were recorded before insertion and at specific intervals for 4 years.Conclusion: Using the LNG-IUS is an effectiveand well-accepted option overall for the medical management of menorrhagia.
Mirena is an effective and well-accepted option for the medical management of menorrhagia in India : An AIIMS Study 2007
![Page 26: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/26.jpg)
• OBJECTIVE : To evaluate the efficacy of an intrauterine system releasing levonorgestrel (LNG-IUS, Mirena) in the treatment of women with menorrhegia .
• METHOD(S) : This was a prospective, non-comparative study. Twenty patients who had Menorrhagia due to non-malignant causes were included in the study (age range 20-42 years). However patients of fibroid uterus with uterine size more than 12 weeks and those with submucous fibroid were excluded. A LNG-releasing-intrauterine system was inserted on any day during bleeding or within a week of cessation of bleeding. Menstrual blood loss was assessed, before LNG-IUS was inserted, and after 3, 6, and 12 months of use.
• RESULTS : The most common bleeding pattern at 3 months after insertion was spotting and after 6 and 12 months the majority of women presented with amenorrhea or oligomenorrhea. One woman requested removal of the LNG-IUS because of continuous spotting even after 4 months of insertion. The remaining women continued the use of LNG-IUS beyond 1 year.
• CONCLUSION: LNG-IUS is an effective treatment for Menorrhagia due to benign causes and could be an alternative to hysterectomy.
Mirena is an effective treatment for Menorrhagia and could be an alternative to hysterectomy: An Indian Study
2005
![Page 27: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/27.jpg)
Bleeding pattern in the first 5-year period
Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21
Infrequent3.7% Regular
70.3%
Ammenorhea 26%
![Page 28: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/28.jpg)
2nd challenge
![Page 29: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/29.jpg)
How to insert Mirena properly???
It has been seen that properly placed Mirena rarely gets displaced
![Page 30: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/30.jpg)
![Page 31: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/31.jpg)
3rd challengePractical tips for
post insertion success
![Page 32: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/32.jpg)
COUNSELLING
Is it not very costly as compared to oral medication?
Doctor, I am spotting daily? What do I do?
I have not had periods since 6 months? Am I in menopause?
![Page 33: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/33.jpg)
Counselling !!!
• Spotting after insertion
• Amenorrhea in 25 % of women
![Page 34: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/34.jpg)
Irregular Bleeding or spotting
May last for 3 - 4 months COC Progesterone GnRHa are used to tide over this period Sevista
Acceptance depends on good pre insertion counselling
![Page 35: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/35.jpg)
4th
challenge
![Page 36: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/36.jpg)
COST EFFECTIVENESS
LNG IUS
• Cost- Rs 8205/-• Insertion cost – Rs.
2000 - 5000 Covered by Insurance
ORAL PROGESTERONE
1 mnth – Rs. 3000 6 months Rs. 18000 1 Yr Rs. 36000
No insurance
![Page 37: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/37.jpg)
Emerging new indications for use
of mirena
![Page 38: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/38.jpg)
Endometriosis it provides long term relief of chronic pelvic pain
Obstet gynecol 2012;119:519-526
![Page 39: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/39.jpg)
FIBROIDS
Significant reduction in both the uterine volume and blood loss
![Page 40: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/40.jpg)
Endometrial Hyperplasia
• Beneficial effects are observed by1 year.
• Treatment should be reliably monitored through regular 6-montly outpatient follow up
Eur J Obstet Gynecol Reprod Biol. 2008
![Page 41: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/41.jpg)
Early-stage Endometrial Carcinoma
May have a role in selected patients willing to preserve fertility
• Endometrial protection for women on tamoxifen • Women With Clotting Disorders Or Under Anti
Thrombotic Treatment
Conservative treatment of early endometrial cancer: preliminary
results of a pilot study.Gynecol Oncol. 2011; 120(1):43-6
![Page 42: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/42.jpg)
How long ? NICE GUIDELINES : If inserted > 45 yrs of
age and has complete amenorrhea may
continue to use it until menopause. It can be removed at mid 50s as long as it controls the
bleeding
HRTChange it after 4 years “licenced”
Contraception< 45years…..5 years
> 45 years ….7 years
![Page 43: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/43.jpg)
Are there any drugs that interact with mirena ?
• Women using mirena may be reassured that
• No drugs are known to interact with mirena
• Can be used safely with ATT
• No effect on BMD
Not to be used as Emergency Contraceptive
![Page 44: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/44.jpg)
Health Benefits
No significant change in• Blood pressure• Lipid profile• Coagulation factors• Carbohydrate metabolism• Liver function• Bone mineral density
![Page 45: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/45.jpg)
Sonographic Evaluation
Routine use of ultrasound is not indicated
![Page 46: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/46.jpg)
Our Experience
with
MIRENA in
Heavy Bleeding
![Page 47: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/47.jpg)
Used in 300 casesINCLUDING FIBROIDS AND ENDOMETRIOSIS
(July 2014)
Expulsion in 3
(UBT , hysterectomy , reinsertion )
• It can replace the need of hysterectomy in
50 % of cases.
• Especially useful when future fertility is
desired
![Page 48: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/48.jpg)
Mirena
Positive Side
• Effective after 4 month • Major Surgery is saved – Mortality
- Morbidity
Cost Effective
![Page 49: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/49.jpg)
To conclude …..
![Page 50: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/50.jpg)
![Page 51: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/51.jpg)
HYSTERECTOMY
as Treatment
Should be last resort
![Page 52: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/52.jpg)
LNG - IUS
Its not simply a Pregnancy
Hormone.
But in true sense,a
Mother Hormone.
![Page 53: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/53.jpg)
ADDRESS 11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
CONTACT US 9650588339, 011-22414049,
WEBSITE : www.lifecarecentre.in
www.drshardajain.com www.lifecareivf.com
E-MAIL [email protected]
[email protected]@lifecareivf.com
&
Thank You
![Page 54: LNG-IUS: heavy menstrual bleeding What is new??? Dr. Jyoti Agarwal / Dr. Sharda jain / Dr. Jyoti Bhaskar](https://reader033.fdocuments.us/reader033/viewer/2022052117/5880ea171a28ab0d358b657d/html5/thumbnails/54.jpg)