A BOON FOR COMPLICATED AND INOPERABLE CASES

By:

DR. MRS. MANJUSHREE BOOB

M.D., D.N.B., FICMCH, FICOG

DIPLOMATE OF NATIONAL BOARD.

CONSULTING OBSTETRICIAN GYNAECOLOGIST

INFERTILITY & LAPAROSCOPIC SURGEON

SHUBHAM HOSPITAL BADNERA ROAD, AMRAVATI

REAL LIFE SITUATION• YOUNG LADY 28 YRS. OLD • SEVERE MENORRHAGIA REPEATED • Hb% 5 - 8gm%• M/4 8 – 10 / 28 – 30 / HOW +++ 6 – 8 Pads WITH

CLOTS.• O/H PARA 1 – FTN 2 YRS. ANXIOUS TO HAVE

FURTHER CHILDBEARING.• P/V / TVS UTERUS BULKY• T/T NOT RESPONDING TO ORAL HORMONES

AND D & C MIRENA INSURTED 4 ur fACT.

CASE STUDY- 2• 48 YRS OLD.• SEVERE MENORRHAGIA.• H/O RENAL TRANSPLANT & ON REGULAR

ANTI PLATELET DRUGS.• NOT FIT FOR SURGERY.• MIRENA INSURTED 3 YRS. BACK.

RESULT: GOOD CONTROL FOR BLEEDING

CASE STUDY- 3

• 37 YRS. OLD.• PARA – 4. ALL C SECTION ALIVE – 2• H/O HERNIA REPAIR BY PROLENE MESH.• SEVERE MENORRHAGIA SINCE 2 YRS.• TVS MULTIPLE FIBROID• SIZE -- & 2-3 IN NUMBER• T/T MIRENA.

CASE STUDY- 4• 4 CASES OF 45 – 48 YRS. OLD.• PREV 3 C- SECTION.• SEVERE MENORRHAGIA• NOT RESPONDING TO DRUGS AND D & C• T/T MIRENA

CASE STUDY- 5

• 32 YRS OLD.• SEVERE MENORRHAGIA SINCE 2 YRS.• TVS FIBROID OF SIZE 3 X 3 CM. INTRAMURAL• NOT WILLING FOR SURGERY• PARA 2• MIRENA INSERTED.

CASE STUDY- 6

• 30 YRS OLD.• PARA 1 WITH ITP• SEVERE MENORRHAGIA SINCE 2 YRS. • MIRENA INSERTED.

CASE STUDY- 7• 34 YRS OLD.• PARA 1 – LCB 1 YR.• MENORRHAGIA • TVS CHOCOLATE CYST AND ENDOMETRIOSIS• OPERATIVE L’SCOPY CYSTECTOMY WITH BIPOLAR

FULGERATION DONE.• MIRENA INSERTED.• BLEEDING AND PAIN REDUCED

CASE STUDY- 8• 45 YRS OLD FEMALE• WEIGHING 95 KG.• SEVERE HT AND DM• MENORRHAGIA • D & C DONE• MIRENA INSERTED.

MIRENA: BOON FOR COMPLECATED AND

INOPERABLE CASESCAFETARIA APPROACH

MENORRHAGIA

DUB FIBROID ELSEENDOMETRIUM

• ORAL OR INJECTABLE HORMONES• MIRENA• THERMA CHOICE• TCRE• HYSTERECTOMY

VAGINAL LAPAROTOMY LAPAROSCOPIC

“ T/T SHOULD BE TAILORMADE TO THE PATIENT AND HER DISEASE ”

Therapeutic Use of LNG IUS

• Prevention of anemia • Treatment of menorrhagia / dysmenorrhea • Alternative to sterilization• Endometrial protection with ET• Promising findings:

Treatment of endometriosis / adenomyosisEndometrial protection with TamoxifenTreatment of endometrial hyperplasia

Normal menstrual cycle

Menorrhagia

Metrorhagia

MBL 40 ml

Over 80ml

Variable

Bleeding pattern of Menorrhagia

280Days

Menstrual Blood Loss before and after LNG-IUS insertion

0

20

40

60

80

100

Baseline 3 months 6 months 12 months

MBL(estimated by PBACs

score)

p<0.0001

p<0.0001p<0.0001

97

3222

16Vera Grigorieva,

Fertil. Steril. 2003

LNG-IUS

Only careful fundal insertionNo special surgical skillsTakes care of contraceptionTherapeutic in adenomyosisCost for five years lowFertility preservedHas shown to replace

hysterectomy

Resection

Operation with complicationsSpecialist with endoscopic skillsIntrauterine and ect. pregnanciesAdenomyosis a problemCost for five years high;

recurrenciesFertility lostHysterectomy increased

LNG-IUS and Endometrial Resection in Menorrhagia

Summary of LNG-IUS

• LNG-IUS is effective and inexpensive medication in the treatment of menorrhagia

MIRENA® in the Symptomatic Treatment of Endometriosis

Endometrial Hyperplasia, Effect of MIRENA®

LNG IUS: Mode of action

• Prevention of endometrial proliferation• Thickening of cervical mucus• Local effects on the endometrium• Effects of ovum fertilization, without complete inhibition of ovulation• Minor effect on ovarian function

LNG IUS

Bleeding & spotting days per

month

LNG IUS (n = 1495)Nova-T (n = 739)

8

6

4

2

0

Mea

n nu

mbe

r of d

ays

Months

Mea

n nu

mbe

r of d

ays

0

4

8

12

16

0 2 4 6 8 10 12

Bleeding per month in 1st year

Andersson et al., 1994

p < 0.001

Bleeding days per month

Contraceptive efficacy of LNG IUS

•Overall pregnancy rate: 0.16 per 100 woman-years •European multicentre study: cumulative gross pregnancy r ate

- 1-year rate LNG IUS: 0.1%Cu IUD: 1.0%- 5-year rate LNG IUS: 0.5%Cu IUD: 5.9%

•Risk of ectopic pregnancy: 0.06 per 100 woman-years. Ectopic rate for women not using any contraception: 0.3-0.5 per 100 woman-years

What is menorrhagia?• Menstrual bleeding (bleeding occurring at normal

intervals (21─35 days), but with– Heavy flow ( 80 mL) or – Duration ( 7 days)

• Excessive menstrual blood loss can cause apprehension, embarrassment and inconvenience and, over several cycles, may cause iron deficiency anaemia

Causes of menorrhagia

• Idiopathic• fibroids• endometriosis / adenomyosis• genital infections• polyps• hyperplasia• malignancy• coagulation or endocrine disorders• medications

Medical therapy for menorrhagia

• Mirena • Progestogens (oral or injectable)• Tranexamic acid• Non-steroidal anti-inflammatory agents• Combined oral contraceptives• Danazol • GnRH analogues

74-97%

32-50%

47-54%20-50%

43%

50%

>90%

Surgical options for menorrhagia• Hysterectomy

– Vaginal– Abdominal– Laparoscopic

• Endometrial ablation/resection– Laser– Thermal balloon – Microwave– Transcervical resection of the endometrium (TCRE)– Fluid instillation– Cryotherapy

Summary of studies comparing Mirena with endometrial ablation/resection

97% (36 months)99% (36 months)

1922

Rauramo et al, 2004MirenaTCRE

90% (12 months)98% (12 months

3029

Istre and Trolle, 2001MirenaTCRE

71% (6 months)50% (6 months)

2525

Barrington et al., 2003MirenaThermal balloon

82% (median 20.9 month)73% (median 8.3 months)

2035

Henshaw et al., 2002Mirena Microwave ablation

Reduction in menstrual blood loss (duration of assessment)

NStudy

TCRE; transcervical resection of the endometrium