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A 37 year-old with Menorrhagia

A 37 year-old with Menorrhagia. Max Brinsmead PhD FRANZCOG March 2010. What are the treatment options for a 37 year-old Para 1 who has menorrhagia and a 5 cm fibroid in the fundus of her uterus? She is a smoker. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid.

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A 37 year-old with Menorrhagia

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  1. A 37 year-old with Menorrhagia Max Brinsmead PhD FRANZCOG March 2010

  2. What are the treatment options for a 37 year-old Para 1 who has menorrhagia and a 5 cm fibroid in the fundus of her uterus? She is a smoker.

  3. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Combined OC with 20 ug EE • Combined OC with 50 ug EE • Oral iron • Intramuscular iron • NSAID • Tranexamic acid (Cyklokapron) • Ethamsylate • Primolutwith each menstrual period • Primolutbefore each menstrual period • Depot Provera • Copper IUCD • Mirena IUS • D&C • Endometrial ablation • Myomectomy • Abdominal hysterectomy • Vaginal hysterectomy

  4. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Combined OC with 20 ug EE • Combined OC with 50 ug EE Relatively contraindicated in this patient who is >35 years of age and smoking However, may be a good option if she wants another baby soon, will stop smoking and has no other risk factors for thrombo-embolism Use the lowest dose of oestrogen possible and Avoid 3rd generation Progestins

  5. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Oral iron • Intramuscular iron • Iron dextran infusion • If the patient’s menorrhagia is mild then iron may be all that she needs • Haematologists say that there is no place for IM Iron • Iron by infusion with appropriate precautions against anaphylaxis can be a good alternative to blood transfusion

  6. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Tranexamic acid (Cyklokapron) • Ethamsylate • NSAIDs • 85% of patients with menorrhagia will have reduced menstrual flow using menstrual phase Cyklokapron in adequate doses • There is no risk of thromboembolism • Tranexamic acid is more effective than the other anti-fibrinolytic agent Ethamsylate and NSAIDs • NSAIDs may be useful if there is also dysmenorrhoea

  7. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Primolut with each menstrual period • Primolut before each menstrual period • Depot Provera • There is no evidence that progestins have any role in the management of menorrhagia • Depot Provera is unpredictable in its onset, control of the endometrium and duration of action

  8. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Copper IUCD • Mirena Intra Uterine System • In general menstrual flow is increased for patients who use inert or copper-containing IUD’s • The Mirena IUS may be a good option for this patient. Reduces menstrual loss by a mean of 95% and up to 20% of patients become amenorrhoic • The fibroid, even if impinging on the uetrine cavity, does not preclude a trial of Mirena

  9. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • D&C • Endometrial ablation • Myomectomy • D&C reduces menstrual flow for no more than 2 – 3 cycles in most patients. • It may be of use in assessing suitability for vaginal hysterectomy and placing a Mirena • Up to 50% of patients who undergo endometrial ablation require further therapy. The Mirena is a better option in the long term. • Myomectomy if the fibroid is solitary my be an option but up to 50% of patients require further treatment

  10. A 37-year old Para 1 with menorrhagia and a 5 cm fundal fibroid • Abdominal hysterectomy • Vaginal hysterectomy • Is 100% effective in the management of menorrhagia • But carries a 10 – 40% risk of minor morbidity and 1 – 2% risk of major morbidity • The vaginal route is associated with lower morbidity and quicker recovery (RCT data) • And a fibroid of this size should be no problem to an experienced operator

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