mirena lng iucd case discussions
TRANSCRIPT
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