1.Amalina Mohd Daud 0917298 Management of Menorrhagia

2. Outline Pharmacological treatment Surgical treatment Lifestyle modifications 3. Pharmacological treatment Choices 1. Hormonal treatment 2. Non-hormonal treatment 4. HORMONAL TREATMENTS 5. LNG-IUS Vertical stem: release daily doses of 20 micrograms of LNG Effects: -prevent endometrial proliferation -thicken cervical mucus -suppress ovulation Cost effective when compared with other hormonal and non hormonal treatments Reduction of MBL between 71-96% -benefit seen after 6 months 6. COCP Contain estrogen and progestogen in combinations Act on HPO axis to suppress ovulation and fertility -cause withdrawal bleeding Reduces MBL by 43 % - Greater than naproxen - Lesser than danazol and tranexamic acid Less benefit with higher cost 7. Oral Progestogen Progesterone -hormone produced during luteal phase -cause secretory transformation of endometrium bleeding when levels fall Reduction of MBL by 84% (93% : LNG) Requires long course regimen 8. Danazol Anti-estogenic and anti-progesteronic activity -antiproliferative to endometrium -anovulatory by preventing GnRH at pituitary Reduce MBL by 50% Significant androgenic side effects -weight gain -acne -hirsutism -voice changes Reversible with treatment cessation 9. GnRH-analogues Synthetic peptide that act like a natural GnRH but with longer biological half life Action 1. Flare effect -increase FSH and LH 2. Profoung hypogonadal effect - after 10 days downregulation No follicular development, estrogen production, no ovulation, no progeterone, no menses Treatment 1. Hormonal sensitive cancer -breast cancer, prostate cancer 2. Estrogen dependant lesion - leiomyoma, endometriosis Reduces MBL but with high adverse effects 10. Non-hormonal treatments 11. Tranexamic acid Competitive inhibitor of plasminogen activator -antifibrinolytic agents Menorrhagia -Reduced breakdown of fibrin preformed clot in spiral endometrium arterioles reduce MBL Reduce MBL by 34-59% Cost effective when compared with other NSAIDS and no treatment -not when compared with LNG-IUSHowever, -not reduce dysmenorrhea -not a contraceptive -not regulate cycles Dosage: 1g ( 2 tablets) 3-4x daily from onset of bleeding up to 4 days 12. NSAIDs Reduce prostaglandin synthesis by inhibiting COX Prostaglandin: - Inflammatory response - Pain pathways - Uterine cramps - Uterine bleeds Reduces MBL 20-49% but tranexamic acid and danazol reduces MBL greater -better AE profile than danazol Less cost effective than LNG and tranexamic acid Treatment of dysmenorrhea However, - Not contraceptions - Not to be used in bleeding disorders 13. Recommendation for Pharmaceutical Approach 14. Recommendations Considered in - no structural or histological abnormalities - fibroid