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Editorial April 2010
Simpler Is Often Better, and Patience Can Be a Virtue
Ronald T. Burkman, MD
One of the most common problems we treat as gynecologists is abnormal uterine bleeding.
It may be due to breakthrough bleeding with hormonal contraception or irregular bleeding related to anovulation, or it may be caused by a variety of
conditions such as uterine leiomyomata, polyps, and endometrial hyperplasia.
Menorrhagia, which is abnormally heavy cyclical menstrual blood loss, is particularly common. It is estimated that at least 10% of menstruating women will have complaints related to heavy menstrual blood loss. Once lesions such as polyps or small submucous myomas, which can be cured with hysteroscopic surgery, have been eliminated, one is faced
with the challenge of how to treat the rest.
When I discuss these cases with residents, they tend to embrace more invasive approaches such as endometrial ablation or hysterectomy (particularly if it can be done vaginally or laparoscopically). There is no question that such
approaches are effective, and in the case of hysterectomy, definitive. However, a high percentage of women prefer treatment that will preserve their childbearing capabilities, such that these approaches are not appropriate.
It is not uncommon for a patient to be prescribed a month or 2 of an oral contraceptive (OC) or
progestin-only preparation and return with persistence of the complaint. The resident, particularly if inexperienced, will be in
a quandary about what to do next. In general, my mainstays in the treatment of this problem include NSAIDs, OCs, and the levonor-gestrel-releasing intrauterine
device (LNG-IUD).
Studies evaluating a variety of NSAIDs used during menses to
reduce heavy flow have demonstrated reduction in the amount of overall flow. In at least one study, use of an NSAID appeared to be equivalent in efficacy to a combination OC for reducing menorrhagia. A proposed mechanism of
action is that NSAIDs reduce the rate of production of endometrial prostaglandins leading to vasoconstriction. Advantages of this approach relate to reasonable cost, low frequency of side effects, and reduction of dysmenorrhea.
Combination OCs appear to reduce menstrual blood loss by up to 40% to 50%. For some patients, the use of extended-cycle or continuous OCs may provide additional reduction in days of uterine bleeding. The potential mechanisms of action include stabilization of the endometrium and reduction in levels of luteinizing hormone and follicle-stimulating hormone leading to anovulatory cycles. The advantages of this approach include reasonable cost, an acceptable side-effect profile, contraceptive protection, and reduction of dysmenorrhea.
Studies evaluating the effectiveness of the LNG-IUD in reducing menstrual blood loss have demonstrated reductions in flow, in some cases approaching 100% within a year. Two evidence-based reviews have concluded that the LNG-IUD is effective and that it produces menstrual flow reductions that are equivalent to endometrial ablation. The mechanism of action of the device relates to the direct effect of a potent progestin on the endometrium.
From the standpoint of expense in the treatment of menorrhagia, one study indicated that OCs are the most cost-effective in the first year. However, with prolonged use, the LNG-IUD proved to be significantly more cost-effective.
There are a few more caveats to keep in mind when managing this disorder. Counseling is crucial. It is important that the patient
has reasonable expectations and understands that these measures to treat her menorrhagia yet preserve her fertility do not usually work instantaneously.
In particular, OCs and the LNG-IUD may take up to 3 months, and occasionally longer, to exhibit a reasonable therapeutic effect. When treating with OCs, it is usually better to avoid using 20 μg or less ethinyl estradiol preparations, since the
frequency of unscheduled bleeding is higher with these formulations. Often such preparations are used in perimenopausal women with menorrhagia because of concern about venous thromboembolism in this age-group. However, there are no data to indicate a substantial difference in risk for this complication when comparing these preparations with OCs that have an ethinyl estradiol dose as high as 35 μg.
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Ronald T. Burkman, MD, Editor-in-Chief
Suggested Reading
ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218.
Blumenthal PD, Trussell J, Singh RH, et al. Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception. Contraception. 2006;74(3):249-258.
Côté I, Jacobs P, Cumming DC. Use of health services associated with increased menstrual loss in the United States. Am J Obstet Gynecol. 2003;188(2):343-348.
Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005;(4):CD002126.
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