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Menorrhagia - is hysterectomy the answer? Part II Puberty menorrhagia
Perimenopausal menorrhagia It is seen in women with anoulatory cycles. It is anovulatory cycle. As menopause nears the ovaries got exhausted of their follicles. Hence it is an estrogenic cycle unopposed with progesterone. We should rule out endometrial carcinoma (cancer of the womb). It is better to get a biopsy of the endometrium by D&C. What is D&C? It is a minor surgical procedure. Under mild anesthesia the uterine mouth is dilated with instruments & the endometrium (inner lining of the uterus) is scraped. The patient should be carefully investigated to rule out other causes of menorrhagia. A through detailed history is a must. Onset, duration, and amount of bleeding - Antecedent causes like I.U.C.D recent delivery or abortion & sterilization . Full general examination, which should include - Thyroid dysfunction, Renal causes & Hepatic causes. Ultra sound to rule out other pelvic causes. A diagnostic curettage (D&C) primarily to obtain materials for histopathology. If we cannot substantiate a cause & if the patient still bleeds, Hystero salpingogram may help us to rule out some intra-uterine causes like fibroid polyp. Hysteroscopic visualization is a better alternative, both for diagnostic and therapeutic purpose. But this procedure needs special expertise and training. Treatment of Menorrhagia Treatment depends on many factors. a) The age of the patient, her fertility and her desire for children & retaining the menstrual cycles. Under forty years, treatment is essentially conservative. b) The degree of aneamia. The response to curettage, which was performed primarily as diagnostic is therapeutic in about 30-40% cases. Hence I strongly stress curettage to precede hysterectomy in all the cases. It is mandatory in Perimenopausal women to exclude endometrial cancer. But it is not so in the younger age. The failure of hormonal treatment is an indication for D&C. The incidence of endometrial carcinoma in women below 40 years is 1:10,000----1:100,000 but the incidence raises to 1% in women between 40 and menopause. Conservative management - No treatment: 1. If the bleeding is not heavy 2. Patient's hemoglobin is normal Under these conditions observation and maintenance of menstrual chart for a few months is sufficient. 3. Iron should be given orally and the response to it should be checked by repeated Hb estimation. If the patient fails to use or intolerance to iron is found out, parenteral iron treatment is indicated. Blood transfusion may be necessary if the bleeding is too heavy. Hormone therapy
MDPA 10 mg three times a day, as a starting dose. Then depending upon the response of the patient the dosage is adjusted. It is free of adverse effect on lipo proteins. It could be given as a cyclical therapy. Duphaston does not suppress ovulation, has no adverse effects on lipid metabolism. Hence, this could be used in the younger age group. Instead of cyclical therapy, progesterone can be given from day 15 of the cycle to day 21. But it is not very effective. Combined oral contraceptive pills are useful in menorrhagia if a women not desirous of a pregnancy reduces the blood loss by 50%. Clomiphene is advocated if pregnancy is desired and if cycles are anovulatory. (to be continued) For further details contact:
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This is a threshold bleeding caused by excess of unopposed oestrogen and the absence of progesterone. Immediately after menarche ovulation might not be a regular feature. Many times it is the anoulatory cycles that causes puberty menorrhagia. Initial few cycles may not be excessive. Puberty menorrhagia may be excessive or normal, but prolonged, continuous bleeding lasts for many days. The pelvic findings (usually per rectal examination preferred since most of these patients are unmarried) under aneasthesia are normal. Ultrasound may be normal. All these patients are aneamic. Hence anemia should be treated with blood transfusion & heamatinics. The bleeding could easily be arrested with heavy doses of Medroxy progesterone acetate depending upon the heaviness of the bleeding. Tab Medroxy progesterone acetate 10 mg t.d.s. Once the bleeding is controlled maintenance dose should be given by gradually reducing the dose & to get withdrawal bleeding. Oral contraceptives can also be used the same way as Medroxy progesterone acetate. Both the drugs can be continued for regularizing the cycle. This treatment can be continued for 6 months. Genital Tuberculosis should be ruled out if a girl fails to respond to hormonal therapy.
Though Estrogen and progestational compounds were indicated previously. Because of the cardiovascular complications, Medroxy progesterone acetate (MDPA) is the drug of choice.
