PETR KREPELKA MENSTRUAL CYCLE DISORDERS THERAPY. Abnorlam uterine bleeding Regularity of cycle...

PETR KREPELKA

MENSTRUAL CYCLE DISORDERSTHERAPY

Abnorlam uterine bleeding• Regularity of cycle

– Iregular – metrorrhagia– Absent – amenorrhoea (primary,

secondary)• Frequency of cycle

– Frequent - polymenorrhoea– Infrequent - oligomenorrhoea

Describing normal uterine bleeding

• Duration of menstrual flow– Prolonged – menorrhagia– Shortened - hypomenorrhoea

• Volume of menstrual flow– Heavy - hypermenorrhoea– Light - hypomenorrhoea

Polymenorrhoea

• Polymenorrhoe – cycle < 21 days• Therapy

– Progestines during luteal phase of cycle (normoestrogenic disorders)

– Progestines+estrogenes (hypoestrogenic disorders)

OligomenorrhoeOligomenorrhoe – cycle > 35 daysTherapy- No therapy (normoestrogenic disorders)

– Progestines during luteal phase of cycle (normoestrogenic disorders)

– Progestines+estrogenes (hypoestrogenic disorders)

– Induction of ovulation (infertility)

Primary amenorrhoe

• Therapy - casual– Progestines+estrogenes (hypoestrogenic

disorders)

Secondary amenorrhoe

• Therapy – normoprolactinemic and normoestrogenic – Progestogenes– Ovulation induction

Heavy or prolonged uterine bleeding

• Menoragia• Hypermenorhea• DUB =dysfunctional uterine bleeding• AUB = abnormal uterine bleeding

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Dysfunctional uterine bleeding - therapy

Observation - - - DG - - Pharmacological

- - - Spont.normalization - - - - -

Recurrence - - - - D & C - - Failure - - - - -

- Surgical - Endometrial ablation/destruction / Hysterectomy

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Hormonal Estrogens (E) Progestins (P) E/P Danazol GnRh - a SERM

Non-hormonalNonsteroidal

antirevmaticsMefenamic acidEthamsylateAntifibrinolytics

• EAC• Tranexamic

acid

Pharmacological therapy of DUB

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Individual Age-specific Treatment outcome and side effects are unpredictable Side effects are common Economic efficiency Need for surgical treatment is often

Pharmacological therapy of DUB

• Estrogens – CEE - 2.5 mg p.o. a 6 h. or 25 mg i.v. a 4 h.

for 48 h.• Progestins

– MPA 10 mg/d for 10-12 d.– NES 10-15 mg/d 10 d.– LNG-IUS

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Pharmacological therapy of DUB

• E/P– Combined orla contraception

• Acute DUB - 70-140 μg/d• Prevention – usual pattern, long cycle pattern,

continual

– Adolescent gynecology• acute DUB• Progesterone 10 mg/ Estradioldipropionate 2 mg

i.m.

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Pharmacological therapy of DUB

• Danazol 200-400 mg/d– not available in Czech Republic

• GnRH agonists– goserelin (Zoladex Depot 3,75 mg)– tryptorelin (Decapeptyl Depot 4,12 mg,

Dipherelin 4,39 mg)– leuprorelin (Lucrin Depot 3,75 mg)

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Pharmacological therapy of DUB

• Nonsteroidal antirevmatics– Naproxen (Aleve tbl.220 mg, Apo-naproxen

tbl. 250 mg, Nalgesin tbl. 270 mg)– Mefenamic acid (Nimesulid tbl. 100 mg)

• Antifibrinolytics– Tranexamic acid (Exacyl p.o. tbl. 500 mg ,

oral solution 10ml/1000 mg a venous injection 5 ml/500mg)

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Pharmacological therapy of DUB

Effectiveness of pharmacotherapy

• Hormonal– Progestins - 21 day cycle 30-90%– Combined oral contraception 43%– Danazol 50-80%– LNG IUS 74-97%– DMPA 50-66%– GnRH agonists >90%

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Effectiveness of pharmacotherapy

• Non-hormonal– Non-steroidal antirevmatics 20-50% ?– Tranexamic acid 47-54%– Etamsylate 13%?

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Surgical therapy of DUB

• Endometrial ablation – hysteroscopical– Roller ball ablation (25-60%)– Transcervical resection (26-40%)– Laser ablation (37%)

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Surgical therapy of DUB

• Endometrial ablation – non-hysteroscopical methods– RFEA – Radio Frequency Endometrial

Ablation (41%)– TBEA – Thermal Balloon Endometrial Ablation

(48%)– MWEA – Microwave Endometrial Ablation

(61%)

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Surgical therapy of DUB

• Vaginal hysterectomy• LAVH – laparoscopically assisted vaginal

hysterectomy• Abdominální hysterektomie

(minilaparotomy)

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Surgical therapy of DUB - controversies

• Dilatation+curettage – Diagnostic procedure

• Endometrial - Resection/ablation– Many costly methods – Many failures selhání

• Hysterectomy– Invazive– Operational risks– Expensive – Suitable for women over 40

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Hypomenorrhoe

• Posttraumatic – Aschermanns syndrome• Therapy

– Hysteroskopy – lysis of adhaesions – IUD - estrogens

Dysmenorrhea- therapy

• Secondary dysmenorrhoea – causative • Primary dysmenorrhoea – combined hormonal

contraception effectivity – 90%• Progestogens contraception – long acting• LNG-IUS• Non-steroidal anti-inflammatory drugs (NSAIDs)

– 2-3 days before menstrual bleeding– Continue to the 2.day of bleeding

Premenstrual syndrome - therapy

• Diet regime – restriction of coffein, alcohol, salt, glycids

• Aerobic exercise• Psychological consultation

Premenstrual syndrome - therapy

• Symptomatic treatment according to prevailing syndrome

• Combined oral contraception (drospirenon)

• Agnus castus• Non-steroidal anti-inflammatory drugs• SIRS - fluoxetin

…thank you for your attention