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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
9
Dysfunctional uterine bleeding - therapy
Observation - - - DG - - Pharmacological
- - - Spont.normalization - - - - -
Recurrence - - - - D & C - - Failure - - - - -
- Surgical - Endometrial ablation/destruction / Hysterectomy
10
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
12
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.
13
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)
14
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)
15
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%
16
Effectiveness of pharmacotherapy
• Non-hormonal– Non-steroidal antirevmatics 20-50% ?– Tranexamic acid 47-54%– Etamsylate 13%?
17
Surgical therapy of DUB
• Endometrial ablation – hysteroscopical– Roller ball ablation (25-60%)– Transcervical resection (26-40%)– Laser ablation (37%)
18
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%)
19
Surgical therapy of DUB
• Vaginal hysterectomy• LAVH – laparoscopically assisted vaginal
hysterectomy• Abdominální hysterektomie
(minilaparotomy)
20
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
21
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