MENORRHAGIA (Part Three)

DIFFERENTIAL DIAGNOSIS:

1. Adnexal tumors
2. Adrenal carcinoma
3. Anovulation
4. Cervicitis
5. Spontaneous abortion
6. Endometrial carcinoma
7. Endometritis
8. Gestational trophoblastic neoplasia.
9. Hyperprolactinemia
10. Hyper - Hypothyroidism
11. Obesity
12. Pelvic inflammatory disease
13. Pituitary microadenomas
14. Pregnancy
15. Uterine cancer
16. Vaginitis

TREATMENT:

Medication:

1. Nonsteroidal anti-inflammatory drugs (NSAIDs) – naproxen, diclofenac, etc.
2. Oral contraceptives. Long-term use of a combination of estradiol valerate and dienogest has been proven to be very effective in the treatment of menorrhagia.
3. Progestin- medroxyprogesterone (Provera) - antiestrogenic.
4. Intrauterine devices with levonorgestrel.
5. Gonadotropin-releasing hormone agonist (GnRH agonist) which are used for a short period due to high cost and numerous side effects. They inhibit the pituitary release of LH, FSH leading to hypogonadism
6. Danazol (Danocrine) – causes amenorrhea from 4-6 weeks and androgenic effects like acne, breast volume reduction, and often voice deepening.
7. Conjugated estrogens – administered intravenously every 4 hours in patients with acute hemorrhage. If there is no result within 24 hours, continue with the dilation – curettage procedure.
8. Tranexamic acid has an antifibrinolytic effect by inhibiting the activation of plasminogen to plasmin.

Surgical:

1. Dilation and curettage – used for diagnosis as much as for treatment.
2. Transcervical resection of the endometrium (TCRE). It is done through a resectoscope, hysteroscopy and the main risk is perforation of the uterus.
3. Endometrial ablation with laser. The laser is inserted into the uterus through hysteroscopy.
4. Endometrial ablation without resectoscopy which include:
• With thermal balloon catheter – a catheter with a balloon filled with NaCl isotonic solution heated to 87 degrees Celsius for 8 minutes that is inserted into the endometrial cavity.
• With hysteroscopy – NaCl solution heated to 90 degrees Celsius for 10 minutes is introduced into the uterine cavity.
5. Cryoablation – liquid nitrogen is used to freeze the endometrium. The procedure lasts for 10 minutes and is done under ultrasound guidance.
6. Endometrial ablation with microwaves.
7. Myomectomy is usually used when there is one or a few myomas and when the woman wants to preserve the uterus and fertility.
8. Hysterectomy