CC Nov 2015 Medical treatment of menorrhagia

echoecho's version from 2015-12-04 14:27


Question Answer
Define menorrhagia?is excessive bleeding during REGULAR-interval menses
Regular-interval menses means what?a predictable pattern reliable indicates that ovulation is occurring
Define menometrorrhagia?IRREGULAR, unpredictable, intermenstrual, excessive bleeding
What is the cause of menometrorrhagia?anovulation
Define excessive bleeding?bleeding that lasts > 7 days with blood loss of > 80 mL per cycle
List the characteristics of blood loss > 80 mL?1) clot size > 1 inch 2) need for dual sanitary protection (pad plus tampon) 3) need to change sanitary protect every 1-2 hours
*** It is important to recognize that heavy menstrual bleeding has a major impact on a woman's ____ ____ ____ and that any intervention should aim to improve ___ ____ ____ rather than focus on the quantity of menstrual blood loss?quality of life (QOL); quality of life (QOL)
;is the most common cause of abnormal bleeding in the reproductive years?pregnancy
List the initial lab work-up for menorrhagia in woman < 35 y.o.?1) hgb 2) urine pregnancy test 3) pap and genital cultures if indicated by hx
What labs are not routinely necessary in the work-up of menorrhagia?1) ferritin 2) PT/PTT 3) von Willebrand panel
Wile irregular bleeding in early adolescence usually only requires reassurance, very heavy bleeding since menarche may indicate what?a coaulation disorder and require further evaluation
Coagulation disorders may be further indicated by what?1) personal hx of bleeding 2) family hx of bleeding 3) postpartum hemorrhage 4) frequent bruising 5) epitaxis 6) abnormal bleeding following surgery or dental work
Anovulatory bleeding patterns should trigger what evaluation?1) TSH (r/o thyroid disease) 2) fasting AM prolactin (r/o prolactinoma) 3) if patient has clinical signs of hyperandrogenism such as acne or hirsutism, order LH, FSH, testosterone to r/o PCOS, GTT to r/o insulin resistance, 17-OH prosterone to r/o late-onset congenital adrenal hyperplasia (CAH)
What 2 medications are also potential causes of anovulatory bleeding?1) antipsychotic meds 2) anti-epileptic meds
What s/s may be a cause of cervical polyps or fibroids?1) pelvic pain 2) pelvic heaviness 3) intermenstrual bleeding 4) postcoital bleeding
What exam is done to evaluate for uterine enlargment?palpable on bimanual exam
*** If hx and physical exam suggest heavy menstrual bleeding WITHOUT structural abnormalities, what trial may be reasonable prior to imaging in patients < 35 y.o.?medical treatment
*** If hormonal therapy fails or if there is suspicion of structural abnormalities or if the patient is > 35 y.o., what imaging is indicatedTVUS (transvaginal US)
*** Endometrial biopsy is indicated if the woman is at risk for CA due to other risk factors, list these risk factors?1) infertility 2) nulliparity 3) obesity 4) chronic anovulatory cycles 4) tamoxifen use 5) family hx of colon CA
What procedure has replaced D & C (dilatation and curettage) in postmenopausal women with vaginal bleeding?endometrial biopsy
What procedure is indicated if in postmenopausal women, the TVUS shows a endometrium of > 5 mm?saline ifusion sonograms for better visualization of polyps and other focal abnormalities
Strong evidence shows that what procedure is as accurate as office hysteroscopy in detecting intracavitary focal lesions and usually is better tolerated?hysterosonography with saline infusion
Why is hysterectomy not done as a rotine procedure for menorrhagia?1) unnecessary risk 2) 80% of women with menorrhagia have no anatomical abnormality
*** Medical treatment with what medication has been shown to regulate and reduce menstrual bleeding?COCs (combined oral contraceptives)
*** What 2 medications may be considered for long-term menstrual suppression?1) continuous COCs depot medroxyprogesterone acetate (DMPA) Depo-Provera 2) levonorgestrel intrauterine system (LNG-IUS) Mirena
*** Of the above two treatments, which one has been deomonstrated as the most effective first choise with fewer treatment failures, a lower rate of discontinuation and improved quality of life (QOL)?Mirena (levonorgestrel intrauterine system or LNG-IUS)
COC's decrease long-term blood loss by about ____% and have even greater efficacy with extended-cycle or continuous treatment?50
What 2 cancer risks are decreased by COCs?1) endometrial cancer 2) ovarian cancer
The decrease in blood loss during LNG-IUS use is about _____% after 3 months and ___% at one year?86; 97
***Use of luteal phase progestins (days 15-26) was significantly less effective than 21-day progestin use (days 5-26), and both were significantly to _______?LNG-IUS
For the treatment of menorrhagia, what is the most cost-effective treatment in the first year?For those who do not respond to this therapy, what is most cost-effective in the long term?COCs; LNG-IUS
For women who do not respond to COCs, LNG-IUS is the most cost-effective treatment, followed by ____ if treatment fails?surgery
Although not FDA approved for use in menorrhagia, _________ which suppresses the pituitary-ovarian axis, can effectively decrease blood loss?danazol (Danocrine)
There is a risk of significant androgenic side effects, but a recent small study of danazol used ______ with dose of ________ showed efficacy with minimal side effects?intravaginally; 200 mg each night
List the medication that recently received FDA approval for treatment of menorrhagia?Lysteda
Describe what Lysteda is?an oral form of tranexamic acid (antifibrinolytic agent)
Lysteda decreases blood loss by about ____% if taken for a maximum of 5 days during menstruation? Does it affect fertility?no
Lysteda is contraindicated in what disorder?thromboembolic disorders
Lysteda should be taken with extreme caution if a women is also taking what other medication?hormonal contraceptives
Those taking Lysteda should report what disturbances because thromboembolism of the rental vein or artery has occurred with the use of this medication?visual
Long term use of Lysteda (> 1 month) requires baseline and regular _______ monitoring?ophthalmologic
NSAIDs reduce blood loss by about ____%?29
How does NSAIDs work?probably due to vasoconstriction, improved platelet aggregation and prostaglandin inhibition
When are NSAIDs useful?for those trying to conceive or who do not tolerate hormone therapy
*** NSAIDs are significantly less effective than what 4 medications?1) danazol 2) COCs 3) tranexamic acid 4) LNG-IUS
*** SUMMARY = A trial of med rx may be reasonable prior to imaging in patients < ____ years of age.
Question Answer
*** SUMMARY = What are the indications for the use of transvaginal US?1) if a structural abnormality is condiered OR 2) if hormonal therapy fails for women > 35 y.o.
*** SUMMARY = List 3 medications that can be considered for long-term menstrual suppression?1) continuous combined oral contraceptives (COCs) 2) depot medroxyprogesterone acetate (DMPA)(Depo Provera 3) levonorgestrel intrauterine system (LNG-IUS)(Mirena)
*** SUMMARY = NSAIDs reduce blood loss by ____% but are less effective than other interventions?29