MENSTRUAL CYCLE DISORDERS THERAPY PETR KREPELKA 1

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)

Oligomenorrhoe Oligomenorrhoe – cycle > 35 days Therapy 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

Endometrial ablation/destruction / Hysterectomy Dysfunctional uterine bleeding - therapy Observation    DG   Pharmacological    Spont.normalization    Recurrence     D & C   Failure        - Surgical - Endometrial ablation/destruction / Hysterectomy 9

Pharmacological therapy of DUB Non-hormonal Nonsteroidal antirevmatics Mefenamic acid Ethamsylate Antifibrinolytics EAC Tranexamic acid Hormonal Estrogens (E) Progestins (P) E/P Danazol GnRh - a SERM 10

Pharmacological therapy of DUB Individual Age-specific Treatment outcome and side effects are unpredictable Side effects are common Economic efficiency Need for surgical treatment is often 11

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

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 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

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