Surgical & Other Treatment Options
Management options depend on the presumed diagnosis, and on the patient’s wishes regarding pregnancy Medication Drug treatment may be given for at least 3 months, and the patient may be reviewed after that, to continue or to stop treatment. • Tranexamic acid (Cyclokapron) 0.5 to 1 g orally 3 times daily for the first 3 days of bleeding. Can reduce regular heavy bleeding by 50%. Useful for acute bleeding and long term. Does not make irregular bleeding regular. Do not prescribe in patients with a history of thromboembolism. Injectable Medroxyprogesterone acetate (Depo-Provera) 150 mg IM every 3 months, Norethisterone ethanoate(Nur-isterate) 200mg; useful for acute bleeding and long-term. At first, bleeding may be irregular, if this happens add 4 weeks of Norethisterone (Primolut) 10 mg orally twice daily. Reduce bleeding by 95-100%. Progestogens may cause slight weight gain, feeling of heaviness, oily skin, mood changes and rarely headache • Medroxyprogesterone acetate (Provera) 5 mg orally twice daily for 21-28 days per month (never only 5-14 days: has no effect) • Norethisterone (Primolut) 10 mg orally twice daily or 5 mg orally 3 times daily for 21-28 days per month (not 5-14 days, as the package insert suggests – this is ineffective); useful when bleeding is irregular • Combined oral contraceptives. They also reduce dysmenorrhea and provide contraception. Beware of contraindications. Decrease bleeding up to 50%. • Nonsteroidal anti-inflammatory drugs such as Ibuprofen 400 mg orally 3 times daily, mefenamic acid 500 mg orally 3 times daily, or naproxen 500 mg orally 3 times daily for the duration of bleeding. Useful for dysmenorrhea, but decrease bleeding variably 10-45%. Beware of contraindications – peptic ulceration, asthma, renal dysfunction • Levonorgestrel-containing intrauterine system (Mirena) is effective, not available at some public hospitals, irregular spotting may occur at first. Reduce bleeding 95-100%. • For prolonged bleeding following use of Depo Provera, or oral contraceptives, one can give conjugated oestrogen (Premarin) 0.625 mg daily for three weeks, after demonstrating a thin endometrium on ultrasound
Management for multifibroid uterus
Surgery depends on the cause, e.g. myomectomy or hysterectomy for fibroids (below), or hysterectomy for persistent excessive bleeding not responding to drug treatment. N.B. a small submucous fibroid may lead to heavy bleeding & may be resected by hysteroscope. Endometrial ablation can be considered in some units for bleeding from a normal uterus – i.e. when the uterus is of normal size & no specific cause is found. If there is marked dysmenorrhoea there is less satisfaction with ablation. Many different types of ablation exist. Pregnancy after ablation is contra-indicated, & specified as such in consent. Uterine artery embolisation may be offered in some units. Pregnancy after is cautiously allowed. Catheterisation & occlusion of both uterines is achieved via the femoral artery. A watery blood stained discharge follows, which is very rarely associated with overwhelming sepsis.
MANAGEMENT OF MULTIFIBROID UTERUS
Drug treatment (as for excessive vaginal bleeding) may control haemorrhage sufficiently to avert hysterectomy, at least in the short term.
- Do not force a hysterectomy an unwilling patient
- Consider myomectomy. Consent for a myomectomy must include specific mention of proceeding to hysterectomy if there are intraoperative problems
- Consider alternatives: Uterine artery embolization (UAE) or High Intensity Focused Ultrasound (HIFU) for suitable patients who want to preserve their fertility. UAE may shrink the uterus by 50%. Pregnancy Following UAE may have complications (IUGR, prem labour, placenta accreta). This should enter consent. HIFU has not to date been used much on the larger uterus (the current limit is 18 weeks size). Always discuss with a consultant.
- Where fertility is an issue, consider other causes.
N.B. if, for a person with bleeding, there is a delay while awaiting an operation or a procedure & that person is not maintained on progestagens & haematinics, when the procedure is due there will be anaemia & it will be cancelled.