MEDICAL TREATMENT OF AUB

In the myometrium there are different types of chemicals which keep a balance between those which can help with stopping the bleeding and help with coagulation, others which promote the bleeding. When this balance is upset a woman bleeds more than normal. One group of drugs called nonsteroidal anti inflammatory drugs (NASIDS) commonly called neurofen or naprosyn can easily correct this imbalance, hence they are the first line of treatment for heavy menstrual bleeding (HMB). The drug most commonly used is Mefenamicacid. It is best to take 500mgm of this tablet just before your period is about to start or just started with a glass of milk. This can upset your stomach hence I am suggesting milk. Subsequently you can take 250 mgm tablets two to three times a day. They help with period pain as well. This can be done during the duration of bleeding. If it helps you it is very good. If you suffer from Asthma, be careful taking NASIADS.  The other side effects of these drugs can cause diarrhoea and gastric upset. In my practice I used Naprosyn SR (Slow release, meaning continues pain relief) 1000 mgm once a day with very good effect.

The other drug very useful for any bleeding problem is Tranexamic acid including HMB orAUB. It is the most effective and safe drug needed in the medical system. The WHO lists it as the most essential medicine. It is available around the world in almost every country under different names. It can be used in any type of bleeding, gynaecology, trauma, and obstetric. It can be used as intravenous in severe emergency. It is a cheap drug. Tranexamic acid is used to prevent the fibrin not being totally consumed when there is profuse bleeding thus it acts as antifibrinolytic agent, after certain other activities go on in the bleeding and clotting cascade. Thus protecting the fibrin; for coagulation. Women are advised to use 1gm of tranexamic acid 4 times a day during the bleeding phase. A dose of 4 gms can also be used once a day. If urgent tranexamic acid is required a dose 10mgm per kg body weight is given intravenously, 6 hourly slowly over a 20 minutes period. This does not relieve pain. None of these two drugs are contraceptives. When prescribing treatment for AUB it is very important to have the woman’s input while offering her the treatment. Using Tranexamic acid for treatment there is concern about thromboembolic (thrombosis) problems. However a recent study from Sweden did not find any risk. Other side effects include headaches, colour vision change, musculoskeletal pain, stuffy nose and fatigue.

The next and the easiest treatment are combined oral contraceptives (COC).These act by suppressing the ovarian activity. You do not have to worry about if the bleeding is ovulatory or anovulatory. Make sure the woman’s blood pressure is not raised, she is not a smoker. The COC help with the pain as well, period pain usually happens with ovulatory period, COC stop ovulation choose suitable pill if she has pimples or PMT. They can be offered to use the pill for 3-4 months without a break. Have a period 3-4 times a year. If the tablets are causing breakthrough bleeding, the type or the strength can be adjusted. You have to make sure she is happy to use contraceptives.

For anovulatory bleeding which is often erratic and irregular you can use progesterone in the second half menstrual cycle. This can regulate the cycle and decrease the bleeding. It can be norehisterone (PRIMOLUT) 5 mgms three times a day for 12 -14 days of each cycle. This is not a contraceptive. If contraceptive is desired than COC is the best to regulate the cycle as these put the ovaries to sleep. A very good alternative is an intrauterine IUD called Mirena (LNG- IUS) this t shaped IUD with levonorgestral stored on it. It releases 10microgms every day. It can be easily fitted in the uterine cavity. You may have a period like pain for a few days .In the next 6 months you may have irregular bleeding but then it settles, remains for 5 years; generally you do not have any period problems. You can have it removed at your convenience than can get pregnant. If you are young and have never had a baby, then there is a younger sister of Mirena. It is called Skyla it is smaller in size, and has less levonorgestral and is good for 3 years. Mirena, is suitable for most women.

Some clinicians advise to use what is called GnRH. This is a very expensive drug. I personally do not feel we need to use it here. It causes menopausal symptoms and then you have to add back HRT. If you are older and fertility is not a question than a minor surgical procedure called endometrial ablation is excellent. If for some reason; for example endometrial thickening or the woman has any risk factors for endometrial cancer Hysterectomy is the best answer.

The risk factors for endometrial cancer are obesity, weight more than 90kgs, diabetes, infertility and nulliparity, atypical endometrial hyperplasia, fibroids, Tamoxifan (used as prophylaxis against breast cancer recurrence) family history   and age more than 45.

Treatment for coagulation disorders

It depends on the severity of the problem, age, need for preservation of fertility. If the problem is not acute and the woman is happy or desires contraception can, COC is the best treatment to start with. Before starting this treatment study the factor VIII and vonWillebrands factor, as hormones increase the factor VIII, vonWillebrands factor, thus they can mask the diagnosis of vonWillebrands disease. Treatment can be started with COC pill. Often this may be enough, as they enhance the factor VIII and vonWillebrands factor.

If not we can use tranexamic acid 1gm 4 times per day during the bleeding phase.

Desmopressin (DDAVP), it is a synthetic hormone similar to the natural hormone vasopressin. Many doctors use it as a first line of treatment. Some women use the nasal spray (STIMATE) at the start of the bleeding. It works by making the body to release vonWillebrands factor stored in the lining of the blood vessels. The other treatment can be blood clotting factors infusion. This contains factor VIII and vonWillebrands factor.

Another product approved by FDA is genetically engineered vonWillebrands factor called Vonvendi. It contains no plasma hence there is no risk of viral infection or allergy.

If the bleeding is due to platelet deficiency a platelet transfusion is given. Involvement of a haematologist is required in these situations. Oral progesterone has been tried but it did not show any benefit and hence not commonly used.

Progesterone injections called Depo-Provera (150mgms per ML is injected every 12 weeks. It is a contraceptive and does not have too many side effects, there is one problem,   and it causes amenorrhea in 50% hence oestrogen deficiency. This can result in osteoporosis, if used long term. Women loose 1% of their bone density in one year’s use of Depo-Provera.

DANAZOL is another synthetic hormone which is often used more so in the past. It helps with period pain to some extent. It causes endometrial atrophy it acts by suppressing ovarian activity. 30% of women get amenorrhea. It used to be used more often in the past in the management of endometriosis. We have come a long way to manage endometriosis.The dose of the Danazol is 100 to 200 mgms/day.  One serous side effect is masculization. If by chance the woman gets pregnant, it causes masculization of the female foetus. Again this is not a contraceptive, so you have to discuss contraception with a woman, if she desires it.

GONADOTROPIN RELEASING HORMON AGONISTS (GnRH)

This is a very useful treatment for premenopausal female. It is generally used when other medical or surgical treatment is contraindicated or not accepted by the woman. It is expensive. GnRH works by inducing a hypogonodal state that means that the ovaries are suppressed. Women start getting hassled by menopausal symptoms, hot flashes, night sweats, and dry vagina.  HRT is required. A synthetic drug called LIVIAL is used for HRT. It is very useful for decreasing the size of fibroids. A course of GnRH is given for 4-6months before surgery is planned. It is also used when a decision is made to do a uterine artery embolization. This procedure is done by the radiologists. At this stage it is not common as it needs a lot more work on it. The drugs used as GnRH is Leuprolide acetate 3.75mgms/month or as 11.25 mgms intramuscular every 3 months. The other drug is Nafarelin which is used as intranasal spray 200 micro gms twice daily. Some clinicians   consider GnRH to be, the first line of treatment for adenomyosis as it helps with pain.  Levonorgestral IUD (LNG -IUS) is also useful for adenomyosis.

Ulipristal acetate which is a selective progesterone receptor modulator. In common English it means, it blocks the action of progesterone therefore it is useful to prevent pregnancy and is also very useful for decreasing the size of fibroids as progesterone promotes the growth of the fibroids.

The other conditions are treated depending on the what the problems are such as hypothyroid they are given thyroxin, if a woman has high prolactin she is given a drug called bromocriptine (2.5 mgms daily). It acts by decreasing the production of prolactin from the pituitary gland.

  

Treatment of acute very heavy menstrual bleeding

We can divide this in two parts

Make sure her general condition is not too bad, she is not hypovolemic. Does she need resuscitation or a blood transfusion? Make sure there is no bleeding disorder, put up an IV drip, and arrange, blood for a transfusion. For stopping the bleeding we usually give 25 mgms of IV Premarin every 4 hours until the bleeding stops. It usually stops in 24 hours.If the bleeding continues we can use tranexamic acid IV 10/20 mgms per kgms body weight, twice a day, no more than 650mgms per injection for 2-3 days. Once the bleeding settles down we can give, COC pill three times per day which contains 35 microgms of ethinyl oestradiol, or oral progesterone(Medroxyprogesterone acetate) 25mgm, three times a day for 7 days. Later on we may find some anatomical features that require surgical treatment, we deal with them.

In some situations and in some places when the modern facilities are not available, old fashioned dilatation and curettage still comes to our rescue. It stops the bleeding, and gives us the lining of the uterus to study.  We can see if there is any evidence of infection, then the woman can be given suitable antibiotics, or if there is any atypical thickening of the lining of the uterus (which can be precancerous) or if the woman is older, is there any evidence of uterine cancer?

In some situations when the woman is on anticoagulants, she suffers from AUB, it is a real challenge. Temporarily one can stop her anticoagulants or decrease the dose, but is only a temporary measure.  Different specialists e.g. cardiologists in case she has cardiac prosthesis, thrombosis intern, gynaecologist, haematologist and a physician should be involved. Excluding cancer and major gynaecological (Large fibroids, ovarian cysts) we should aim to treat them medically. The treatments which have been used and are useful is Tranexamic acid, COC cannot be used. However Tranexmic is not a contraceptive. Depo -provera injections have been used short term, with some success .Mirena (LNG-IUD) is useful. Minor side effects are breast tenderness, pain and cramps, headaches some irregular bleeding. Big advantage, it is a contraceptive.

Endometrial ablation is a very simple and effective treatment; however you lose your fertility.