Management Approaches to Menstrual Disorders

Management Approaches to Menstrual Disorders - Charting the Chaos

• Initial Assessment: Detailed history (menstrual, medical, family), physical exam (general, pelvic).
• Investigations:
  • Lab: CBC, TSH, PRL, hCG. Consider coagulation profile, androgens if indicated.
  • Imaging: Pelvic USG (transvaginal preferred).
  • Hysteroscopy/Endometrial biopsy: If structural pathology suspected or >45 yrs / risk factors for endometrial hyperplasia/cancer.

• General Management:
  • Lifestyle: Weight management, stress reduction, exercise.
  • Symptomatic relief: NSAIDs for dysmenorrhea.
• Medical Management (Hormonal):
  • Combined Oral Contraceptives (COCs)
  • Progestins (oral, injectable, IUD - Mirena)
  • GnRH agonists (with add-back therapy)
• Medical Management (Non-Hormonal):
  • Tranexamic acid (for HMB)
  • NSAIDs (Mefenamic acid)
• Surgical Management: Indicated for structural lesions or failed medical therapy.
  • Hysteroscopic procedures (polypectomy, myomectomy)
  • Endometrial ablation
  • Hysterectomy (definitive)

⭐ Levonorgestrel-releasing IUD (Mirena) is highly effective for heavy menstrual bleeding (HMB), reducing blood loss by up to 80-95% and providing contraception. (📌 Mirena: Manages Increased REd Nuisance Amounts!)

Management Approaches to Menstrual Disorders - Pill & Potion Power

Medical management is tailored to the specific disorder, severity, and patient preference.

• Key Medications:
  • 📌 HMB Meds: "Treat Heavy Menses Now" (Tranexamic acid, Hormonal [COCs, Progestogens], Mirena [LNG-IUS], NSAIDs)
  • NSAIDs:
    • Mefenamic Acid: 500mg TDS (HMB, Dysmenorrhea)
    • Ibuprofen: 400-600mg TDS (Dysmenorrhea)
  • Antifibrinolytics:
    • Tranexamic Acid: 1g TDS (or 10-15mg/kg TDS) for HMB. Max 4g/day.

      ⭐ LNG-IUS (Mirena) is highly effective for HMB, reducing blood loss by up to 80-95% within 3-6 months.

  • Combined Oral Contraceptives (COCs):
    • Cyclic or continuous use for HMB, Dysmenorrhea, Cycle regulation, PMS.
  • Progestogens:
    • Norethisterone: 5mg TDS (days 5-26 for HMB; or luteal phase for 10-14 days).
    • Medroxyprogesterone Acetate (MPA): Oral or depot.
    • LNG-IUS (Mirena): HMB, contraception.
  • SSRIs:
    • Fluoxetine, Sertraline for PMS/PMDD (continuous or luteal phase).
  • GnRH Agonists:
    • Severe HMB/Endometriosis (e.g., Leuprolide, Goserelin) with add-back therapy (to mitigate hypoestrogenic side effects).

Management Approaches to Menstrual Disorders - Precision Procedures

• Dilation & Curettage (D&C)
  • Diagnostic: endometrial sampling for AUB.
  • Therapeutic: retained products, temporary HMB relief.
• Hysteroscopy
  • Gold standard for intrauterine pathology (polyps, fibroids).
  • Operative: polypectomy, submucosal myomectomy, adhesiolysis.
• Endometrial Ablation
  • For HMB; fertility not desired.
  • Techniques: thermal, radiofrequency, cryoablation.
  • Avoid if endometrial hyperplasia/cancer.
• Uterine Artery Embolization (UAE)
  • Minimally invasive for symptomatic fibroids (HMB).
• Myomectomy
  • Surgical fibroid removal; preserves uterus & fertility.
• Hysterectomy
  • Definitive for severe/refractory AUB, large fibroids, cancer.

⭐ Hysteroscopy is the gold standard for diagnosing and treating intrauterine abnormalities like polyps or submucous fibroids causing AUB.

High‑Yield Points - ⚡ Biggest Takeaways

• NSAIDs (Mefenamic acid) are first-line for dysmenorrhea & reducing HMB.
• COCs regulate cycles, ↓ HMB, & manage PCOS irregularities.
• Progestins are key for anovulatory bleeding, HMB, & endometrial protection.
• LNG-IUS is highly effective for HMB & long-term contraception.
• GnRH agonists treat severe endometriosis/fibroids by inducing temporary menopause.
• Tranexamic acid is effective for HMB if hormones are contraindicated.
• Surgery (ablation, hysterectomy) for refractory cases or structural issues_._