Long-acting progesterone therapy in the form of medroxyprogesterone (Depo-Provera; Pharmacia Corp, Peapack, NJ) will stop menses in the majority of patients. Standard dosing is 150 mg administered intramuscularly (IM) every 3 months. Approximately 80% to 90% of patients who complete 12 months of Depo-Provera therapy will be amenorrheic. Potential side effects include weight gain, irregular bleeding, and depression.
Danazol. This pituitary suppressant creates a hypoestrogenic state and decreases menstrual blood loss by 70% to 80%. A daily dose of 50 to 100 mg may be adequate in some cases; otherwise, the conventional 400 to 800 mg is recommended. Potential side effects include weight gain, acne, and alteration of lipids.8
GnRH therapy. Gonadotropin-releasing hormone (GnRH) therapy with leuprolide or nafarelin creates a hypoestrogenic menopause-like condition, with menstruation usually ceasing within 3 months. Menopausal symptoms may include hot flushes, night sweats, vaginal dryness, bone loss, decreased concentration, and diminished libido. Nevertheless, compliance generally is good. Because prolonged therapy can lead to osteoporosis, treatment usually is limited to 6 months unless estrogen “addback” therapy is instituted.
GnRH therapy is a valuable option for the late perimenopausal woman who has significant contraindications to other medical regimens. For most of these women, the cessation of menses is a relief. After therapy, many patients spontaneously transition into the menopause. An intermittent 6-month course of leuprolide is an option for women with uterine fibroids. Data indicate that it provides an additional 9 months of symptom control (range: 2 to longer than 25 months).9
Progesterone intrauterine system. The recently introduced levonorgestrel-releasing intrauterine system (IUS) (Mirena, Berlex Laboratories, Montville, NJ) also is effective therapy for DUB. This IUS causes pseudodecidual changes and amenorrhea, decreasing menstrual blood loss by 65% to 98% within 12 months, with little systemic absorption of progesterone. It is likely to prove quite valuable for women with menorrhagia who need contraception, have a normal uterine size, and wish to avoid surgery.10
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the rate of dysmenorrhea, improve clotting, and reduce menstrual blood loss. Some studies have demonstrated a 50% to 80% reduction in blood loss with proper use.11 Patients are advised to begin therapy 1 to 2 days before their period is expected and continue throughout the menses. NSAIDs may be combined with OCs, if necessary.
The menstrual cycle: what is the norm?
Most menstrual cycles occur every 21 to 35 days. Normal menstrual flow lasts 3 to 7 days, with most blood lost within the first 3 days. The typical menstrual flow averages 35 mL and consists of effluent debris and blood. Women with normal menstrual cycles use an average of 5 to 6 pads or tampons each day. Social obligations, sexual activity, hobbies, work, and travel are not interrupted with normal menstrual function.
When menorrhagia is present, a woman may lose more than 80 mL of blood with each menstrual cycle. Since approximately 16 mg of iron is lost in normal cycles, women with menorrhagia often develop anemia. They also typically have an imbalance of prostaglandin levels and increased fibrinolytic activity.
It is important to note that more than 50% of women who complain of menorrhagia do not have heavy menses. Some patients change their sanitary products more often not because of heavy flow, but for reasons concerning hygiene, personal preference, or fear of toxic shock syndrome.—Linda D. Bradley, MD
FIGURE 5
When medical therapy fails
When the patient fails to improve after 3 months of medical therapy, additional evaluation such as endometrial biopsy is warranted. For hemodynamically stable patients with normal laboratory evaluation, imaging may be a valuable adjunct. In fact, imaging is increasingly used during the initial workup.12
Biopsy. The endometrium generally is sampled in an office setting using a Pipelle instrument. The biopsy can be performed quickly and generally is well-tolerated by the patient, with few complications. While it has a high sensitivity for detecting endometrial cancer and hyperplasia, it is not as effective in detecting intracavitary lesions, including polyps and submucosal fibroids. Lesions that encompass a small surface area are likely to be missed, as the instrument samples only 10% to 25% of the endometrial cavity. Patients with persistent symptoms despite a normal biopsy require further evaluation.
Transvaginal sonography (TVS). This imaging modality is extremely helpful in evaluating women with postmenopausal bleeding. TVS enhances the detection of uterine fibroids and aids in determining their size and position. Adnexal pathology also can be assessed. If the uterine size is greater than 12 to 14 gestational weeks, transabdominal scanning is preferred.
Measurement of the endometrial echo is helpful in determining whether endometrial biopsy or further imaging studies are necessary. Normally, the postmenopausal endometrial echo measures less than 5 mm. Greater thicknesses are associated with endometrial hyperplasia, polyps, fibroids, and cancer. When the endometrial echo exceeds 5 mm or is indistinct or indeterminate, an enhanced view using saline infusion sonography (SIS) or hysteroscopy is advised. When the endometrial echo is less than 5 mm, malignancy is present in fewer than 0.5% of cases.