Medical tx for heavy menstrual bleeding

Question 1

Order of tx for heavy menstrual bleeding

Answer 1

• Levonorgestrel-releasing intrauterine system (LNG-IUS) provided long-term (at least 12 months) use is anticipated
• Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives (COCs)
• Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens
• Use of NSAIDs and/or tranexamic acid should be stopped if it does not improve symptoms within 3 menstrual cycles.

Question 2

Endometrial ablation indications

Answer 2

• Normal uterus and also those with small uterine fibroids (less than 3 cm in diameter)
• HMB alone, with uterus no bigger than a 10-week pregnancy

Question 3

Oophorectomy at the time of hysterectomy

Answer 3

• Removal of healthy ovaries at the time of hysterectomy should not be undertaken
• Removal of ovaries should only be undertaken with the express wish and consent of the woman.
• Women with a significant family history of breast or ovarian cancer should be referred for genetic counselling prior to a decision about oophorectomy
• In women under 45 considering hysterectomy for HMB with other symptoms that may be related to ovarian dysfunction (for example, premenstrual syndrome), a trial of pharmaceutical ovarian suppression for at least 3 months should be used as a guide to the need for oophorectomy.
• If removal of ovaries is being considered, the impact of this on the woman’s wellbeing and, for example, the possible need for hormone replacement therapy (HRT) should be discussed.
• Women considering bilateral oophorectomy should be informed about the impact of this treatment on the risk of ovarian and breast cancer.