PHARMACOLOGICAL TREATMENT OPTIONS OF HEAVY MENSTRUAL BLEEDING

Edited by, JASPER VICTORIA

Though women and the clinicians find it hard to quantify the absolute volume of loss of blood, Blood loss is considered heavy if it crosses 80 mL per period.

Heavy menstrual bleeding may arise due to dysfunctional uterine bleeding occurring as a result of uterine or ovarian tumours, endometriosis, IUCDs, pelvic inflammatory diseases; or due to endocrine and haematological causes such as thyroid disorders, platelet problems or clotting abnormalities.

Irregular bleeding, sudden change in blood loss, intermenstrual bleeding, dyspareunia (painful sexual intercourse), pelvic and premenstrual pain may all suggest a heavy bleeding underlying a pelvic pathology.

The following are the drug options which may be exploited for use in the pharmacological treatment of heavy menstrual bleeding:

COMBINED ORAL CONTRACEPTIVES

Combined oral contraceptives can be taken for 21 days followed by a seven day pill free period.

PROGESTOGEN-ONLY PREPARATIONS

Norethisterone and similar compounds can be used as in 5mg t.i.d. or 10mg b.i.d. daily for the next half of the cycle. The therapy should go on for 10 days if in ovulatory phase and 12 days if in anovulatory phase and to prevent the risk of endometrial hyperplasia in women taking oestrogen.

INTRAUTERINE PROGESTOGEN-ONLY CONTRACEPTIVES

20 micrograms of levonorgestrel is released for every 24 hours from the levonorgestrel-releasing intrauterine device.

This device appears to reduce the menstrual blood loss by exerting the local actions of progestogen. The side- effects associated with the device is also potentially reduced.

DANAZOL

Danazol should be taken daily. It is known to suppress the pituitary ovarian stimulation. It is associated with the adverse effects such as hot flushes, amenorrhoea, sweating, vaginitis, changes in libido and emotions and androgenic effects such as hirsutism, acne, oily hair and skin, weight gain, oedema, deepening of voice and reduction in breast size.

GNRH ANALOGUES

GNRH analogues such as Gonadorelin, also suppress the pituitary ovarian stimulation and hence they must be used only for six months as they may excessively drive low the oestrogens resulting in various complications associated with the hypo-oestrogenic state.

NSAIDs

They inhibit the cyclo-oxygenase and reduce the production of prostaglandins, which results in decreased conversion of prostacyclins to thromboxane. They are only meant to be taken for 3-4 days of the period.

TRANEXAMIC ACID

It is an antifibrinolytic agent, which works by blocking the formation of blood clots and hence prevent bleeding. They can be taken on the first 3 days. They are well tolerated, but can produce G.I. disturbances and may cause thrombosis with antifibrinolytic therapy.