Dysfunctional uterine bleeding (D.U.B.) is an abnormal uterine bleeding in absence of organic cause ( pregnancy, inflammation or tumor). It is diagnosed by exclusion.
Medical treatment is the usual first line of treatment ; non steroidal anti inflammatory drugs such as mefenamic acid or antifibrinolytic agents such as tranexamic acid will reduce blood loss by 25-50%. The combined oral contraceptive pills may reduce blood loss by 50%. Cyclical progestins such decreases MBL by 80%.
Medications such as danazol or gonadotrophin releasing hormone analogues are highly effective in inhibiting menstrual blood loss but they cause amenorrhea in more than 50%. As they suppress ovarian function.
Progestogen releasing intra uterine system reduces menstrual blood loss by 90%. Levonorgestrel releasing intra uterine device developed recently for treatment of dysfunctional uterine bleeding without hysterectomy proved to be highly effective, it is used as an alternative to hysterectomy. It releases levonorgestrel which causes atrophy of endometrial glands and it may also inhibits ovulation.
If medical treatment fails, hysterectomy should be considered, though less invasive surgical methods of endometrial ablation are being developed and proved to be very effective in treatment of menorrhagia with success rate ranging from 70 – 97%.
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This study was done to evaluate the efficacy and safety of LNG-IUS , endometrial resection and thermal balloon ablation versus for treatment of dysfunctional menorrhagia.
This Prospective comparative study carried out at Benha univeristy hospital departement of Obstetrics and Gynecology for patient with dysfunctional menorrhagia at the age ranging (40- 49) years old and during the period from february 2014 to in July 2016.
Indications, contraindications, patient selection, counseling and preparation were reviewed.
The study included sixty patients presenting with menorrhagia. They were divided into two groups:
Group A: ( 20) patients underwent insertion of mirena
Group B: (20) patient uderwent endometrial resection .
Endometrial ablation was performed using the ‘Gynecare Thermachoice’ uterine balloon therapy system .
Group C: (20) patient underwent endometrial thermal balloon ablation.
Operative and postoperative complications and results of the procedure during a two year follow up period. with the following being performed:
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All studied groups underwent:
• Complete history taking.
• General, abdominal and local examinations.
• Laboratory investigations, vaginal ultrasonographic examination, and D&C in a prior setting to exclude any premalignant or malignant endometrial pathology.
All the results obtained were analyzed statistically, and the following results were obtained:
• In present study all patients age were between 40-49 years old .
• In present study all the patients were multipara except for two cases in LNG-IUD group and one case in TBA group and which was not enough to comment on the effect of TBA and LNG-IUD with different parities.
• In present study the mean value of body mass index in the LNG-IUD group (A) (27.30±1.87), resection group (B) (27.35±1.66) and TBA group (C) (26.65± 1.90)
.
• In present study the mean value of uterine cavity length in the group A was (8.06 ± 0.48 cm) while in group B was (8.38 ± 0 . 70 cm) and group C(8.90±0.75)
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• In present study the mean value of endometrial thickness in group A was (7.95± 0.92mm) , group B (9.48±0.68) and group C was (8.53 ± 0.62 mm).
• In present study the menstrual blood loss at 6, 12 and 24 months is dramatically decreased in all women after insertion of LNG-IUD, endometrial resection and using TBA & and spotting and decreased in the same proportion as amenorrhea increased after the two years of observation of resection.
Post treatment outcome for three groups regarding PBLAC showed significantly reduction in PBLAC in three groups compared with pretreatment scores but in resection group (from 128.6±2.04 to 75.1±3.06 ) lower than TBA group PBLAC scores (from127.55±1.76 to 88.05 ± 4.75) were lower than scores of LNG-IUD group (from 127.55±1.85 to 97.45± 5.52).
• Overall the endometrial resection is more effective than thermal balloon ablation and levonorgestrel releasing IUD in reduction of MBL.
• The marked reduction of MBL at the end of our study resulted in an improvement of blood haemoglobulin (Hb) level.
• At the beginning of our study the mean value of the Hb conc, while group B (10.02±0.36) to (11.65±0.20) increased in Hb after two years is more than group C as it increased from
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(9.94±0.34) to (11.59±0.15) gm/dl and more than group A as it increased from ( 9.77 ± 0.42 gm/dl ) to (11.4± 0.28) .
• So that the mean value of Hb level (gm/dl) at 6 month, 12 month and 24 months was significant increased in three groups but more in resection group.
• Post- treatment (24 months) bleeding pattern in three groups showed that the incidence of cases of amenorrhea was significant higher among endometrial resection 13 cases (59%) , TBA group 8 cases (36.3%) and LNG-IUD 1 case(4.5%).
• While the prevalence of menorrhagia was significant higher among LNG-IUD group in 4 cases (50%) and TBA 2 cases (25%) and resection 2 cases(25%). spotting was observed in our study at 24 months after insertion of LNG-IUD 3 cases (42.8%) , after application of TBA in 2 cases (28.5%) and resection 2 cases(28.5%)) .
In present study no serious side effect after use of LNG- IUD ,endometrial resection and TBA , only vaginal discharge and endometritis , the vaginal discharge on 3 cases (50 %) in LNG-IUD group and one case (16.6%) in resection group and 2 cases ( 33.33%) in TBA group ,while endometritis on 2 case ( 33.33%) in LNG-IUD 3(50%) in TBA group and resection 1 case (16.66%).
• In present study, we did not encounter any case of uterine perforation during IUD insertion or mechanical preparation of the endometrium by D&C or during the balloon ablation
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procedure or resection .We suggest that this complication can be avoided by evaluation of the patient by clinical and sonographic measures.
• Concerning the post treatment effectiveness at 24 months of both groups procedure showed significant number of successful patients and patients satisfaction in resection was more than TBA group more than LNG-IUD group.
• The total number of successful patients was 45 cases(75%) ,in resection group 16 cases(35.55%), in TBA group 15 cases (33.33%) and LNG-IUD group 14 cases (31.11%) , and while total number of patients with satisfaction was 39 cases (65%) ,in resection 14(35.98%) ,TBA group 13 cases (33.33%) while in LNG-IUD group 12 cases (30.7%).
• Effectiveness of the procedure means the success in elimination of bleeding (amenorrhea) or reduction to light (hypomenorrhea) or normal flow (eumenorrhea).
• In present study as regard further surgery in three group include, D&C total number was 8 cases (8.3%) , 1 case (20%) in endometrial resection , 2 cases ( 40)% in TBA group while 2 cases as 40% in LNG-IUD group.
• The total number of women subsequently underwent a hysterectomy was 9 cases (15%), higher in LNG-IUD group were 44.44% (4/9) for LNG-IUD,33.33% (2/9) for TBA and resection 1 case (11.1%) at 24 months |
