Clinical practice guidelines on menorrhagia
 

Eur J Obstet Gynecol Reprod Biol. 2010 Aug 3.

Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.
Marret H, Fauconnier A, Chabbert-Buffet N, Cravello L, Golfier F, Gondry J, Agostini A, Bazot M, Brailly-Tabard S, Brun JL, De Raucourt E, Gervaise A, Gompel A, Graesslin O, Huchon C, Lucot JP, Plu-Bureau G, Roman H, Fernandez H; On behalf of the CNGOF.

Abstract
BACKGROUND: Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. INVESTIGATION: A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. TREATMENT: In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.

У нас инструкции требуют в первую очередь делать кюретаж "D&C" с гистологическим исследованием. Может лет через 10 и мы изменим тактику...

ну это только в менопаузе выскабливание сразу.А в репродуктивном возрасте-естроген и ибупрофен очень даже ничего идут.Только со спиральюю перебор-кто заплатит за гормональную спираль 200 долларов(у нас стоимость),.если противозачаточные стоят доллар,для их приема не надо мед вмешательства

Все же в этом гайде рекомендуют гистероскопию, как процедуру первого этапа диагностики. Наверняка берут пайпель биопсию при гистероскопии, ведь глазами не увидишь структуру эндометрия и при гистероскопии нельзя оценить идиопатически женщина кровит или все же проблемы есть. А за спираль платят те, кто не хочет пить таблетки. К тому-же 200 дол из расчета на 4 года - не так уж и много. Таблетки стоят дороже.

зачем ставить спираль и при этом кровотечение может и не остановится(например фиброид),все-таки лучше сначало гистероскопию,УЗИ,кровь на гормоны,а потом уже выскабливание и если у нее подтвердится abnormal uterine bleeding,то можно и спираль

Спираль без обследования не ставят и нужна она не для того, чтобы остановить кровотечение, а для того, чтобы предотвратить дальнейшие кровопотери.

Гистероскопия -это второй этап диагностики, не первый. Зачем для обнаружения миомы - гистероскопия? И , если есть сомнения, пробуете КОК, помогают, предлаете спираль. Не хотят гормоны - циклокарпон (tranexamic acid ), тоже действенно весьма, только недавно новые исследования , подтверждающие эффекивность , вышли.
Конечно, если женщина в группе риска на злокачественный процесс по возрасту или другим причинам - тогда да, гистероскопия-биопсия, а у молодой женщины - надо идти наименее инвазивным путем, где возможно.
Гайды не спроста создаются:-))

еще один свежий обзор, показывающий эффективность и безопасность транексамовой кислоты как средства выбора по снижения обьема теряемой крови при обильных месячных, как связанных с нарушениями гемостаза, так и не связанных с ними:

Thromb Res. 2011 Feb;127 Suppl 3:S113-5.
Antifibrinolytics in women with menorrhagia.
Philipp CS.
UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903, USA.
Heavy menstrual bleeding is associated with increased local fibrinolysis. Antifibrinolytic agents have been used in women with menorrhagia with and without bleeding disorders, and have been demonstrated to decrease menstrual blood flow approximately 50% and improve quality of life. Most studies have been done with the antifibrinolytic agent tranexamic acid, a synthetic lysine derivative. Studies have been performed comparing tranexamic acid with placebo, non-steroidal anti-inflammatory agents, and progesterone in women with menorrhagia and have predominantly demonstrated a greater reduction in menstrual blood flow with tranexamic acid. In women with menorrhagia and an underlying bleeding disorder, tranexamic acid was compared to intranasal desmopressin and also demonstrated a greater reduction in menstrual blood flow. In aggregate the studies demonstrate that antifibrinolytic agents are effective medical management for women with menorrhagia with or without bleeding disorders, reducing menstrual blood flow and improving quality of life.

tranexamic acid in the treatment of heavy menstrual bleeding
 

Acta Obstet Gynecol Scand. 2012 Jan 10. doi: 10.1111/j.1600-0412.2012.01361.x.
Efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding: A systematic review.
Naoulou B, Tsai MC.
Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA.

Objective. To evaluate the efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding.

Design. Systematic review. Population: Women with diagnosis of idiopathic and non-functional heavy menstrual bleeding treated with tranexamic acid.

Method. Electronic searches were conducted in literature database up to February 2011 by 2 independent reviewers. We included all trials involving efficacy of tranexamic acid for the treatment of heavy uterine bleeding. Pregnant, postmenopausal and cancer patients were excluded.

Main outcome measures. Effect of tranexamic acid treatment on objective reduction of menstrual bleeding and improvement of patient quality of life.

Results. A total of 10 studies met our inclusion criteria. Available evidence, indicates that tranexamic acid therapy in idiopathic menorrhagia women resulted in 34-54% reduction in menstrual blood loss compared to. Following tranexamic acid treatment patient's life quality parameters improved by 46-83% compared to 15-45% with norethisterone. When compared to placebo, tranexamic acid use significantly decreased the blood loss by 70% in women with menorrhagia secondary to intrauterine device (P<0.001). Limited evidence indicated potential benefit in fibroid patients with menorrhagia. No thromboembolic event was reported in all studies analyzed.

Conclusion. Available evidence indicated that tranexamic acid treatment is effective and safe, and could potentially improve quality of life of patients presenting with idiopathic and non-functional heavy menstrual bleeding. Data on the therapeutic efficacy of tranexamic acid in patients with symptomatic fibroids is limited and further studies are therefore needed.

J Womens Health (Larchmt). 2012 Mar 19.
Tranexamic Acid Increases Hemoglobin and Ferritin Levels in Women with Heavy Menstrual Bleeding.
Muse K, Mabey RG, Waldbaum A, Gersten JK, Adomako TL.
University of Kentucky , Lexington, Kentucky.

Background: Heavy menstrual bleeding (HMB) is the most common cause of iron deficiency anemia (IDA) in women. A novel, modified-release oral formulation of tranexamic acid (TA) designed to reduce gastrointestinal side effects was approved recently for treatment of HMB. We assessed improvements in objective laboratory measures of IDA in women with self-reported HMB who received long-term TA therapy.

Methods: Women enrolled in a long-term, open-label, multicenter study self-medicated with TA 3.9 g/day administered as 1.3 g orally up to three times daily for 5 days/menstrual cycle for 27 cycles. Oral iron therapy was required if serum hemoglobin (Hgb) levels decreased to <11 g/dL.

Results: A total of 723 women (mean age 38.3 years) were included in the intent-to-treat (ITT) population. Significant increases in mean serum Hgb and ferritin were observed throughout the study (p<0.01). Among 191 patients with low Hgb (<12 g/dL) at baseline, mean serum Hgb increased by ≥0.71 g/dL after the third cycle and all subsequent assessments (p<0.001). After 3 and 27 cycles, 34.1% and 45.7%, respectively, of patients with low Hgb at baseline shifted to within normal range, respectively. Among 233 patients with low ferritin (<10 ng/mL) at baseline, mean serum ferritin increased by >5.38 ng/mL after cycles 15 and 27. After 6 and 27 cycles, 35.2% and 58% of patients, respectively, with low ferritin levels at baseline shifted to within normal range.

Conclusions: Long-term self-medication with this novel TA formulation improved Hgb and ferritin levels in women with self-reported HMB.

Int J Womens Health. 2012;4:413-21.
Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety.

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Основываясь на результатах двух проведенных в США клин. исследованиях по транексамовой кислоте при обильных месячных, авторы показали, что она эффективна и при фибромиоме:

Womens Health (Lond Engl). 2013 Jul;9(4):397-403.
Efficacy and safety of oral tranexamic acid in women with heavy menstrual bleeding and fibroids.
Eder S, Baker J, Gersten J, Mabey RG, Adomako TL.
Aim: To evaluate the efficacy and safety of oral, modified-release tranexamic acid in women with heavy menstrual bleeding and fibroids. Materials & methods: This was a pooled analysis of two pivotal Phase III studies. Fibroids were evaluated by transvaginal ultrasonography. Menstrual blood loss (MBL) was measured via a validated alkaline hematin method. Results: In women with and without fibroids, mean MBL was reduced compared with placebo across all treatment cycles (p < 0.001). Within the tranexamic acid group, more statistically significant (p < 0.001) reductions in MBL compared with placebo occurred in women with fibroids than in those without fibroids. Adverse events were similar between treatment groups. Conclusion: Tranexamic acid was well tolerated and reduced MBL in women with and without fibroids.

Новая классификация маточных кровотечений FIGO 2011
 

Munro M.G., Crichley H.O., Broder M.S., Fraser I.S. FIGO Working Group on Menstrual Disoders, FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age / Int.Gynecol.Obstet. 2011; 113; 3–13.

В 2011 году FIGO предложило отказаться от использования старой терминологии в отношении маточных кровотечений (метрорагия или менорагия) и предложило использовать новую классификацию аномальных маточных кровотечeний, основанную на этиологии кровотечения

Классификационная система FIGO (PALM-COEIN) выделяет две большие группы причин аномальных маточных кровотечений у небеременных женщин репродуктивного возраста и расшифровывает их по первым буквам.
PALM: Polyp (полип); Adenomyosis (аденомиоз); Leiomyoma (лейомиома); Malignancy (малигнизация) и Hyperplasia (гиперплазия) – группа маточных кровотечений, главной причиной которых являются структурные изменения матки,

и COEIN: Coagulopathy (коагулопатия); Ovulatory dysfunction (овуляторная дисфункция); Endometrial (эндометриальная); Iatrogenic (ятрогенная); и Not yet classified (еще не классифицировано) – иные причины маточных кровотечений, не связанные со структурными изменениями.

Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women
Am Fam Physician. 2012 Jan 1;85(1):35-43.
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Спираль с левоноргестрелом или другое лечение, применяемое для уменьшения обильности ментр. кровопотерь у женшин, показали примерно одинаковую эффективность/безопасность спустя 5 лет наблюдения:

Br J Gen Pract. 2016 Dec;66(653):e861-e870.
Usual medical treatments or levonorgestrel-IUS for women with heavy menstrual bleeding: long-term randomised pragmatic trial in primary care.
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