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Levonorgestrel intrauterine system for menorrhagia

  1. Top of page
  2. Levonorgestrel intrauterine system for menorrhagia
  3. Pain relief after caesarean section
  4. Maintenance tocolysis
  5. Flu vaccination and fetal death
  6. Women who smoke like men—die like men

Heavy menstrual bleeding accounts for one in five referrals to a gynaecologist in developed countries. Looked at another way, about a third of women will be troubled by the condition sometime during their reproductive lives. The modes of management are wide-ranging from cyclical medical treatment to chronic medication and from minimally invasive procedures to radical surgery.

Matching the most appropriate treatment to the woman depends on symptoms, pathology, age, parity, lifestyle and costs. It is not merely a matter of ‘volume loss reduction’. Empirical data on which to base the most suitable therapy are difficult to find so it is refreshing to come across a pragmatic trial reported from the UK (Gupta et al. N Engl J Med 2013;368:128–37).

Over 500 women were recruited by their primary-care doctors because of excessive bleeding. Women with genital tract pathology were excluded. All participants scored the burden of their affliction according to five domains of daily life, being practical difficulties, social life, daily routine, family life and relationships. In addition they assessed their own quality of life and sexual activity scores at 6 months, 1 year and 2 years.

At randomisation they were allocated to receive medical management or be fitted with a levonorgestrel-releasing intrauterine system (LNR IUS Mirena®). The medical treatment consisted of mefenamic acid (nonsteroidal anti-inflammatory), tranexamic acid (antifibrinolytic), combined oral contraceptives, high-dose progestins or depot medroxyprogesterone acetate by injection.

Although the medical treatment—most commonly tranexamic acid or mefenamic acid—was effective, the LNR IUS gave overall better outcomes according to the six domains being measured at each time interval. These were clinically and statistically significant. The quality of life and sex life questionnaires were also improved significantly in favour of the LNR IUS, resulting in two-thirds of the medical treatment group stopping their medication at 2 years compared with one-third having their LNR IUS removed.

The authors and an editorial (Espey N Engl J Med 2013;368:184–5) conclude that an LNR IUS is superior to the usual medical treatment for the management of menorrhagia in the primary-care setting. Perhaps these findings will finally sway opinion towards the LNR IUS, which is initially expensive but ultimately cost-effective, and make it the first-line therapy for menorrhagia.

A recognised side effect of the LNR IUS is the development of alopecia areata. A case report in the RANZCOG O&G Magazine (Sexton. Summer 2012:53–5) reminds clinicians that bald patches of the scalp can occur within months of its insertion but the condition is reversible on removal of the device—again within months. The incidence is estimated to be 0.1% to 1% so this unintended consequence should be mentioned when counselling about LNR IUS use.

Pain relief after caesarean section

  1. Top of page
  2. Levonorgestrel intrauterine system for menorrhagia
  3. Pain relief after caesarean section
  4. Maintenance tocolysis
  5. Flu vaccination and fetal death
  6. Women who smoke like men—die like men

Pain relief after a caesarean section is important for mothers and babies. The maternal time to mobility has an effect on her emotional wellbeing and on the likelihood of venous thromboembolism while the initiation of infant care, especially breastfeeding, depends on her ability to move without pain.

Usually the duration of analgesia from spinal anaesthesia of 5% lidocaine is from 1 to 1½ hours, whereafter nonsteroidal anti-inflammatory suppositories are given—diclofenac sodium 100 mg rectally immediately after the operation then 8-hourly for 24 hours. Most units include rescue opioids for breakthrough pain as required. However, the use of additional local anaesthetic agents to the incision site before closing the skin incision is not thoroughly researched.

A team from Iran (Navali et al. SAJOG 2013;19:8–12) compare the injection of 20 ml of 1% lidocaine radially into the wound just before closing the skin with placebo. Either 2.5 ml of 1% lidocaine plus 1 : 100 000 adrenaline or saline was administered to eight sites around the wound. All incisions were transverse and the local or placebo was injected into the subcutaneous fat or into the rectus abdominis muscle wound edges, or a combination of subcutaneous and intramuscular infiltration was used.

Patients receiving the active intervention had lower pain scores than those who were given placebo at all times when these were measured up to 24 hours postoperatively. The differences were statistically and clinically significant both at rest and on ambulation but the time to initiating breastfeeding was not different. There were no side effects noted in the 200 women in the trial so should this inexpensive method of pain relief not be more widely used and reported on in obstetric practice?

Maintenance tocolysis

  1. Top of page
  2. Levonorgestrel intrauterine system for menorrhagia
  3. Pain relief after caesarean section
  4. Maintenance tocolysis
  5. Flu vaccination and fetal death
  6. Women who smoke like men—die like men

When a woman presents in preterm labour, there has to be a clinical decision whether to intervene. Such a decision depends on maternal and fetal wellbeing, the gestational age and the cause of the onset of the labour—if identified. Obstetric opinion is divided as to the fundamental practice of tocolysis with the RCOG Guidelines 2011 stating ‘There is no clear evidence that tocolytic drugs improve outcome and therefore it is reasonable not to use them. However, tocolysis should be considered if the few days gained could be put to good use, such as completing a course of corticosteroids or in utero transfer.’

If the decision is made to inhibit uterine activity, and this is achieved for a day or two, then ongoing or maintenance medication is the next clinical question to be answered. Does ongoing treatment buy more time, is such time meaningful and could the treatment itself be harmful? These are grey areas for women, partners and care-givers so a study from the Netherlands gives welcome information (Roos et al. JAMA 2013;309:41–7).

All the perinatal units in the country collaborated in the trial and women in threatened preterm labour at less than 32 weeks of gestation were considered for ongoing tocolysis with nifedipine after initial inhibition of their uterine contractions, the administration of steroids and a delay of 48 hours. There were over 400 pregnancies divided to receive nifedipine 80 mg/day in divided doses or placebo for 12 days. The mean gestational age at trial entry was 29 weeks and it was 32 weeks at delivery for both groups with no significant difference in outcomes in terms of mortality, morbidity, neonatal intensive care admissions or in either the short-term or 1-year follow-up. Those women delivering while on maintenance therapy had a greater postpartum blood loss than those delivering while on placebo so there was some risk attributable to ongoing treatment.

This study confirms the lack of benefit achieved by maintenance tocolysis described by Cochrane reviews of β-mimetics, oxytocin antagonists and magnesium sulphate. Drugs with potential harm and no proven benefit should not be administered at any time.

Flu vaccination and fetal death

  1. Top of page
  2. Levonorgestrel intrauterine system for menorrhagia
  3. Pain relief after caesarean section
  4. Maintenance tocolysis
  5. Flu vaccination and fetal death
  6. Women who smoke like men—die like men

The 2009 H1N1 influenza epidemic is still being analysed as far as pregnancy is concerned. There is no doubt that influenza poses a greater threat to pregnant women compared with nonpregnant women and it is accepted they should be considered a high-risk group and be given priority for vaccination. This lowers maternal morbidity and mortality rates.

The vaccine does not appear to be teratogenic and should be administered at any stage of pregnancy. However, in Norway questions were raised about fetal deaths related to vaccination so a retrospective study was carried out comparing stillbirth rates of pregnancies where the mother was vaccinated or not (Haberg et al. N Engl J Med 2013;368:333–40). Looking at over 100 000 deliveries in 2009 and 2010 they found an overall fetal mortality rate of 5 per 1000 but if the woman had a clinical diagnosis of influenza this doubled the rate so there is no doubt that the fetus can be protected by the mother's vaccination.

Other data showed that vaccinated women had lower stillbirth rates than nonvaccinated women although the difference was nonsignificant. Overall, with fewer mothers contracting influenza after vaccination plus lower stillbirth rates the weight of evidence strongly favours vaccination against influenza in pregnant women.

Women who smoke like men—die like men

  1. Top of page
  2. Levonorgestrel intrauterine system for menorrhagia
  3. Pain relief after caesarean section
  4. Maintenance tocolysis
  5. Flu vaccination and fetal death
  6. Women who smoke like men—die like men

Women have really only started smoking like men since the 1960s. Because smoking takes quite a long time to kill someone, it is now becoming apparent that the devastating effects of smoking on men's mortality are equally applicable to women.

Data from the USA show that women develop lung cancer, chronic obstructive pulmonary disease, ischaemic heart disease and strokes at rates identical to men (Thun et al. N Engl J Med 2013;368:351–64). These conditions can be lethal and a quarter of middle-aged Americans die from smoking, making it the most important health hazard in that or any other country (Schroeder N Engl J Med 2013;368:389–90). In fact, women have a poorer prognosis than men for lung cancer and many more die from it than from breast cancer. Smoking also increases the rates of all solid organ cancers plus breast and cervical cancers so women bear an extra burden of smoking-related disease.

The figures are echoed by a study of one million women in the UK (Pirie et al. Lancet 2013;387:133–41) who were recruited at the end of the last century and followed up till 2011. Mortality was tripled in those who were smokers at entry to the trial compared with never-smokers. Of the smokers who died, two-thirds succumbed to smoking-related causes.

There is now statistically sound evidence concerning smoking cessation showing that quitting is beneficial at any age (Jha et al. N Engl J Med 2013;368:341–50). Those stopping smoking from their mid-20s to mid-30s gain 10 years of life, from mid-30s to mid-40s gain 9 years of life and from mid-40s to mid-50s gain 6 years of life. Even people diagnosed with lung cancer have a better prognosis if they quit.

Persuading a woman to stop smoking will do her more good than any screening or laboratory test ordered. The following facts may strengthen a woman's resolve to quit:

  • smoking shortens your life expectancy by 10 years
  • more women die of lung cancer than breast cancer
  • smoking increases your chances of breast, cervical and almost all other cancers
  • smoking increases your chances of lung disease, heart disease and stroke, which kill more women than any other causes
  • the sooner you quit the greater the benefit.