Question: A woman in her early 40s is suffering from menorrhagia and dysmenorrhoea. She also has renal failure and is on dialysis waiting for a renal transplant. She is also on warfarin for a previous arterial thrombosis, cause unknown. Is there any guidance from the literature on the management of menstrual problems in these complicated cases?
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Answer: Some rather old articles were identified - two about improvement in menstrual problems in women on dialysis with IUDs (Fedele, Newton), a description of various treatments for hypermennorhoea in a series of 11 young hemodialysis patients (Rice) and a case report of a woman on dialysis, taking warfarin and with menorrhagia (Ogg).
One small study suggests LNG-IUS is effective in reducing the duration and amount of menstrual bleeding in women with menorrhagia associated with oral anticoagulation (Pisoni) and cases have been reported of adverse interactions between warfarin and danazol in women with menorrhagia. (Small and Tapper)
(Evidence level III)
References:
- Fedele L. Gammaro L. Bianchi S. Levonorgestrel-releasing intrauterine device for the treatment of menometrorrhagia in a woman on hemodialysis. New England Journal of Medicine. 341(7):541, 1999 Aug 12. Full text
- Newton J. Snowden SA. Parsons V. Letter: Control of menstrual bleeding during haemodialysis. British Medical Journal. 1(6016):1016-7, 1976 Apr 24. Full text
- Ogg CS and Cattell W. Clinicopathological conference. A patient's life. British medical journal. 3 (5977) (pp 209-213), 1975. Date of Publication: 26 Jul 1975. Full text
- Pisoni CN. Cuadrado MJ. Khamashta MA. Hunt BJ. Treatment of menorrhagia associated with oral anticoagulation: efficacy and safety of the levonorgestrel releasing intrauterine device (Mirena coil). Lupus. 15(12):877-80, 2006. Abstract
- Rice GG. Hypermenorrhea in the young hemodialysis patient. American Journal of Obstetrics & Gynecology. 116(4):539-43, 1973 Jun 15. Comment in Obstetric and Gynecological Survey. 1974 29(3):217-8. Full text available to RCOG Fellows, Members and Trainees here
- Small M. Peterkin M. Lowe GD. McCune G. Thomson JA. Danazol and oral anticoagulants. Scottish Medical Journal. 27(4):331-2, 1982 Oct. Abstract
- Tapper A.-M., Heinonen P.K. An interaction between danazol and warfarin in women with menorrhagia treated for thinning the endometrium prior to resection. Gynaecological Endoscopy. 5 (1) (pp 29-31), 1996. Abstract
Search date: November 2010
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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