- Mirena
- A progesterone-impregnated Intrauterine Device (IUD).
- Typically placed for contraceptive purposes, it is a small T-shaped device placed into the uterus during a speculum exam.
- The mechanism of action is unknown but likely is via inhibition of fertilization.
- Highly effective with a 1-year pregnancy rate of 0.1 to 0.2. Completely reversible.
- Effective for 5 years.
- Patients experience a 40-50 percent reduction in bleeding and dysmenorrhea compared to preinsertion levels.
- Has proven quite useful for treating heavy periods though, specific menorrhagia indication not given by FDA.
- The most common reason given for discontinuation is lack of menstrual bleeding.
- During the first 3 months, irregular bleeding and spotting is common. It decreases profoundly with time. After 5 years of use, 26 percent of users are amenorrheic.
- Risks of Mirena are the same as any IUD. There is a risk of uterine perforation at insertion. There is a risk of infection after insertion especially if the patient is exposed to sexually transmitted infections. There is a risk of cramping and spotting after insertion.
- Source: Dean G, Goldberg A. Intrauterine Device I. UpToDate. Boston. Version 13.2.
- Miscarriage
- Term used to describe a nonviable pregnancy. Medically, all miscarriages are called abortions.
- Very common occurrence in reproductive medicine. Miscarriage affects 15-30 percent of clinically-recognized pregnancies.
- Typically, the miscarriage presents in the first trimester with bleeding. Anytime there is bleeding, it is called a threatened abortion. Fifty percent of threatened abortions will end in miscarriage. Bleeding during the first trimester can be from a variety of causes. Some common sources include trauma from intercourse and vaginal or cervical inflammation. Sometimes, there will even be some bleeding from the placental implantation site.
- Ectopic or tubal pregnancy can be a life-threatening condition and must be differentiated from threatened miscarriage. Ectopic pregnancy will commonly present with significant pelvic discomfort as well as vaginal bleeding.
- The evaluation for threatened abortion involves an exam and labs such as the HCG or pregnancy hormone level and possibly an ultrasound.
- If the pregnancy has advanced to 5 weeks, a small gestational sac should be visible in the uterus on ultrasound. Commonly, early in the sixth week, an embryo can be identified. If that embryo has a heartbeat, that is a very reassuring sign, and we can usually counsel the patient that we anticipate a routine course.
- If the pregnancy has not progressed to the point where it is visible on ultrasound, we typically have to follow serial blood levels and ultrasounds. This can be a frustrating time because the question of viability is not immediately answered, and the bleeding may be ongoing or progressive.
- Myomectomy
- Procedure to remove the fibroid tumors from a uterus. It is usually done through an abdominal incision. May potentially be done through a laparoscope.
- Ideal to treat symptomatic fibroids in a patient who desires preservation of fertility.
- Typically requires cesarean delivery for subsequent pregnancies.
- Considerable risks of postoperative bleeding with this procedure.
- Seven percent risk or requiring reoperation.
- Eighty percent cure rate for menorrhagia.
- Source: Thompson JD, Rock JA. Leiomyomata Uteri and Myomectomy. Telinde’s Operative Gynecology. 8th ed Lippincott-Raven. 1997. pp554-564.
