Research

 Dysfunctional (heavy) menstrual bleeding

Contrel is is a research organization active in the field of women’s health care in the following area’s:

Dysfunctional menstrual bleeding is very common during the whole of women’s reproductive life.  The condition is more frequent in the climacteric (perimenopause): 25% of women aged 41-49 complain of too heavy bleeding and up to 17% of women aged 41-55 years are actually affected. 50% of the patients with this condition are over 45 years.

WHY IRREGULAR OR EXCESSIVE BLEEDING?
 Regular periods are the result of a precise hormone balance causing regular ovulation.  During the years preceeding the menopause, changes in hormone levels interfere with ovulation.  If ovulation does not occur, the ovary will continue making estrogen, causing the endometrium to keep thickening.  This often leads to a late and heavy menstrual period followed by irregular bleeding and spotting.  This can also result in endometrial polyps, a greater thickening called “hyperplasia,” or in extreme long-standing cases, cancer of the lining of the uterus.

It is not unusual to have irregular bleeding for up to 6 months before menstrual periods stop completely. Unless the bleeding is excessive, or a woman is at high risk for uterine cancer.  As a result, abnormal uterine bleeding is a common reason for consulting general practitioners.  It is estimated that approximately 10-15% of all gynecological patients receive treatment for repeated episodes of dysfunctional uterine bleeding.  The quality of life of women suffering from excessive bleeding is impaired in many respects.  Excessive bleeding or pain, or both, may impose severe constraints on their professional, social, and family activities.

TREATMENT  
 Hysterectomy
Until recently, medical treatment has been disappointing, and various surgical techniques in the form of endometrial ablation have been developed.  Excessive bleeding is a major reason for hysterectomy among fertile women. Approximately 30% of patients referred for gynecological treatment are for menorrhagia, often leading to surgical intervention if conservative treatment (e.g. contraceptive pills, progestogens, fibrinolytic inhibitors and prostaglandin inhibitors) fails. In the USA, 700,000 hysterectomies are performed each year of which 30% for excessive menstrual bleeding. In the UK 40% of the 100,000 hysterectomies are performed for that reason.

 

Intrauterine treatment : a  highly effective alternative to hysterectomy
LNG-releasing intrauterine systems (IUS) have been developed to provide a localised effect, suppressing the endometrium.  The localized effect of LNG is many times stronger than the effect which can be obtained by oral treatment.  Even when the uterus harbours fibroids, a LNG IUS is effective in the majority of patients.  Between 50 up to 70 or 80% of hysterectomies can be avoided.

 

Uterus containing fibroids. Uterine myoma (leiomyoma, fibroid) is a very common disease. Leiomyomas occur with an incidence of up to 77%.  They are often asymptomatic but some 25-50% of women will experience symptoms such as menorrhagia (heavy or excessive menstrual periods) and pelvic discomfort. Around 5% of the fibroids are intracavitary and submucosal and are most difficult to treat.  Hysterectomy is still the most commonly used procedure although medical treatments are preferable.  Uterine fibroids are responsible for 30% of hysterectomies.  Recently, new conservative treatment options have been developed such as the treatment with GnRH analogs and the levonorgestrel-releasing intrauterine system (LNG IUS) releasing small amounts of the hormone levonorgestrel per day for several years.  The system avoids surgery in many women.

 

 

RHormone Replacement/Substitution Therapy

Menopause is the time in a woman’s life when the ovaries cease to produce an egg cell every four weeks and therefore menstruation stops.   This can occur at any age between the middle thirties and the late fifties.  At the time of the menopause, there is a change in the balance of sex hormones in the body, primarily a reduced estrogen level.   This change often leads to hot flushes, palpitations, night sweats, dryness of the mucous membrane lining the vagina, bone loss leading to osteoporosis.  In addition, many women also develop emotional disturbances during the menopause. Prof. J. Studd of London, a highly recognized clinician, has conducted many studies in this field. Visit www.studd.co.uk.

Hormone replacement therapy (HRT) is administered to perimenopausal and postmenopausal women.  There are several reasons why HRT is important:

The leading drug is an estrogen replacement only drug (ERT).  ERT shows benefits not only in terms of relieving menopausal symptoms (hot flashes, mood swings, vaginal dryness), but also in the prevention of serious geriatric disorders :

Transdermal/transcutaneous or subdermal estrogen + intrauterine levonorgestrel 
HRT regimen, however, are not free from adverse effects, particularly orally administered combined (estrogen + progestogen) postmenopausal hormone replacement therapy.  With these preparations, there is a slightly increased risk of cardiovascular disease and breast cancer. Evidence suggests that one of the safest and best tolerated combination in postmenopausal women is to deliver progestogens directly to the uterine mucosa, instead of orally, combined with transdermal/transcutaneous or subdermal estrogen as this regimen could avoid reversal of the beneficial effect of systemic estrogen replacement therapy.

Progestogens are needed to suppress the endometrium and eliminate the risk of endometrial cancer. Local intrauterine therapy is the best and safest route of administration and prevents menstrual bleeding due to the local effect of the hormone.

Much debate is going on at present related to the benefits of HRT. Estrogen replacement therapy (ERT) is likely to be beneficial in preventing cardiovascular disease if initiated early in the postmenopause and if oral progestogens are avoided.  The transdermal and subdermal route of administering estrogens is probably safer than when estrogens are administered orally as the first pass liver effects are avoided. Estrogens prevent osteoporosis.  The evidence is also growing that estrogens are neuroprotective.

Also visit  www.menopausesociety.be
 

RPremenstrual Syndrome

According to experts in this field, premenstrual syndrome (PMS) can be defined as distressing physical, behavioural and psychological symptoms not due to organic disease which regularly recur during the same phase of each menstrual (ovarian) cycle and which disappear or significantly regress during the remainder of the cycle. It is the severity of symptoms and the resulting deterioration in interpersonal relationships and interference with normal activities which distinguishes PMS form the minor physical and emotional changes which often precede the onset of menstruation in normal women. Defined in this way, PMS affects between 5 and 10 % of women.

The underlying cause of PMS remains unknown, but cyclical ovarian function appears to play an essential role in the genesis of symptoms. The condition depends upon ovulation as PMS does not occur before puberty, during pregnancy or after the menopause. The underlying cause may be related to changes in the ovarial hormones or their metabolites from the time of ovulation which have an influence on neurological functions.

The symptoms include mood swings, irritability, anger, loss of energy, loss of libido, depression, and the physical symptoms of headaches, breast pain and abdominal bloating.

Various treatments have been tried but one of the most effective ways to treat severe PMS is to stop ovulation and remove the cyclical hormonal changes of this event.  For many women, suppression of the menstrual cycle will be neccesary. Hysterectomy with ovarectomy has often been done in the past. Progestogen therapy is widely prescribed as a first-line treatment but, the symptoms commonly return when the medication is stopped. Danazol is effective at high doses. However, both have often severe side effects and compliance is, therefore, poor. Gonadotrophin therapy is also effective but expensive and there is concern about the long term safety. It is known that oestradiol implant suppress the ovarian cycle but in non-hysterectomised patients, unopposed oestrogens are contraindicted due to the risk of endometrial malignancy.

In practice, women with severe PMS benefit enormously from the use of oestradiol implants, or moderately high dose transdermal oestradiol, combined with an intrauterine system releasing levonorgestrel. This treatment results in suppression of the menstruation. This intrauterine system is also an extremely effective form of contraception if required and can be continued for many years. A small dose of the male hormone, testosterone, can be added for energy and libido.

 also visit www.studd.co.uk