What suggestions do you have for treating menorrhagia in a 28-year-old nulliparous patient? She is on oral contraceptives (OCs) and has a history of deep venous thrombosis (DVT). Dilation and curettage has been moderately effective. Do you recommend norethindrone (Aygestin), etonogestrel (Implanon), or a levonorgestrel-releasing intrauterine system (Mirena)?—NORAH NUTTER, MSN, WHNP, Myrtle Beach, S.C.
A patient with a personal history of DVT is not a good candidate for combined OCs or other estrogen-containing products. While dilation and curettage may provide some acute relief of heavy or prolonged vaginal bleeding, this is not an effective long-term intervention and may not prevent recurrent episodes. Once possible underlying causes of the menorrhagia (e.g., thyroid dysfunction, uterine fibroids, bleeding disorders) have been ruled out or corrected, ongoing treatment with any of the progestin options described above would be appropriate. Injectable medroxyprogesterone (Provera) is another option to consider. Nonsteroidal anti-inflammatory drugs are a nonhormonal alternative that may be effective alone or in conjunction with hormonal interventions. Depending on your patient’s future childbearing desires, endometrial ablation could also be considered. For more information, see “Assessing excessive menstrual bleeding” in the January 2009 issue of The Clinical Advisor. – Lisa Stern, APRN (134-8)