Hormonelle Behandlungsoptionen

 

The hormonal agents that can be used for treating dub include 

  • Combined oral contraceptive pills 
  • Progestins 
  • GnRH- analogues 
  • Danazol 
  • Others


COMBINATION ORAL CONTRACEPTIVES

Oral contraceptives (OCs), commonly known collectively as "the Pill," contain combinations of an estrogen and a progestin (either a natural progesterone or the synthetic form called progestogen). 

These agents block production of male hormones and inhibit receptors for estrogen in the uterus. 

OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). 

They also protect against ovarian and endometrial cancers . 

It is not clear, however, if they are any more effective than NSAIDs in reducing heaving bleeding, but they may still be a good option for women seeking both birth control and relief from menorrhagia. 

Combination pills are sold in 21-day or 28-day packs: 

  • Each pill in the 21-day pack contains the necessary estrogen and progestin. 
  • The 28-day pack adds seven differently colored "reminder" pills; they are inactive and do not contain hormones, but help the user maintain her daily routine during seven days between active pill use.


OCs may be taken in cycles that include pills of the same or different strengths. 

These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). 

  • Monophasic regimen 

    A 21-day pack uses tablets that are one strength and one colour for 21 days. (A 28-day pack adds seven inactive tablets of a different colour.) 

  • Biphasic regimen

    A 21-day pack consists of tablets of one strength and colour taken for seven or 10 days, then a second tablet with a different strength and colour for the next 11 or 14 days. 

  • Triphasic regimen

    This pack consists of tablets with three different colors and strengths. In the first phase, there are tablets of one color for five to seven days; for phase two, a second color and strength tablets is taken for five to seven days; and for phase three, a third color and strength tablet is taken for five to 10 days.


The difference in duration of each phase depends on the brand. 

In all cases, women continue to menstruate, but their periods are lighter, shorter, more regular, and less painful than bleeding in women who are not on the pill. 

The monophasic regimen is the most studied regimen and at this time is preferred. 

Estrogen and progestin each cause different side effects 

Uncommon but more dangerous complications of OCs include high blood pressure and deep-vein blood clots (thrombosis), which may contribute to heart attacks or strokes. 

It should be noted that a long-term study of 46,000 British women found no difference in mortality rates between women who took OCs and those who did not. 

The most serious side effects are due to the estrogen in the combined pill. Women at risk can usually take progestin-only contraceptives. 

Other Forms of Combination Contraceptives. 

Other methods for delivering contraceptives include skin patches, monthly injections, and vaginal rings. It is not clear, however, if they have any advantages for women with heavy bleeding. 

PROGESTINS

  • Progestins (either natural progesterone or synthetic progestogen) are used by women who clearly have dysfunctional uterine bleeding caused by unopposed production of estrogen.
  • A number of forms are available and have specific advantages and disadvantages. 
  • In addition to reducing bleeding, another important advantage is that they appear to protect against uterine and ovarian cancers. 
  • It should be noted that some progestin treatments, such as implants, can cause menorrhagia in the first few months. 
  • Progestins can be delivered in various forms.


Progestin-Releasing IUDs

  • Intrauterine devices (IUDs) that release progestin may be very beneficial for menstrual disorders. 
  • Specifically, the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena, FibroPlant) is proving to have important effects on menstrual disorders, regardless of its contraceptive effects. 
  • The LNG-IUS is now considered to be one of the best options for treating menorrhagia. 
  • It also reduces pain and may help prevent endometriosis. 
  • Progestin released by an IUD mainly affects the uterus and cervix and so it causes fewer widespread side effects than the progestin pills do. 
  • It should be noted that the other major IUD–the Copper T–may increase bleeding. 
  • Irregular break-through bleeding can occur for the first six months, but afterward 80% to 90% reduction in blood loss has been reported. 
  • It is well tolerated. It may even be appropriate and protective for women with uterine fibroids, but studies to date suggest it is less effective in reducing menstrual bleeding from fibroids than from other causes.


Oral Progestins.

  • Oral progestins include medroxyprogesterone, norethindrone acetate, and norgestrel 
  • Taking such agents for 21 days is effective in reducing bleeding. 
  • Oral progestins, however, have unpleasant psychological and physical side effects such as bloating, depression, moodiness, and breakthrough bleeding. 
  • Natural progestins (called progesterone) may be helpful. 
  • A natural oral form of finely ground (micronized) progesterone is also available and has fewer side effects.


Injections (e.g., Depo-Provera).

  • Depo-Provera uses a progestin called medroxyprogesterone.
  • Unlike users of the implants, most users of Depo-Provera stop menstruating altogether after a year. 
  • It may be beneficial for women with heavy bleeding, severe cramps, or both. 
  • Women who eventually want to have children should be aware that Depo-Provera can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months. 
  • Weight gain can be a problem, particularly in women who are already overweight.


GNRH AGONISTS

  • Gonadotropin releasing hormone (GnRH) blocks the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). 
  • As a result, the ovaries stop ovulating and no longer produce estrogen. 
  • GnRH agonists include goserelin (Zoladex), buserelin, a monthly injection of leuprolide (depot Lupron), and a nasal spray, Nafarelin (Synarel). 
  • Such agents may be used to alone or in combination for procedures used to destroy the uterine lining. 
  • They are not generally suitable for long-term use. 
  • Commonly reported side effects (which can be severe in some women) include menopausal-like symptoms that include hot flashes, night sweats, changes in the vagina, weight change, and depression. 
  • They may be more intense with leuprolide and persist after the drug has been stopped. 
  • The most important concern is possible osteoporosis from estrogen loss. Women ordinarily should not take them for more than six months.


DANAZOL

  • Danazol (Danocrine) is a synthetic substance that resembles a male hormone. 
  • It suppresses estrogen, and therefore menstruation, and is used (sometimes in combination with an oral contraceptive), to help prevent heavy bleeding. 
  • It is not suitable for long-term use. 
  • Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and dandruff. 
  • It may also increase the risk for unhealthy cholesterol levels. 
  • Pregnant women or those trying to become pregnant should not take this drug because it may cause birth defects.


AGENTS USED FOR WOMEN WITH VON WILLEBRAND DISEASE AND OTHER BLEEDING DISORDERS

Desmopressin. 

  • Desmopressin is a drug that stimulates the release of blood factors that are particularly important for women with certain bleeding disorders, especially von Willebrand disease. 
  • High doses of a nasal spray containing desmopressin acetate, or DDAVP (Stimate) have reduced menorrhagia in women with bleeding disorders, including von Willebrand disease and mild hemophilia. 
  • Side effects are mild to moderate. They include headache, nausea, and weakness.


Tranexamic acid.

  • Tranexamic acid is also useful for treating bleeding disorders. 
  • This is a synthetic form of the amino acid lysine and enhances blood clotting. (This agent is discussed under Nonhormonal Agents.)