Minimally invasive surgery is not always the best option … and more
Dr. Stokes’ clinical advice to ensure that the placenta is completely removed, to perform hemorrhage drills, and to consult a hematologist are excellent. I will emphasize those points when I write about postpartum hemorrhage in the future.
Dr. Pang raises the question of the value of TEG in the management of postpartum hemorrhage. TEG measures the viscosity of blood, a proxy for its ability to initiate and maintain a clot. A recent review of postpartum hemorrhage recommended TEG.1 However, in practice, I wonder who is going to run the test. In the hospital, a certified technician or physician would be needed to do so. Until the test is easier to perform, I doubt that it will be used widely in obstetric practice.
To assess the coagulation profile, I recommend the use of the whole-blood clotting test (“red-top tube test”), described in my editorial, and the measurement of prothrombin time, partial thromboplastin time, platelets, and fibrinogen. An experienced and alert clinician is the best measure of incoagulable blood.
“HAVE YOU TRIED A PROGESTIN FOR YOUR PATIENT’S PELVIC PAIN?”
ROBERT L. BARBIERI, MD (EDITORIAL; FEBRUARY 2012)
For pelvic pain, try the LNG-IUS
It is reassuring to discover that I counsel patients who use medical therapy for chronic pelvic pain and endometriosis in a manner similar to that of Dr. Barbieri. Progestin-only therapy, particularly norethindrone acetate (NEA), is too often overlooked. In many cases, various birth control pills have been tried without much success yet plenty of adverse effects.
When presented with the options of NEA, oral medroxyprogesterone acetate (MPA), and depot medroxyprogesterone acetate (DMPA), many women express an interest in NEA because of the clinically proven benefit. In addition, many women who already have abandoned several therapies because of unpleasant side effects desire the potential for more rapid reversibility with NEA, compared with DMPA. Nevertheless, over the past few years, I have encountered many women (far beyond the incidences reported in the observational study Dr. Barbieri mentioned1) who dislike the androgenic effects of long-term use of NEA. Therefore, I increasingly rely on the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena, Bayer), regardless of parity, to provide a potent progestin with fewer undesirable systemic effects.
That said, I am curious to see where aromatase inhibitors and other new medical therapies ultimately fit into the picture.
Marc Kleinberg, MD
Chicago, Illinois
Other remedies for pelvic pain
I enjoyed the editorial on the use of progestins in the management of endometriosis-related pain. Does Dr. Barbieri also warn patients about the risk of pregnancy?
I have started giving my patients pycnogenol 30 mg twice per day because some studies show that it is effective in decreasing inflammation. I also prescribe mefenamic acid (Ponstel, Shionogi Inc) for dysmenorrhea-related pain with endometriosis.
I find that some patients just want to undergo repeat laparoscopic resection every few years to manage their endometriosis until they reach their 40s, when they opt for more definitive treatment.
Nicole Varasteh, MD
Concord, New Hampshire
Adding an aromatase inhibitor to an OC
When oral contraceptives (OCs) or gonadotropin-releasing hormone (GnRH) agonists fail to relieve pain, I prescribe a continuous OC with an aromatase inhibitor—typically letrozole (Femara, Novartis) at a dosage of 2.5 mg/day. This regimen has worked extremely well over the past 4 or 5 years for these patients.
Donald C. Young, DO
Clive, Iowa
Dr. Barbieri responds LNG-IUS is a useful tool
I thank Dr. Kleinberg for sharing his expert clinical experience with our readers. I agree that the LNG-IUS is an excellent way to deliver a progestin to the endometrium and pelvic tissues. Data continue to accumulate showing that the LNG-IUS is effective in the treatment of pelvic pain caused by endometriosis.1
As Dr. Varasteh recommends, anti-inflammatory agents often are effective in the treatment of pelvic pain. Unlike ibuprofen (a propionic acid anti-inflammatory), mefenamic acid is a fenamate anti-inflammatory agent and may be effective when propionic anti-inflammatory agents are not. However, mefenamic acid is expensive in the United States—between $4 and $18 per 250-mg pill (pricing from www.drugstore.com).
I agree with Dr. Young that, for patients who have endometriosis and pelvic pain and who do not experience sufficient relief with an OC or GnRH agonist, a combination of an OC and an aromatase inhibitor, or NEA plus an aromatase inhibitor, may be effective.2,3
References “IS THE HCG DISCRIMINATORY ZONE A RELIABLE INDICATOR OF INTRAUTERINE OR ECTOPIC PREGNANCY?”
ANDREW M. KAUNITZ, MD (EXAMINING THE EVIDENCE; FEBRUARY 2012)
Many providers misinterpret the hCG level
I have been teaching and lecturing on ectopic pregnancy for many years, and I share some of the concerns that Dr. Kaunitz and others have raised in regard to the human chorionic gonadotropin (hCG) discriminatory zone.
