Commentary

Cost is an issue in applicability of new agent…...and more


 


“A NEW (TO THE US) FIRST-LINE AGENT FOR HEAVY MENSTRUAL BLEEDING”
ROBERT L. BARBIERI, MD (EDITORIAL; OCTOBER 2010)

Cost is an issue in applicability of new agent

In regard to tranexamic acid [Lysteda] for menorrhagia, I find it hard to believe that anyone would, in good conscience, recommend this drug for long-term therapy unless all other options have been exhausted. The $2,000 yearly cost is prohibitive.

Ann Wasson, MD
Falcon Heights, Minn

A question about the new drug

Is intrauterine tranexamic acid of any benefit?

George Kovacs, MD
Hawthorne, Calif

Dr. Barbieri responds:
Tranexamic acid is often a bridge
to other approaches

I respect and share Dr. Wasson’s concern that we should only use the most cost-effective treatments for our patients. In countries where tranexamic acid has been used for many years, it is typically prescribed as an initial treatment for menorrhagia and is often a bridge to a procedure-based approach such as placement of a levonorgestrel-releasing intrauterine system (LNG-IUS), endometrial ablation, hysteroscopic surgery for polyps or myomas, or hysterectomy.

Recently, I saw a patient with menorrhagia who would be a good candidate for a LNG-IUS. Her employer was a religious organization, and it was going to take 2 months to get insurance approval for the LNG-IUS. She did not want to use a hormone such as an estrogenprogestin or progestin pill. We used tranexamic acid for those 2 months until she received insurance approval for her LNG-IUS.

I appreciate Dr. Kovacs’s creative idea. Major advances in medical treatments are often made by using an approved medication in a new manner. However, I know of no formulation of tranexamic acid that can be utilized as an intrauterine treatment.


“AT WHAT THICKNESS IS THE ENDOMETRIAL STRIPE CAUSE FOR CONCERN IN A WOMAN WHO HAS POSTMENOPAUSAL BLEEDING?”
LINDA R. DUSKA, MD (EXAMINING THE EVIDENCE; OCTOBER 2010)

Endometrial assessment
is not always clear-cut

I agree with Dr. Duska that lowering of the cutoff of endometrial thickness to 3 mm, with all values at that level or above meriting biopsy, would not be advisable at this time. I also fully support the ACOG Committee Opinion on ultrasonographic (US) assessment of the endometrium, which recommends that this cutoff be 4 mm.1

However, I would suggest the following refinements to terminology and practice:

  • In its opinion, ACOG refers to “endometrial thickness.” I refer to it as an “endometrial echo” on transvaginal US. The term “stripe” is not a medical term, and I would implore readers to abandon this slang terminology.
  • Dr. Duska recommends that “only women who have postmenopausal bleeding and an endometrial stripe thicker than 4 mm need to undergo endometrial biopsy.” The failure of endometrial biopsy to detect pathologies that are not global (i.e., >50% of surface area) is now well known and needs to be acknowledged and incorporated into the clinical recommendations.2,3 For example, I would suggest that if a patient who has a thin echo (<4 mm) rebleeds, her risk of endometrial cancer is increased, indicating the need for further evaluation, such as hysteroscopy, sonohysterography, etc.4

Steven R. Goldstein, MD
Professor of Obstetrics and Gynecology
Director of Gynecologic Ultrasound
Co-Director of Bone Densitometry
New York University Medical Center
New York City

Endometrial thickness doesn’t always reflect pathology or health

I enjoyed Dr. Duska’s timely commentary on endometrial assessment. I recently had a patient who had an endometrial thickness of 3 mm. She underwent dilatation and curettage (D&C), and an endometrial carcinoma was detected. Another patient had endometrial thickness of 10 mm, but the endometrium was inactive and scant at the time of D&C. I suspect there is some variability between ultrasonographers in the measurement of endometrial thickness. To a radiologist, the endometrium appeared to be thin in the first case, but there was abundant tissue at D&C. In the second case, there was very little tissue, yet it was measured at 10 mm.

Daniel M. Avery Jr, MD
Professor and Chairman
Obstetrics and Gynecology
University of Alabama School of Medicine
Tuscaloosa, Ala.

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