Raja Devi 45 yrs old women present with history of polymenorrhea for last six months. The first line of management is :
Ans. is c i.e. Dilatation and curettage Friends. I have given these questions (36 and 37) together, so that you understand the difference between the two. Question 36 asks : Polymenorrhea in a 45 years old woman for 6 months - first line of management. Whereas question 37 asks : Polymenorrhea in a 45 years old woman for 6 months - best line of management. Another thing which I want to point out here is : Question is on "Polymenorrhea' and not DUB (Which generally refers to anovulatory DUB). As far as first line of management is concerned definately I would investigate the patient to rule out endometrial cancer. In this process I would perform diagnostic D & C . "In the later reproductive years, even more care must be given to exclude pathological cause because of the possibility of endometrial cancer. Aspiration, curettage or both should clearly establish anovulatory or dyssynchronous cycles as the cause before hormone therapy is staed." As far as medical therapy is concerned : In ovulatory cycles - combined oral pills for 3 cycles is given. But staing OCP's in a perimenopausal female without prior investigations is not recommended. Now comes the -tricky" pa : Best line of management in such cases. As far as D & C is concerned : "Therapeutic curettage is of no value in the treatment of polymenorrhea." So, now we are left with 2 options either medical management with OCP's or hysterectomy. The place of surgery in the treatment of excessive bleeding without an organic basis varies with the age of the patient; it should be a last reso in young girls but may be considered earlier in women above the age of 40 years. Neveheless, in the latter group it is good practice to exclude organic disease by ultrasound and endometrial aspiration, to try medical therapy and proceed to hysterectomy if the response is inadequate or not sustained. When the patient is above 40 years of age, and when the hemorrhage fails to respond to simpler measure, hysterectomy is indicated. It is the treatment of choice in all cases of persistent or recurrent postmenopausal bleeding for which there is no obvious cause. Therefore, hysterectomy is the last reso, first medical management is tried. Hysterectomy personally I feel is not the best treatment as it is a major surgery, has its own complications and high rate of morbidity. I will not advise hysterectomy to all patients who come to me with complain of polymenorrhea of 6 months duration. But it is a dicy question. You will have to decide for yourself.
Hysterectomy
Progesterone for 3 cycles
Dilatation & curettage
Oral contraceptive for 3 cycles