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Pleno scenario E

bloc 9

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Scenario E

Mrs. Jasmine, 30 years old, married 5 years,has a child.

1. Vaginal bleeding

2. Lower abdominal discomfort

3. Period delay 4 days

4. Used COC, has stopped since 6 months

ago.5. No history of chronic diseases or surgery

procedure.

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Vaginal bleeding

physiologic-clinical approach

1.Is it a normal or abnormal vaginal

bleeding?

2. Origin of blood ?

3. How much blood loss?

4. What is/are causes of it ?

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Mrs. Jasmines case

1. abnormal, not her usual period.

2. Origin of bleeding uterus

(gynecological exam ) type of

menstrual blood

3. Blood loss mildphysical exam

normal, anemic sign (-)

4. Causes DD

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Differential diagnosis

1. Menstrual abnormality

2. Laceration of internal or external

genitalia

3. Tumor of uterus or adnexa

4. Impending abortion

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Menstrual cycle

Normal menstrual cycle

1. Follicular phase

final stage of follicular maturationmost variable segment of cycle

end in ovulation

in uterus : proliferative phase

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Menstrual cycle

2. Luteal phase

from ovulation to mens

formation of Corpus Luteumvariation of length ; little 14 days

primary indicator of luteal function

increase of progesteronein uterus: secretory phase

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Hormonal control of menstrual

cycle

1. Negative feed back control of tonic mode

of gonadotropin secretion

increase estrogen decrease LH, FSH

2. Positive feed back of phasic mode of

gonadotropin secretion.

increase of estrogen

LH, FSHpreovulatory surge

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Integration of feed back control

1. At the end of luteal phaseincrease basal LH, FSHincrease follicle growthincrease estrogen

2. FSH, LH, estrogenmaturation of follicle estrogenincrease

3. Estrogenpositive feed back LH, FSH surge4. LH,FSH surgeovulation

5. Corpus luteum formation ( 1 day after ovulation)increase of progesterone, estrogen

6. Progesterone blocks positive feed back signal7. Regression of CL ( in absence of fertilization)

decrease of estrogen and progesterone increaseLH, FSH menstrual flow

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Whats cause Mrs. Jasmin

menstrual abnormality?

She used COC, but has stopped taken it

since 6 months ago.

What is COC ( combined oral

contraceptives) ?

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Types of COCs

Monophasic: All 21 active pills contain

same amount of Estrogen/Progestin (E/P)

Biphasic: 21 active pills contain 2 different

E/P combinations (e.g., 10/11)

Triphasic: 21 active pills contain 3 different

E/P combinations (e.g., 6/5/10)

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COCs: Mechanisms of Action

Suppress ovulation

Change endometrium making

implantation less likely

Thicken cervical mucus

(preventing sperm

penetration)

Reduce sperm transport

in upper genital tract(fallopian tubes)

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COCs: Contraceptive Benefits

Highly effective when taken daily (0.1!51 pregnancies

per 100 women during the first year of use)

Effective immediately if started by day 7 of menstrual

cycle

Pelvic examination not required to initiate use

Do not interfere with intercourse

Few side effects

Convenient and easy to use Client can stop use

Can be provided by trained nonmedical staff

1

Hatcher et al 1998.

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COCs: Noncontraceptive

Benefits Decrease menstrual flow (lighter, shorter

periods)

Decrease menstrual cramps

May improve anemia

Protect against ovarian and endometrial cancer

Decrease benign breast disease and ovarian

cysts Prevent ectopic pregnancy

Protect against some causes of PID

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COCs: Menstrual Blood Loss

and Anemia Decrease menstrual blood loss (20 ml

versus 35 ml)

Prevent iron deficiency anemia (50%)

Improve existing iron deficiency anemia

Source: Mishell 1982.

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COCs: Decreased Ovarian

Cancer Risk 40!80% decrease in risk compared to

nonusers

Protection:

Begins by 1 year of use

Increases with duration of use

Persists at least 10!15 years after COCs are

stopped

Is biologically possible

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COCs and Breast Cancer

There is no overall measurable increase of

breast cancer risk except possibly among

younger women.

Breast cancer at a young age represents a verysmall proportion of all cases and may represent

acceleration of preexisting breast cancer or

detection bias.

COC use may provide protection against

postmenopausal breast cancer.

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COCs: Limitations

User-dependent (require continued motivation and daily

use)

Some nausea, dizziness, mild breast tenderness,

headaches or spotting may occur

Effectiveness may be lowered when certain drugs are

taken

Forgetfulness increases method failure

Can delay return to fertility

Rare serious side effects possible

Resupply must be readily and easily available

Do not protect against STDs (e.g., HBV, HIV/AIDS)

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Who Can Use COCs

Women:

Of any reproductive age or parity who want

highly effective protection against

pregnancy

Who are breastfeeding (6 months or more

postpartum)

Who are postpartum and are notbreastfeeding (begin after third week)

Who are postabortion (start immediately or

within 7 days)

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COCs: Common Side Effects

Amenorrhea

High blood pressure

Nausea/dizziness/vomiting

Bleeding/spotting

Acne

Breast fullness or tenderness (mastalgia)

Chest pain (especially if it occurs with exercise)

Depression (mood change or loss of libido)

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COCs: General Information

Some nausea, dizziness, mild breast tenderness and

headaches as well as spotting or light bleeding are

common during menstrual cycle (usually disappear within

2 or 3 cycles).

Certain drugs (rifampin and most anti-epilepsy) may

reduce effectiveness of COCs. Tell your provider if you

start any new drugs.

Use a condom if at risk for STDs (e.g., HBV, HIV/AIDS).

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COCs: Warning Signs

Severe chest pain or shortness of breath

Severe headaches or blurred vision

Severe leg pain

Absence of any bleeding or spotting during

pill-free week (21-day pack) or while taking 7

inactive pills (28-day pack) may be a sign of

pregnancy