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7/30/2019 Pleno E Bloc 9 2009
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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
Recommended