Pleno scenario E bloc 9

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.

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 ?

Mrs. Jasmines case

1. abnormal, not her usual period. 2. Origin of bleeding uterus (gynecological exam ) type of menstrual blood 3. Blood loss mild physical exam normal, anemic sign (-) 4. Causes DD

Differential diagnosis
1. Menstrual abnormality 2. Laceration of internal or external genitalia 3. Tumor of uterus or adnexa 4. Impending abortion

Menstrual cycle
Normal menstrual cycle 1. Follicular phase final stage of follicular maturation most variable segment of cycle end in ovulation in uterus : proliferative phase

Menstrual cycle
2. Luteal phase from ovulation to mens formation of Corpus Luteum variation of length ; little 14 days primary indicator of luteal function increase of progesterone in uterus: secretory phase

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, FSH preovulatory surge

Integration of feed back control

1. 2. 3. 4. 5. 6. 7. At the end of luteal phase increase basal LH, FSH increase follicle growth increase estrogen FSH, LH, estrogen maturation of follicle estrogen increase Estrogen positive feed back LH, FSH surge LH,FSH surge ovulation Corpus luteum formation ( 1 day after ovulation) increase of progesterone, estrogen Progesterone blocks positive feed back signal Regression of CL ( in absence of fertilization) decrease of estrogen and progesterone increase LH, FSH menstrual flow

Whats cause Mrs. Jasmin menstrual abnormality?

She used COC, but has stopped taken it since 6 months ago.

What is COC ( combined oral contraceptives) ?

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
Reduce sperm transport in upper genital tract (fallopian tubes)
Change endometrium making implantation less likely

Thicken cervical mucus (preventing sperm penetration)

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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
1Hatcher

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 very small 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 not breastfeeding (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

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