D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine BleedingLifecare Centre
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta
A case study interactive presentation illustrating the importance of identifying the cause of irregular bleeding in the reproductive age, the new FIGO classification and the role of progestogen supplementation in the treatment of irregular bleeding. The contents were modified from a presentation given online by Professor Peter HM van de Weijer, MD, PhD
University of Auckland- Waitemata District Health Board- Auckland, New Zealand and ccessible at peervoice.com
AUB in ADOLESCENTS Dr. Jyoti Bhaskar Dr. Sharda Jain Dr. Jyoti AgarwalLifecare Centre
PREVALENCE
A population based study of 1000 adolescents:
Incidence of AUB is 40%
Out of those who have AUB
20% have bleeding disorders
Von Willebrand disease, 5%-36%;
Platelet function defects, 2%-44%;
Thrombocytopenia, 13%- 20%
Clotting factor deficiencies, 8%-9%.
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine BleedingLifecare Centre
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta
A case study interactive presentation illustrating the importance of identifying the cause of irregular bleeding in the reproductive age, the new FIGO classification and the role of progestogen supplementation in the treatment of irregular bleeding. The contents were modified from a presentation given online by Professor Peter HM van de Weijer, MD, PhD
University of Auckland- Waitemata District Health Board- Auckland, New Zealand and ccessible at peervoice.com
AUB in ADOLESCENTS Dr. Jyoti Bhaskar Dr. Sharda Jain Dr. Jyoti AgarwalLifecare Centre
PREVALENCE
A population based study of 1000 adolescents:
Incidence of AUB is 40%
Out of those who have AUB
20% have bleeding disorders
Von Willebrand disease, 5%-36%;
Platelet function defects, 2%-44%;
Thrombocytopenia, 13%- 20%
Clotting factor deficiencies, 8%-9%.
Abnormal uterine bleeding can occur when a woman experiences a change in menstrual loss, or the degree of loss or vaginal bleeding pattern differs from that experienced by the age-matched general female population
AUB is not restricted to menstrual bleeding that is abnormally heavy, but includes bleeding that is abnormal in TIMING
Insight AUB Management Guidelines on AUB in Reproductive PeriodLifecare Centre
DISCLAIMER
Use of these slides is permitted only for the purpose of scientific and educational presentations.
While every reasonable effort has been made to ensure accuracy of content, it is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. DGF shall not be responsible or in any way liable for the continued accuracy &/or veracity of the information or for any errors, omissions or inaccuracies or for any injury and/or damage to persons or property arising from relying on the information contained in the presentation or otherwise.
Medical management of heavy menstrual bleedingNiranjan Chavan
heavy menstrual bleeding (HMB), formerly referred to as menorrhagia, is defined as blood loss exceeding 80 mL or bleeding that lasts longer than 7 days each menstrual cycle. Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormone issues (such as hypothyroidism) or cancer of the reproductive tract.
Case Study: Recurrent myoma with menorrhagiaLyndon Woytuck
A case study on a patient presenting with menorrhagia in a history of recurrent myomatous disease. The patient details have been changed to anonymize the individual.
Endometriosis – Changing Perspective - Case based approach Lifecare Centre
Endometriosis – Changing Perspective - Case based approach
MODERATOR : Dr Sharda Jain
Dr Meenakshi Sharma
PANELIST : Dr. Rupam Arora
Dr. Dipti Nabh
Dr. Renu Chawla
Dr. Vandana Gupta
Dr. Jyoti Agarwal
Dr. Poonam Goyal
On 31st Oct 2018
Women with benign heavy menstrual bleeding have the choice of a number of medical treatment options to reduce their blood loss and improve quality of life.
Abnormal uterine bleeding can occur when a woman experiences a change in menstrual loss, or the degree of loss or vaginal bleeding pattern differs from that experienced by the age-matched general female population
AUB is not restricted to menstrual bleeding that is abnormally heavy, but includes bleeding that is abnormal in TIMING
Insight AUB Management Guidelines on AUB in Reproductive PeriodLifecare Centre
DISCLAIMER
Use of these slides is permitted only for the purpose of scientific and educational presentations.
While every reasonable effort has been made to ensure accuracy of content, it is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. DGF shall not be responsible or in any way liable for the continued accuracy &/or veracity of the information or for any errors, omissions or inaccuracies or for any injury and/or damage to persons or property arising from relying on the information contained in the presentation or otherwise.
Medical management of heavy menstrual bleedingNiranjan Chavan
heavy menstrual bleeding (HMB), formerly referred to as menorrhagia, is defined as blood loss exceeding 80 mL or bleeding that lasts longer than 7 days each menstrual cycle. Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormone issues (such as hypothyroidism) or cancer of the reproductive tract.
Case Study: Recurrent myoma with menorrhagiaLyndon Woytuck
A case study on a patient presenting with menorrhagia in a history of recurrent myomatous disease. The patient details have been changed to anonymize the individual.
Endometriosis – Changing Perspective - Case based approach Lifecare Centre
Endometriosis – Changing Perspective - Case based approach
MODERATOR : Dr Sharda Jain
Dr Meenakshi Sharma
PANELIST : Dr. Rupam Arora
Dr. Dipti Nabh
Dr. Renu Chawla
Dr. Vandana Gupta
Dr. Jyoti Agarwal
Dr. Poonam Goyal
On 31st Oct 2018
Women with benign heavy menstrual bleeding have the choice of a number of medical treatment options to reduce their blood loss and improve quality of life.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Abnormal uterine bleeding (AUB) is bleeding from the uterus that is longer than usual or that occurs at an irregular time. Bleeding may be heavier or lighter than usual and occur often or randomly. AUB can occur: As spotting or bleeding between your periods.
Similar to D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding (20)
PCOS -INDIAN STORY (IFS Good clinical practice recommendations) Dr. Sharda ...DGFPublicAwareness
INCIDENCE 20-40% PCOS...., as high as 2 in 5 adolescents and 1 in 5 adult women in India suffer from PCOS
REASONS OF HIGH INCIDENCE IN INDIA
• Urbanisation leading to stress and less physical activity.
• Earlier age of menarche, increased insulin resistance and obesity in India due to bad eating habits with genetic predisposition of Indian women for PCOS
• Early malnutrition also lead to PCOS
• Autosomal dominant genes Follistatin gene implicated in PCOD
45X LOSS OF WHOLE OR PART OF X XP DELETION OR XQ DELETION OR ISO CHROMOSOME XP OR XQ OR RING CHROMOSOME X
CLINICAL FEATURES- FEMALE INFANTILISM
• Webbed neck * Coarctation and other cardiac AS A R
• Short height * Horseshoe kidney
• Broad chest * Hypothyroidism
• Wide carrying angle arm * High LH FSH
• Infantile ovaries
HEAVY MENSTRUAL BLEEDING IN ADOLESCENTS DR. Sharda Jain , Dr. Meenakshi Dr. M...DGFPublicAwareness
CAUSES: Anovulatory bleeding :
Early menarche earlier is the commonest cause to cycles become ovulatory: if menarche 13 year it takes 4,5 year for cycle to become ovulatory due to unopposed estrogen thick endometrium thin stromal layer causes AUB in adolescence
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
PANEL DISCUSSION
MODERATOR: DR. RUPAM ARORA / Dr. Sharda Jain
PANELISTS:
DR. ARUNA SAXENA
DR. DEEPTI NABH
DR. ILA GUPTA
DR. JYOTI AGARWAL
DR. RAJ BOKADIA
DR. RENU CHAWLA
Is cervical cancer common
MEDICO LEGAL FOUNDATION FORMED IN MARCH 2016 WITH SOLE AIM OF INCREASING AWARENESS AND EDUCATING MEDICAL FRATERNITY ABOUT MEDICO LEGAL ISSUES
2 ND APRIL -- AMC MUMBAI OFFICE BEARERS INVITED TO DELHI
AMC DELHI FORMED – AFFILIATED TO AMC INDIA
50 LIFE MEMBERS ENROLLED
Insight AUB Presentations based on FOGSI AUB GUIDELINES DGFPublicAwareness
DISCLAIMER
Use of these slides is permitted only for the purpose of scientific and educational presentations.
While every reasonable effort has been made to ensure accuracy of content, it is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. DGF shall not be responsible or in any way liable for the continued accuracy &/or veracity of the information or for any errors, omissions or inaccuracies or for any injury and/or damage to persons or property arising from relying on the information contained in the presentation or otherwise.
INTRAUTERINE DEATH CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016, Dr sharda...DGFPublicAwareness
HOW TO DEFINE
IUD or STILL BORN
fetal death after period of viability ( 28 weeks )
24 weeks in USA
24WEEKS OR >500 Gms by WHO
ACOG refers to IUFD as the demise occurring at or later than 20weeks.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. CASE DISCUSSION
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta
3.
4. CASE STUDY 1
• A busy 30 years old lawyer from an affluent class had NVD 9
months ago.
• She complains of heavy bleeding and dysmenorrhoea since past 5
months.
• She is currently breastfeeding and concerned about the effects of
medicines on her baby.
• Not comfortable with taking tablets daily due to her hectic life
style
• Pelvic examination revealed no abnormality.pap smear normal
• What further investigations are required. Is there any need of EB
in this case.
6. • What options can be suggested
for her menorrhagia issue ?
7. MANAGEMENT OPTIONS
• LNG IUS
• Anti-fibrinolytics like Tranexamic acid and NSAID
• MPA
• DMPA
• Surgical methods like TCRE, EA, Hysterectomy
• COC pills
• Progesterone Only Pill
8. DISCUSSION
• Pills/Injectables
– Compliance is an issue
– Pills are Category 4 for breastfeeding as estrogen is excreted in the breast
milk
• Surgical methods:
– Irreversible
– Risk of complications
• Anti-fibrinolytics
– Daily compliance is a problem
– Efficacy not very great in reducing blood loss
– Can’t be used on a long term basis
WHO medical eligibility criteria for contraceptive use; 5th edition, 2015. Available at : http://www.who.int/reproductivehealth/publications/family_planning/Ex-Summ-MEC-5/en/
Last accessed on February 29, 2016
9. LNG IUS VERSUS ORAL MEDICAL THERAPY
• LNG IUS proved significantly superior to Tranexamic acid and NSAID in
reducing blood loss and was the only treatment that achieved
normalization of menstrual blood loss
• In addition, the duration of bleeding was not altered by either
Tranexamic acid OR NSAID and the frequency of side-effects with these
forms of treatment was greater than with LNG IUS
Reduction in
menstrual blood
loss
Milsom I, Andersson K, Andersch B, et al. A comparison of flurbiprofen, tranexamic acid, and a levonorgestrelreleasing intrauterine contraceptive device in the treatment of idiopathic
menorrhagia. Am J Obstet Gynecol 1991;164:879–83
LNG IUS-
3 months
LNG IUS-
6 months
LNG IUS-
12 months
Tranexamic
Acid Flurbiprofen
10. LNG IUS versus Medroxy Progesterone Acetate (MPA)
• The absolute reduction in median menstrual blood loss (MBL) was
significantly greater in the LNGIUS group (– 128.8 mL) than in the MPA
group (– 17.8 mL).
Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT.
11. DISCUSSION
• Levonorgestrel Intra Uterine System
– Considered as the first line management therapy in Menorrhagia
– Studies have shown that LNG IUS has no effects on breast-feeding
performance, infant growth and infant development1
• Shaamash AH, Sayed GH, Hussien MM, Shaaban MM. A comparative study of the LNG IUS versus Copper T380A during lactation: breast-feeding performance, infant growth and
infant development.
• **Murad F, & Haynes RC. (1985). Estrogens and progestins. In Goodman and Gilman's the Pharmacological Basis of Therapeutics, pp. 1412-1439. Edited by LS Goodman, AG
Gilman, TW Rall & F Murad. New York: Macmillan Publishing Company.
12. CASE STUDY 2
• A girl aged 15 years reports with severe cyclical bleeding since last 2
months along with pain and intense abdominal cramps
• She had menarche at 13 yrs.Periods were normal for two years.
• No medical illness/ pelvic pathology/ family history
• On blood investigation, Hemoglobin dropped to 8.7g/dl
• WHAT DO YOU THINK IS PROBABLE CAUSE OF AUB IN THIS CASE
• And what further investigations are required.
13. DISCUSSION DIAGNOSIS
• While there are many etiologies of AUB, the one most likely among
otherwise healthy adolescents is DUB.
• The most common cause of DUB in adolescence is anovulation, which is
very frequent in the first 2–3 post-menarchal years and is associated
with immaturity of the hypothalamic – pituitary – ovarian axis (HPO
axis)1.
• Management of AUB is based on the underlying etiology and the
severity of the bleeding and primary goals are prevention of
complications, such as anemia and reestablishment of regular cyclical
bleeding.2
1. E.H. Quint and Y.R. Smith. Abnormal Uterine Bleeding in Adolescents. Journal of Midwifery & Women’s Health. Volume 48, No. 3, May/June 2003
2. Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology,
Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384
14. Differential Diagnosis of AUB in Adolescents
Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and
adolescent gynecology, Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384
16. How would the treatment protocol be prepared
for this patient
17. MANAGEMENT OPTIONS
• Combined Oral Contraceptives (COCs)
• Progestogens- MPA or DMPA
• Non steroidal anti-inflammatory drugs (NSAIDs)
• Tranexamic acid (anti-fibrinolytic)
• GnRH analogues- Danazol and
• Desmopressin- Synthetic analog of Arginine-
Vasopressin
• Levonorgestrel releasing intra uterine system
(LNG IUS)
.
Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and
adolescent gynecology, Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384
18. Management of Dysfunctional Uterine Bleeding
Hemoglobin
level
Bleeding
Intensity
Management
Hb>10 g/dl
1) Reassurance and education;
2) Iron Supplementation
3) Menstrual calender
4) Consider oral contraceptives if desired by patient
5) Prostaglandins inhibitors
6) Periodic re-evaluation
Hb < 10g/dl
No active bleeding
1) Consider referral or consult with a physician
2) Iron supplementation
3) Therapy: oral contraceptives
4) Levonorgestrel-releasing intrauterine device if appropriate
5) Cyclic progestin therapy; prostaglandin inhibitors
6) Reevaluation in 3 to 6 months
Active bleeding but
stable
1) Consider referral or consult with a physician
2) Cascade oral contraceptive regimen: 30 to 35-mcg ethinyl estradiol
a) 1 pill qid for 4 days
b) 1 pill tid for 4 days
c) 1 pill bid for 4 days
d) 1 pill qd until two pill packs are finished
3) Iron supplementation
4) Reevaluate by phone in a few days; if bleeding not slowed down, physician
consult
5) Continue treatment for 1 year; then reevaluate
Acute Hemorrhage Immediate consult with physician for possible transfusion and admission
E.H. Quint and Y.R. Smith. Abnormal Uterine Bleeding in Adolescents. Journal of Midwifery & Women’s Health. Volume 48, No. 3, May/June 2003
19. CASE STUDY 3
• A middle class lady 40 years old, P2 with 12 months of
heavy, painful, irregular and often long periods with clots
and cramps.
• She also c/o relapsing weight gain
• She was referred by her primary care provider after she
failed to respond to 2 months of intensive oral iron therapy
for severe Iron Deficiency Anemia (IDA); although she admits
she missed few pills
• Pelvic examinations was normal.
• Pelvic sonogrphy revealed endometrial thickness of 11 mm
with normal adenexa
• What further investigations are to be done ?
20. CBC,THYROID,BLOOD SUGAR
Endometrial aspiration/biopsy---- method?
purpose
Whether D&C to be done or not?
What is the role of hysteroscopy
Any role of 3D/4D or MRI or sonohysterography
21. • What therapeutic measures need to be
initiated to control her heavy bleeding?
22. COUNSELLING AND OPTIONS
• She was counseled about her condition, and the fact that her chronic IDA
is due to excessive menstrual losses which are not being adequately
replenished due to impaired iron absorption in the gut
• She was also counseled that her relapsing weight gain is likely due to
ovulatory dysfunction causing abnormal uterine bleeding
• Options available:
– COC Pills
– Trenexamic acid and NSAID
– Progesterone only pills
– DMPA
– LNG IUS
– TCRE/EA/Hysterectomy
23. DISCUSSION
• OCP and progestin only pills and tranexamic acid
– Since the woman is forgetful , there are compliance issues for the pills
• DMPA1
– erratic heavy bleeding,
– further weight gain and
– osteoporosis (in case of prolonged DMPA use)
• TCRE/ EA/ Hysterectomy
– Irreversible
– Risk of complications
– Higher surgical cost
1. PINKERTON. Pharmacological therapy for abnormal uterine bleeding. Menopause: The Journal of The North American Menopause Society
Vol. 18, No. 4, pp. 453/461. DOI: 10.1097/gme.0b013e318212499c
2. Dennis A. Hidlebaugh. COST AND QUALITY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT SURGICAL THERAPIES FOR THE TREATMENT OF ABNORMAL UTERINE
BLEEDING. OBSTETRICS AND GYNECOLOGY CLINICS OF NORTHAMERICA. VOLUME 27 • NUMBER 2 • JUNE 2000
24. DISCUSSION
• LNG IUS
– First choice therapy in management
of menorrhagia
– Rapidly induces clinically and
statistically significant long-term
reductions in MBL, paralleled by
increases in Hb and serum ferritin levels
– Long term management option for
control of symptoms and improvement in
quality of life
26. CASE 4
• 32 years old banker 5’4” in height and with a body weight of 60 kgs.
• Sexually active and wants effective contraception but couldn’t enjoy
properly due to heavy bleeding issues and severe abdominal pain
• She wants a lasting solution which will effectively reduce bleeding and at
the same time no surgical procedures being involved
• Not keen on pregnancy for at least 3-4 years.
What options available for her?
28. Discussion
• LNG IUS:
– 2 pronged approach to cater both
• Contraception
• Menorrhagia
– Most effective with a failure rate of 0.1% in the first year – similar to or
even better than female sterilization
– Provides significant reduction in MBL within few months of insertion
(>90% reduction)
29. Case 4
• 18 years old girl.
• H/o MTP done 12 months ago. Pregnancy occurred after being prescribed
oral contraceptive pills.
• She is sexually active
• Wants information regarding contraception.
What options are available for her ?
31. Contraception for adolescents
• Adolescents are eligible for all contraceptives which are suitable for adults
• Proper counseling regarding its use is important.
• DMPA – can interfere with bone growth
• However, an adolescent girl tends to start and stop injections
• Dual protection be stressed upon
• Abstinence can be promoted as a method
• OC pills with benefits beyond contraception should be stressed upon along
with disciplined usage
32. Case 5
• A healthy, lean 36-year-old woman who is a heavy smoker (since past 2
years) requests advice about contraception.
• She used to take OC pills 3 years back but stopped after 6 months due to
peer pressure on bad effects of OC pill !!
• She notes that her menstrual periods are irregular than previously, and
she also reports severe abdominal pain and cramps along with heavy
bleeding.
• She is in a new relationship after a divorce, and she is sexually active.
• She asks if she can begin to use an oral contraceptive or any other
methods are available for her ?
33. Options available:
• Combined Oral Contraceptive Pills
• Progestin Only Pills
• Vaginal rings
• Intra Uterine Contraception
– Cu T
– LNG IUS
• Barrier methods- by both partners
34. Combined Oral Contraceptive Pills
• COCs can provide her with effective contraception
• Also by decreasing the menstrual related pain and cramps, the compliance
and tolerability with the COC pill increases
• COCs can also help to regularize the cycles and thus help in achieving a
good cycle control
• COCs are generally not advisable in females more than 35 years and who
are smokers due to cardio vascular risks
35. LNG IUS
• In long-term studies comparing LNG IUS and Cu-IUDs, the use of LNG IUS
results in significantly higher levels of hemoglobin, serum ferritin and
serum protein than in the use of Cu-IUDs*
• LNG IUS has no clinically significant effects on serum lipids, carbohydrate
metabolism, liver enzymes or the coagulation system*
• LNG-IUS provides a good alternative to systemic hormonal methods,
particularly in diabetics with vascular disease, smokers, and women with
a history of thrombosis**
• Women with coagulopathies, including those on warfarin, experience a
reduction in bleeding with the LNG-IUS**
* Luukkainen T. (1991). Levonorgestrel-releasing intrauterine device. Ann N Y Acad Sci 626, 43-49.
** Bednarek and Jensen International Journal of Women’s Health 2009:1 45–58
36. Case 6
• 27 year old female, recently married, infected with HIV past 4 years wants
to have contraception
• Husband’s HIV status unknown
• Using Condoms since past few months, but wants a more sustained and
long acting contraception
• What options can be suggested to her ?
38. Discussion
• IUD shows high efficacy and reversibility, and it requires minimal
interval maintenance, which is especially appealing to women using
complex antiretroviral regimens
• There is limited evidence on disease progression in HIV-infected
women who use hormonal contraception versus women who do
not, because no study has directly evaluated markers of disease
• Hormonal contraceptives probably do not increase disease
progression or risk of transmission (Level B).
• Caution should be used in prescribing COCs to women on
antiretroviral medications, which increase or decrease contraceptive
steroid or antiretroviral area-under the- curve.
Teal, Ginosaur; Obstet Gynecol Clin N Am 34 (2007) 113–126
39. Discussion
• Reproductive-aged women are one of the fastest growing demographics
acquiring HIV infection
• Concerns regarding contraception in women who have HIV include
possible promotion of disease progression, exacerbation of sequelae,
increased risk of transmission, and interaction with antiretroviral therapies
Teal, Ginosaur; Obstet Gynecol Clin N Am 34 (2007) 113–126
40. Case Study 7
• 31 years old sexually active female, suggested sterilization for
contraception about one and half year back, but she didn’t opted for
surgery rather practiced barrier methods
• Now complains of regular heavy intermenstrual bleeding along with pain
in abdomen area intermittently
• She was also diagnosed with PID, 7 months back which got completely
resolved
• She is now in need of an option to solve her bleeding troubles and a
reversible contraceptive which will cater to her lifestyle and might provide
some additional benefits
• What options would you recommend for her ?
42. LNG IUS as the First Line therapy for Menorrhagia
Group 1:
• LNG IUS
Group 2:
(Usual Medical treatment)
• Tranexamic acid, or
• Mefenamic acid, or
• COC pill or
• Progestins: Oral/Injectable
The primary outcome was the score on the Menorrhagia Multi-Attribute Scale (MMAS) (scores
range from 0 to 100, with lower scores indicating greater severity).
Mean MMAS scores are shown for the two groups at 6, 12, and 24 months.
43. LNG IUS versus Sterilization
• The younger the woman is at the moment of sterilization, the more likely
she is to regret the procedure in later life
• Women under the age of 30 at the time of the procedure were twice as
likely as women older than 30 to report regretting having the procedure
performed
Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93:889–895
44. Discussion
Levonorgestrel Intra Uterine System:
• The rate of pelvic inflammatory disease is lower with use of LNG IUS,
compared to the Cu-IUD at 3 and 5 years
• LNG-IUS may actually protect against upper genital tract infection by
thickening of cervical mucus
Therapy Removal Rate due to Pelvic Inflammatory Disease (5years)
Cu T 2.2
Mirena 0.8
* Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial.
Andersson K, Odlind V, Rybo G.
45. Additional Benefits:
• Contraception:
– Highly effective long-acting reversible contraceptive
– Efficacy lasts for 5 years
– Pearl Index of 0.2 at 1 year and a cumulative failure rate of 0.7 at 5 years
• Endometrial Protection from Endometrial Hyperplasia during Estrogen
Replacement Therapy:
– Proven efficacy in endometrial protection
– Easy transition from contraception to ERT
– Convenience and ease of use – “fit and forget”
– High compliance for long-term ERT
46. ADDRESS
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Editor's Notes
Levonorgestrel- and copper-releasing IUDs: Andersson et al.
Pelvic Infections
There was in neither the Nova T nor in the LNG-IUD group an increased
incidence of PID in relation to the IUD insertion (Figure 4). The 60-month
gross removal rates for PID were 2.2 in the Nova T and 0.8 in the LNGIUD
group [(P < O.OS), (Table 3)]. In the LNG-IUD users, the incidence of
PID was low regardless of age whereas in the Nova T group, there was a
significantly (P < 0.01) increased PID rate compared to LNG-IUD among
the youngest women (Table 3).
The absolute risk of pelvic inflammatory disease was low (for all IUDs) : Mohllajee et al, 2006
0–5% for women with infection at the time of IUD insertion, and
0–2% for those without a sexually transmitted infection