Management of Vaginal Bleed

8/11/2019 Management of Vaginal Bleed

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1

Norplant ® Implants: Management of

Vaginal Bleeding Problems

Norplant® is a registered trademark of the Population Council for subdermal

levonorgestrel implants.



3

Norplant Implants: Menstrual Bleeding

Patterns (N*+,-#

Source: $houpe et al &!!&.

&+

,

-

/

0

7

1

&+ +- ,0 -1 0Months

Per2entage

of 3omen

%menorrhea'Infre4uent

Prolonged'Irregular Bleeding %22eptable 2y2les



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Norplant Implants: 5efinitions of Vaginal

Bleeding Problems

! %menorrhea: No )aginal bleeding or spotting for at least ,

2onse2uti)e months

!Irregular bleeding$ Prolonged spotting: 6 1 days

$ Moderate bleeding: normal menses /B1 ml

! Prolonged bleeding: 6 1 days

! ea)y bleeding: t8i2e as long or t8i2e as mu2h as normal

menses



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5MP% )s. Norplant Implants

Comparison of 9ffe2ts

5MP% Norplant Implants

:)arian fun2tion $uppressed ;olli2ular a2ti)ity

9ndometrium %trophi2 5ysyn2hronous

Menstrual 2hanges %menorrhea(2ommon#

Irregular bleeding(2ommon#



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Norplant Implants: 9ndometrial

Changes

5ysyn2hronous 9ndometrium

$ Progestin dominant

$ 22asional estrogen surges



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Norplant Implants: ;a2tors %ffe2ting

%22eptan2e of Menstrual Changes

! Need for 2ontra2eption

! <ea2tion of the partner to menstrual 2hanges

! Interferen2e 8ith se=ual'daily a2ti)ity

! <eligious 2onstraints

! Counseling

! $taff attitudes and >no8ledge

! %)ailability of ?user friendly@ 2lient information



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Norplant Implants: Counseling %ffe2ts

Continuation

+

-

0

1

&

&+

&-

&0

&1

+

Bleeding %menorrhea

<eason for dis2ontinuation

Per2ent

5is2ontinuing

Aroup &

Aroup +

Source: %l)are=$an2he Bra2he and ;aundes &!11.



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Norplant Implants: <esults of Treatment

for Prolonged Bleeding&

& &- subDe2ts 2ompleted one year 8ith 1 e)er used <=.+ $elfadministered on 1th 2onse2uti)e day of bleeding or spotting (B'$#

Source: 5ia et al &!!.

Treatment+ 5uration

(5ays#

Cy2les

(Mean#

<= 5ays

(Mean#

<edu2tion

in B'$ 5ays

5ifferen2e

(B'$<=# 5ays99 + +.+ -- /+ 1

ENA + +.+ -- +1 &0

Ibuprofen / +.7 &- ,/ +&

Pla2ebo + ,.& 0+



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Norplant Implants: <esults of Treatment

for Prolonged Bleeding continued

$ummary:

$ Compared 8ith pla2ebo days of B'$ redu2ed by more than

the days on treatment for:

– 99 group (1 days o)er & year#

– Ibuprofen group (+& days o)er & year#

$ Ibuprofen loo>s li>e a promising alternati)e to 99.

Source: 5ia et al &!!.



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Norplant Implants: Management of

Vaginal Bleeding Problems

! Before insertion ma>e sure 2lient is fully a8are that menstrual

bleeding pattern 8ill 2hange

! %t subse4uent )isits reassure that fre4uent or irregular

bleeding'spotting is not serious

! ea)y'prolonged bleeding o22urs rarely and may re4uire

treatment



12


Irregular Bleeding

! <eassuran2e

! Che2> for gyne2ologi2 problem (e.g. 2er)i2itis#

! $hortterm treatment:

$ CCs (,/ g 99# for & 2y2le& or

$ Ibuprofen (up to 1 mg , = day# = / days

&

<emind 2lient to e=pe2t bleeding after 2ompleting CCs.



13


Prolonged or ea)y Bleeding

! Carefully re)ie8 history and 2he2> gb'2t (if a)ailable#

! Che2> for gyne2ologi2 problem

! $hortterm treatment:

$ CCs for & 2y2le& or

$ Ibuprofen (up to 1 mg , = day# = / days

& <emind 2lient to e=pe2t bleeding after 2ompleting CCs.



14


Prolonged or ea)y Bleeding continued

! If bleeding not redu2ed in ,B/ days gi)e:

$ + CCs per day remainder of 2y2le follo8ed by & pill per

day for & 2y2le or

$ igh dose estrogen (/ g 99 CC or &.+/ mg 2onDugated

estrogen# for &-+& days

! Fterine e)a2uation (MV%#: only if other indi2ations



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%menorrhea

! <eassure

! Che2> for pregnan2y if amenorrhea o22urs after return of

regular 2y2les.

! If no problem found do not attempt to indu2e bleeding 8ith

CCs.



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%menorrhea

3hen to obtain a pregnan2y test (

CA#:

$ If the 2lient is 8orried about pregnan2y

$ If insertion after day 7 of menses and 2lient has had nobleeding or spotting sin2e insertion (6 , days#

$ If amenorrhea o22urs after return of regular 2y2les



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Norplant Implants: Client <esponse to

Common $ide 9ffe2ts

Source: 5arney et al &!!.

9=perien2ed Bothersome

Change in menstrual

bleeding pattern

1+" +7"

3eight 2hange (

+>g# ,+" &7"

eada2he +-" &"

%2ne (mild# &/" !"

None /" +7"

Management of Vaginal Bleed

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