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El spottingo sangrado irregular no menstrual es uno de los principales efectos secundarios de los implantes anticonceptivos, situación que se recomienda discutir con la usuaria previo a la colocación, para evitar falsas expectativas o temores que lleven a la extracción temprana del dispositivo. A propósito de una paciente sin antecedentes relevantes que consultó al centro de salud por spotting desde la colocación del implante cuatro meses antes, decidimos revisar la evidencia sobre la efectividad de los distintos esquemas farmacológicos disponibles para el manejo de este evento adverso. Luego de realizar una búsqueda bibliográfica concluimos que, si bien existe sustento para indicar algunos de los esquemas farmacológicos, este es aún débil y son necesarios estudios clínicos adicionales que brinden evidencia sólida sobre qué esquema en particular utilizar, evaluando sus riesgos y beneficios. (AU)

Spotting or irregular non-menstrual bleeding is one of the main side effects of contraceptive implants, a situation that health professionals must discuss with the user prior to its placement in order to avoid false expectations or fears that lead to early removal of the implant. Regarding a patient with no relevant history who consulted the health center due to spotting four months after implant placement, we decided to review the evidence onthe effectiveness on different pharmacological schemes available for the management of this adverse event. After performing a literature search, we concluded that, although there is support for indicating some of the pharmacological schemes, this is still weak, and further clinical studies are needed to provide solid evidence on which particular scheme touse, assessing its risks and benefits. (AU)

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O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)

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Evaluation of: Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, Phase II study describing the efficacy, bleeding profile, and safety of two low-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil. Steril. 97(3), 616-622.e3 (2012). A randomized, open-label, Phase II study was conducted in 37 centers in five European countries to assess the optimal dose for a new contraceptive levonorgestrel intrauterine system (LNG-IUS). Overall, 742 parous or nulliparous women aged 21-40 years were allocated to receive a LNG-IUS that initially releases 12 µg/day (LNG-IUS(12)) or 16 µg/day (LNG-IUS(16)) in vitro or the currently available device that releases 20 µg/day (LNG-IUS(20)). The two new devices are shorter than the current one. Pearl Indices of 0.17, 0.82 and 0.00 for the LNG-IUS(12), LNG-IUS(16) and LNG-IUS(20), respectively, reflect the contraceptive efficacy of these devices. The mean number of bleeding and spotting days decreased in all three groups; however, this decrease was more significant in LNG-IUS(20) users. Placement of the new shorter devices was considered simple by providers, while patients reported significantly less pain with the two new devices compared with the current one. This study provided further insight into the development of two new LNG-IUS devices as contraceptives, with the additional possibility of using them to treat heavy menstrual bleeding or as endometrial protection during estrogen therapy.

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El uso continuo de anticonceptivos hormonales activos mediante la inserción del sistema intrauterino liberador de progestágenos (Levonorgestrel) ha sido de gran utilidad, pues además de la deseada acción anticonceptiva se le añade un efecto positivo de utilidad para el manejo de algunas afecciones ginecológicas, como son la endometriosis, fibromatosis uterina y ciertas disfunciones menstruales, a los que se han ido agregando recientemente nuevas indicaciones. OBJETIVO: Evaluar la utilidad del SIU liberador de Levonorgestrel (Mirena) en el manejo de las metrorragias y otras afecciones ginecológicas. MÉTODOS: Se realizó un estudio prospectivo, longitudinal, descriptivo que incluyó a 19 pacientes a las que se les insertó Mirena con el propósito de tratar las metrorragias y otras afecciones ginecológicas, en el período de tiempo comprendido entre el 1º de enero de 2003 al 31 de diciembre de 2008. Las pacientes incluidas en el estudio se evaluaron semestralmente mediante interrogatorio, examen clínico, estudios hematológicos y ecografía. RESULTADOS: Encontramos una notoria reducción del flujo menstrual, aquellas con más de 12 meses de uso presentaron un incremento de 1 ¢ gr en las cifras iniciales de hemoglobina. Las pacientes con miomas lograron discreta reducción tumoral y control de las metrorragias en tanto se comprobó una reducción en las masas quísticas y los síntomas en las pacientes con endometriosis, en tanto logramos un endometrio lineal en las pacientes en terapia de reemplazo hormonal (TRH). CONCLUSIONES: Los efectos adversos más reportados fueron los relacionados a la acción local del progestágeno sobre el endometrio como son el spotting y la amenorrea, de forma excepcional se reportaron calambres en miembros inferiores, hasta la fecha ninguna usuaria ha interrumpido la utilización de Mirena

The continuous use of active hormonal contraceptives by insertion of intrauterine system releaser of progestational agent (Levonorgestrel) has been very useful due to its desired contraceptive action as well as its positive effect for managing of some gynecological affections including endometriosis, uterine fibromatosis and certain menstrual dysfunctions and adding recently new indications. OBJECTIVE: To assess the usefulness of the intrauterine releaser system Lovenorgestrel (Mirena) in management of metrorrhagies and other gynecological affections. METHODS: A descriptive, longitudinal and prospective study was conducted including 19 patients underwent Mirena insertion to treatment metrorrhagies and other gynecological affections between January 1, 2003 and December 31, 2008. Patients included in study were half-yearly assessed by interviews, clinical examination, hematology studies and echography. RESULTS: There was a market reduction of menstrual flux; those patients with more than 12 months of use had an increase of 1 ¢ gr in first figures of hemoglobin. Patients presenting with myomata achieved a slight reduction of tumor and a metrorrhagies control also verifying a decrease in cystic masses and in symptoms of patients with endometriosis, while it was possible to obtain a linear endometrium in patients under hormone replacement therapy (HRT). CONCLUSIONS: More frequently reported adverse effects were those related to local action of progestogen on endometrium e.g. spotting and amenorrhea. As exception were the lower extremities cramps. Until now no patient has interrupted the use of Mirena

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Presentamos nuestra experiencia de 6 pacientes con metrorragia a repetición, portadoras de patologías médicas que representaban un riesgo desde el punto de vista anestésico y quirúrgico, en las cuales se insertó DIU-LNG como alternativa a la histerectomía. Todas evolucionan satisfactoriamente y sin complicaciones, con disminución significativa de las pérdidas hemáticas desde el tercer mes de uso, objetivadas por pictogramas. Se concluye que el DIU-LNG es un excelente método para el control de metrorragias en pacientes con patologías médicas relevantes.

We present our experience with 6 patients with menorrhagia and medical conditions considered high risk patients for anaesthesia and surgical procedures. We inserted LNG-IUD as alternative to hysterectomy. Three months later, all of them reduced menstrual blood loss as it was shown by pictorial charts, without complications. LNG-IUD is an excellent alternative to hysterectomy in this group of patients.

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The use of long acting gonadotropin-releasing hormone (Gn-RH) agonist produces a reversible hypogonadotropic hypogonadism. This effect has been used as presurgical treatment of uterine myomata, resulting in amenorrhea and reduction in uterus and tumour sizes. We describe the case of a 43 year old patient, having a uterine myoma associated with metrorrhagia, admitted to hospital because of extensive deep phlebothrombosis requiring urgent anticoagulation. Because of the risk of exacerbating metrorrhagia and considering the high morbidity associated to emergency hysterectomy, we decided medical treatment with a depot GnRH agonist (leuprolide acetate 3.75 mg IM monthly). Bleeding ceased within 3 days, allowing the maintenance of anticoagulant treatment. A marked reduction in uterine size postponed total hysterectomy to 3 months later. The characteristics of GnRH analogues, their action mechanisms, adverse effects and other clinical indications are discussed.

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Se describe un caso clínico de colestasia por anticonceptivos orales de comienzo precoz (al décimo día de tratamiento) en una adolescente, nuligesta, de 11 años de edad, que presentó menometrorragia intensa. La colestasia se trató con altas dosis de clorhidrato de piridoxina (400 milígramos diarios); evoluciona con completa recuperación clínica y bioquímica que permitió mantener el tratamiento con gestágenos por 4 ciclos. Se descartan otras causas de colestasias por estudios complementarios

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PIP: 3 groups of IUD users participated in a preliminary study to evaluate the effect of calcium lonazolac, a nonsteroid antiinflammatory agent, on excessive menstrual bleeding. All participants were parous women aged 20-30 years in good health. Multiload 250 IUDs were inserted in 15 women averaging 24.5 years of age. They were also supplied with calcium lonazolac tablets in 200 mg doses to be taken continuously 3 times daily. 15 women averaging 26.1 years also had multiload 250 IUDs inserted. They were given the same instructions but their medication was a placebo. A third group of 30 women averaging 26.2 years of age who had experienced heavy bleeding during 6-36 months of IUD use were given 200 mg tablets of calcium lonazolac to be taken 3 times daily. The 30 women used various types of IUDs. All 60 women were provided with sanitary pads to be returned at their regular clinic visits. Hemoglobin and hematocrit levels were also determined at each visit. The method of Hallberg and Nilsson was used to measure menstrual blood loss. There were no significant changes in the volume or duration of bleeding or hemoglobin or hematocrit levels in the 15 women given the drug. The 15 women given the placebo had a significant increase in the quantity of blood loss and a significant increase in the duration bleeding in the 3rd month. The 30 women with histories of heavy bleeding had significant decreases in volume and duration of bleeding. Modifications in hemoglobin were not especially significant, while the hematocrit levels increased in the 2nd and 3rd months. None of the women reported significant side effects except 1 woman with a prior history of gastritis. Her gastric distress was controlled by an antacid after meals for 1 week. Comparison of results between the treated and control groups suggests that calcium lonazolac gives good results. Its use should be evaluated at lower doses with consumption limited to days of bleeding only.^ieng

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