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Norplant Implants: Management of Vaginal Bleeding Problems

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Norplant Implants: Management of Vaginal Bleeding Problems

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    1. 1 Norplant® Implants: Management of Vaginal Bleeding Problems Norplant® is a registered trademark of the Population Council for subdermal levonorgestrel implants.

    2. 2 Norplant Implants: Types of Menstrual Bleeding Pattern Changes Irregular bleeding (70B90%) Spotting Amenorrhea (less than 10% first year) Prolonged bleeding/spotting Heavy bleeding (rare)

    3. 3 Norplant Implants: Menstrual Bleeding Patterns (N=234) Typically, the frequency of bleeding changes, especially irregular and prolonged bleeding, decreases with time and is less of a problem by the end of the first year. In this study, 66% of the women had irregular bleeding, 27% regular bleeding and 7% were amenorrheic in the first year. By the fifth year, only 38% had irregular bleeding while 62% had regular bleeding and none were amenorrheic.Typically, the frequency of bleeding changes, especially irregular and prolonged bleeding, decreases with time and is less of a problem by the end of the first year. In this study, 66% of the women had irregular bleeding, 27% regular bleeding and 7% were amenorrheic in the first year. By the fifth year, only 38% had irregular bleeding while 62% had regular bleeding and none were amenorrheic.

    4. 4 Norplant Implants: Definitions of Vaginal Bleeding Problems Amenorrhea: No vaginal bleeding or spotting for at least 3 consecutive months Irregular bleeding Prolonged spotting: > 8 days Moderate bleeding: $ normal menses, 50B80 ml Prolonged bleeding: > 8 days Heavy bleeding: twice as long or twice as much as normal menses

    5. 5 DMPA vs. Norplant Implants Dysynchronous refers to a histological picture when the endometrium is composed of endometrial cells at different stages of development, ranging from proliferative to secretory.Dysynchronous refers to a histological picture when the endometrium is composed of endometrial cells at different stages of development, ranging from proliferative to secretory.

    6. 6 Norplant Implants: Endometrial Changes Dysynchronous Endometrium Progestin dominant Occasional estrogen surges

    7. 7 Norplant Implants: Factors Affecting Acceptance of Menstrual Changes Need for contraception Reaction of the partner to menstrual changes Interference with sexual/daily activity Religious constraints Counseling Staff attitudes and knowledge Availability of “user friendly” client information

    8. 8 Norplant Implants: Counseling Affects Continuation Thorough counseling has been shown to decrease discontinuation as a result of changes in bleeding patterns. This study compared groups of Norplant users over two time periods, 1975-1978 (Group 1) and 1982-1983 (Group 2). Group 2 received counseling before and after insertion of the implants about all the side effects and potential problems during use, partly because the clinic staff had more experience and more confidence in Norplant. As shown in the graph, the group that received more thorough counseling had much lower discontinuation rates.Thorough counseling has been shown to decrease discontinuation as a result of changes in bleeding patterns. This study compared groups of Norplant users over two time periods, 1975-1978 (Group 1) and 1982-1983 (Group 2). Group 2 received counseling before and after insertion of the implants about all the side effects and potential problems during use, partly because the clinic staff had more experience and more confidence in Norplant. As shown in the graph, the group that received more thorough counseling had much lower discontinuation rates.

    9. 9 Norplant Implants: Results of Treatment for Prolonged Bleeding1 The columns in the above table are as follows: Duration is the number of days that the treatment was given. Cycles is the mean number of treatments per year. Rx Days is the mean number of day per year that treatment was given (product of duration multiplied by cycles) Reduction in B/S days is the mean number of days of reduction in bleeding and spotting per year. The columns in the above table are as follows: Duration is the number of days that the treatment was given. Cycles is the mean number of treatments per year. Rx Days is the mean number of day per year that treatment was given (product of duration multiplied by cycles) Reduction in B/S days is the mean number of days of reduction in bleeding and spotting per year.

    10. 10 Norplant Implants: Results of Treatment for Prolonged Bleeding continued Summary: Compared with placebo, days of B/S reduced by more than the days on treatment for: EE group (8 days over 1 year) Ibuprofen group (21 days over 1 year) Ibuprofen looks like a promising alternative to EE.

    11. 11 Norplant Implants: Management of Vaginal Bleeding Problems Before insertion, make sure client is fully aware that menstrual bleeding pattern will change At subsequent visits, reassure that frequent or irregular bleeding/spotting is not serious Heavy/prolonged bleeding occurs rarely and may require treatment

    12. 12 Norplant Implants: Management of Irregular Bleeding Reassurance Check for gynecologic problem (e.g., cervicitis) Short-term treatment: COCs (30-50 Fg EE) for 1 cycle1, or Ibuprofen (up to 800 mg 3 x day) x 5 days

    13. 13 Norplant Implants: Management of Prolonged or Heavy Bleeding Carefully review history and check Hgb/Hct (if available) Check for gynecologic problem Short-term treatment: COCs for 1 cycle1, or Ibuprofen (up to 800 mg 3 x day) x 5 days

    14. 14 Norplant Implants: Management of Prolonged or Heavy Bleeding continued If bleeding not reduced in 3B5 days, give: 2 COCs per day remainder of cycle followed by 1 pill per day for 1 cycle, or High dose estrogen (50 Fg EE COC or 1.25 mg conjugated estrogen) for 14-21 days Uterine evacuation (MVA): only if other indications

    15. 15 Norplant Implants: Management of Amenorrhea Reassure Check for pregnancy if amenorrhea occurs after return of regular cycles. If no problem found, do not attempt to induce bleeding with COCs.

    16. 16 Norplant Implants: Management of Amenorrhea When to obtain a pregnancy test ($HCG): If the client is worried about pregnancy If insertion after day 7 of menses and client has had no bleeding or spotting since insertion (> 30 days) If amenorrhea occurs after return of regular cycles

    17. 17 Norplant Implants: Client Response to Common Side Effects Among women using Norplant Implants, 82% experienced a change in their menstrual bleeding pattern, however, only 27% reported this side effect as bothersome. A smaller number of women reported that other side effects were most bothersome. Among women using Norplant Implants, 82% experienced a change in their menstrual bleeding pattern, however, only 27% reported this side effect as bothersome. A smaller number of women reported that other side effects were most bothersome.

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