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options for emergency contraception include the follow-
ing:
Preven Kit  two pills per dose (0.5 mg of
levonorgestrel and 100 µg of ethinyl estradiol per
dose)
Plan B  one pill per dose (0.75 mg of levonorgestrel
per dose)
Ovral  two pills per dose (0.5 mg of levonorgestrel
and 100 µg of ethinyl estradiol per dose)
Nordette  four pills per dose (0.6 mg of
levonorgestrel and 120 µg of ethinyl estradiol per
dose)
Triphasil  four pills per dose (0.5 mg of
levonorgestrel and 120 µg of ethinyl estradiol per
dose)
References: See page 255.
Endometriosis
Endometriosis is characterized by the presence of
endometrial tissue on the ovaries, fallopian tubes or other
abnormal sites, causing pain or infertility. Women are usually
25 to 29 years old at the time of diagnosis. Approximately 24
percent of women who complain of pelvic pain are subse-
quently found to have endometriosis. The overall prevalence
of endometriosis is estimated to be 5 to 10 percent.
I.Clinical evaluation
A.Endometriosis should be considered in any woman of
reproductive age who has pelvic pain. The most common
symptoms are dysmenorrhea, dyspareunia, and low back
pain that worsens during menses. Rectal pain and painful
defecation may also occur. Other causes of secondary
dysmenorrhea and chronic pelvic pain (eg, upper genital
tract infections, adenomyosis, adhesions) may produce
similar symptoms.
Differential Diagnosis of Endometriosis
Generalized pelvic pain Dyspareunia
Pelvic inflammatory Musculoskeletal causes (pel-
disease vic relaxation, levator spasm)
Endometritis Gastrointestinal tract (consti-
Pelvic adhesions pation, irritable bowel syn-
Neoplasms, benign or drome)
malignant Urinary tract (urethral syn-
Ovarian torsion drome, interstitial cystitis)
Sexual or physical Infection
abuse Pelvic vascular congestion
Nongynecologic Diminished lubrication or
causes vaginal expansion because
Dysmenorrhea of insufficient arousal
Primary Infertility
Secondary Male factor
(adenomyosis, Tubal disease (infection)
myomas, infection, cer- Anovulation
vical stenosis) Cervical factors (mucus,
sperm antibodies, stenosis)
Luteal phase deficiency
B.Infertility may be the presenting complaint for
endometriosis. Infertile patients often have no painful
symptoms.
C.Physical examination. The physician should palpate
for a fixed, retroverted uterus, adnexal and uterine
tenderness, pelvic masses or nodularity along the
uterosacral ligaments. A rectovaginal examination should
identify uterosacral, cul-de-sac or septal nodules. Most
women with endometriosis have normal pelvic findings.
II.Treatment
A.Confirmatory laparoscopy is usually required before
treatment is instituted. In women with few symptoms, an
empiric trial of oral contraceptives or progestins may be
warranted to assess pain relief.
B.Medical treatment
1.Initial therapy also should include a nonsteroidal anti-
inflammatory drug.
a.Naproxen (Naprosyn) 500 mg followed by 250 mg
PO tid-qid prn [250, 375,500 mg].
b.Naproxen sodium (Aleve) 200 mg PO tid prn.
c.Naproxen sodium (Anaprox) 550 mg, followed by
275 mg PO tid-qid prn.
d.Ibuprofen (Motrin) 800 mg, then 400 mg PO q4-6h
prn.
e.Mefenamic acid (Ponstel) 500 mg PO followed by
250 mg q6h prn.
2.Progestational agents. Progestins are similar to
combination OCPs in their effects on FSH, LH and
endometrial tissue. They may be associated with more
bothersome adverse effects than OCPs. Progestins are
effective in reducing the symptoms of endometriosis.
Oral progestin regimens may include once-daily
administration of medroxyprogesterone at the lowest
effective dosage (5 to 20 mg). Depot
medroxyprogesterone may be given intramuscularly
every two weeks for two months at 100 mg per dose
and then once a month for four months at 200 mg per
dose.
3.Oral contraceptive pills (OCPs) suppress LH and
FSH and prevent ovulation. Combination OCPs alleviate
symptoms in about three quarters of patients. Oral
contraceptives can be taken continuously (with no
placebos) or cyclically, with a week of placebo pills
between cycles. The OCPs can be discontinued after
six months or continued indefinitely.
4.Danazol (Danocrine) has been highly effective in
relieving the symptoms of endometriosis, but adverse
effects may preclude its use. Adverse effects include
headache, flushing, sweating and atrophic vaginitis.
Androgenic side effects include acne, edema, hirsutism,
deepening of the voice and weight gain. The initial
dosage should be 800 mg per day, given in two divided
oral doses. The overall response rate is 84 to 92
percent.
Medical Treatment of Endometriosis
Adverse ef-
Drug Dosage fects
Danazol 800 mg per day in 2 di- Estrogen defi-
(Danocrine) vided doses ciency,
androgenic side
effects
Oral contra- 1 pill per day (continuous Headache,
ceptives or cyclic) nausea, hyper-
tension
Medroxyprog 5 to 20 mg orally per day Same as with
esterone other oral
(Provera) progestins
Medroxyprog 100 mg IM every 2 weeks Weight gain,
esterone sus- for 2 months; then 200 mg depression,
pension IM every month for 4 irregular men-
(Depo- months or 150 mg IM ev- ses or
Provera) ery 3 months amenorrhea
Norethindron 5 mg per day orally for 2 Same as with
e (Aygestin) weeks; then increase by other oral
2.5 mg per day every 2 progestins
weeks up to 15 mg per
day
Leuprolide 3.75 mg IM every month Decrease in
(Lupron) for 6 months bone density,
estrogen defi-
ciency
Goserelin 3.6 mg SC (in upper ab- Estrogen defi-
(Zoladex) dominal wall) every 28 ciency
days
Nafarelin 400 mg per day: 1 spray in Estrogen defi-
(Synarel) 1 nostril in a.m.; 1 spray in ciency, bone
other nostril in p.m.; start density
treatment on day 2 to 4 of changes, nasal
menstrual cycle irritation
C.GnRH agonists. These agents (eg, leuprolide [Lupron],
goserelin [Zoladex]) inhibit the secretion of gonadotropin.
GnRH agonists are contraindicated in pregnancy and have
hypoestrogenic side effects. They produce a mild degree [ Pobierz całość w formacie PDF ]