Transcript The End of The Menstrual Period?

Women’s Health Initiative
August 19, 2014
Cleve Ziegler, M.D
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CME Speaker:
Bayer, Schering-Plough (Merck), Bayer, Wyeth
(Pfizer)
Advisory Board:
Bayer, GSK, Schering-Plough (Merck)
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Physiology of Menstruation
Anthropology of Menstruation
Cultural Attitudes Toward Menstruation
Update In New Contraceptive Methods
Concept of Extended Cycle Contraception and
Menstrual Suppression
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Ridding the body of
toxins
Sign of fertility and
femininity
Physiological anemia
and reduction in
cardiovascular disease
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Normal Physiological
Process
Dysmenorrhea
Menorrhagia
Endometriosis
Ovarian cancer
Breast cancer
Premenstrual
syndrome
Migraine headache
Epilepsy
Pathological Entity
Unintended
Pregnancies
Each Year
Unintended
Pregnancies
Using
Contraception
Finer LG. Perspect Sex Reprod Health. 2006; Moreau C. Contraception. 2007.
Frost JJ. In Brief. 2008.
“Arriving at a moment of social
and political upheaval,
the Pill became a handy proxy
for wider trends:
the rejection of tradition,
the challenge to institutions,
the redefinition of women’s roles”
Nancy Gibbs,
Time Executive Editor
Time Magazine, May 3, 2010.
Unintended Pregnancy in
First Year of Contraceptive Use*
*not head-to-head comparison of contraceptive methods
Women with Unintended Pregnancy
within First Year of Use (%)
90
85 85
80
Perfect Use
Typical Use
70
60
50
40
30
20
15
8
10
2
0.3
8
0.3
0.3
3
0.6 0.8
0.1 0.1
0.5 0.5
Copper IUD
LNG-IUS
Female
Sterilization
0
No Method
Condom
COC and POP
Patch / Ring
DMPA
COC=combined oral contraceptive; POP= progestin only pill; DMPA=depot
medroxyprogesterone; LNG-IUS=levonorgestrel releasing intrauterine system
Trussell J. Contraception 2004; 70: 89-96.
Pill
63
39
Male Sterilization
Condom
38
28
Female Sterilization
Injection
23
10
IUD
8
Withdrawal
7
Rhythm
6
Female Condom
4
Diaphragm
1
Cervical Cap
0
10
20
*Based on Respondents Familiar with Method
Fisher WA et al. JOGC 2004;June :580-590.
30
40
Values in %
50
60
70
% of women
0
10
20
30
40
50
60
Condom
Combined oral contraceptive
Male/Female sterilization
Withdrawal
Intrauterine device/system
Rhythm
Natural family planning
Injection:DMPA
Column totals may exceed 100% as women were allowed to choose more than one method.
Base: Women aged 15-50 who have had vaginal intercourse in the previous 6 months, n=2,341
DMPA=depot medroxyprogesterone
Back et al. J Obstet Gynaecol Can 2009;31(7):627–640.
Cultural Preferences
Geographic Trends
21/7 Phasic
21/7 Phasic
160
140
Ethinyl Estradiol
120
Mestranol
80
Estrogen
(µg) 60
40
20
0
1960
1970
1980
Year of Introduction
Thorneycroft IH. Infert Clin North Am. 2000;11:515-529.
1990
2000
Most serious cardiovascular
adverse events associated with all
COCs
Venous
thromboembolism
Stroke
Farley et al., Contraception 1996; 57(3)211-30.
Myocardial
infarction
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Women
NonPregnant
Pregnant
OC Users
Non Users
Dinger Contraception 2007
BMI: body mass index
*Risk estimates based on 115 VTEs in 116,708 WY of exposure
Dinger, EURAS Study, Presentation EC Prague 2008.
Impact of Multiple Risk Factors on
VTE Risk During OC Use
1 Risk Factor
2 Risk Factors
3 Risk Factors
300
271
216
VTE/10,000 WY
200
171
137
111
100
53
B
I2
I3
M
M
0+
;A
ge
is
to
ry
**
40
+
H
ge
A
VT
E
40
5+
+
;H
B
is
M
t.
I3
0+ **
;H
A
ge
i
40 st.
+;
B
H
M
is
I2
t.
5+
;A
B
ge
M
I3
40
0+
+;
;A
ge His
t.
40
+;
H
is
t.
O
be
s
ity
(B
M
I3
0+
)
Fa
ct
or
Ri
sk
o
N
27
21
18
B
4
0
** Family or personal history of VTE
Based on EURAS study results: not yet published
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1. Preferential prescribing of new
preparations to new users
2. Most VTE in first 6 months, newer users at
higher risk
3.Preferential prescribing of new drugs to
higher risk patients because of perceived
“safety”.
4. Preferential prescribing of drospirenone to
hyperandrogenic women who have underlying
vascular disease
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1 ring per cycle
Regimen:
◦3 weeks of ring-use
◦1 ring-free week
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Daily release:
◦15 µg ethinylestradiol
◦120 µg etonogestrel
Pharmacokinetic profile
NuvaRing and 30 EE/150 DSG COC
Etonogestrel (pg/mL)
Css OC
60
50
1500
Css OC
1000
40
30
500
20
0
10
-500
0
0
5
10
15
Time after insertion (days)
Timmer & Mulders, Clin Pharmacokinet, 2000;39:233–42
20
Ethinylestradiol (pg/mL)
Etonogestrel
Ethinylestradiol
2000
Prevalence of IUD use in women aged 15-49, married or in union (2005)
D’Arcangues et a., Contraception. 2007; 75: S2-S7
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Intrauterine system (IUS)
Releases up to 20 μg/day of
levonorgestrel (progestin)
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No estrogen
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5 years of treatment
Indications
 Contraception
Mirena provides contraception through
a combination of 3 main actions:
Minor effect
on ovarian
function
2- Inhibition of
3- Prevention of
endometrial
growth
sperm function
1- Thickening of
cervical mucus
Normal menstrual cycle
Days of cycle
Menstrual cycle in a
woman with Mirena
Endometrium in resting state
Resulting in scanty bleeding
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1. Use 2nd generation pill with lowest
estrogen dose as first choice
2.If adverse effects occur, switch to 3rd or 4th
generation pill.
3.Patients at high risk for VTE should use
progestin only pill, DMPA, or IUS.
4.Use 2nd generation pill in older women