Transcript Mirena IUD
TPMG CME Conference 2015 Jeff Morrison, DO • Searched for New Patient visits and Consults to TPMG Ob/Gyn in 2013 and 2014. • 2070 Patient visits • Menorrhagia • Irregular Menses • Vaginitis • Postmenopausal bleeding • Contraceptive Counseling • Cystocele • Reproductive Age Females • 80 ml • A volume of bleeding that interferes with daily activities • Changing a pad or tampon more that every two hours • Pregnancy, Pregnancy, Pregnancy • • • • • • • Uterine abnormalities Ovulatory dysfunction Cancer Bleeding disorder Infection Endocrine abnormalities Medication • • • • Perimenopause Anovulation Uterine abnormalities Cancer • • • • • • 53/1000 US women experience difficulties 5,300/100,000 Cervical Cancer – 6/100,000 Breast Cancer – 122/100,000 Colon Cancer – 39/100,000 Influenza Deaths – 1.2/100,000 • • • • • • • • • • What’s the source? History Is she pregnant? Contraception, sexual activity? Has this happened before? Previous evaluation? Last Pap smear? Hx of abnormal pap smears? Context of bleeding? New medications? • Physical Exam • Ultrasound • BHCG, CBC, TSH, Chlamydia/Gonorrhea testing • History is unreliable • Physical Exam • Ph testing, Wet prep, Culture • 60% vulvovaginitis • 70% trichomoniasis • 90% bacterial vaginosis • • • • Vaginal pH BV (>4.5) Trichomoniasis (5-6) Candida (4-4.5) • No Microscope • Culture for yeast • NAA (nucleic acid amplification) tests for trichmoniasis, bacterial vaginosis, candida • Culture for candida • Bacterial cultures are unreliable • • • • • DNA tests for Gonorrhea and Chlamydia Cytology – unreliable Confirmation with wet prep BV – sensitivity 49% vs wet prep Trichomoniasis – False-positive rate of 4% • • • • • Non-infectious causes Atrophy Lichen sclerosis Contract dermatitis Stress Incontinence • BV – frequently recurrent (30% within 3 months) • Partner treatment ineffective • Prolonged antibiotic therapy • • • • • • • • • Rule out malignancy History Symptoms Timing Aggravating Factors Medications OTC treatments Family Hx of breast, colon, and gynecologic cancers BMI • Pelvic US • Endometrial lining is > 4mm • Endometrial changes – diffuse or focal increased echogenicity (heterogeneity) • Endometrium not adequately visualized • Endometrial biopsy/sampling • Persistent bleeding • Endometrial biopsy/sampling • • • • • • Cervical cancer Mean age 52.2 years Peaks at 35 – 39, and 60-64 Endometrial cancer Mean Age 61 years >40% women older than 65 • Many changes • Permanent vs. Reversible • • • • Permanent Methods Vasectomy Hysteroscopic tubal occlusion (In-office procedure) Laparoscopic bilateral tubal cauterization • • • • • • • • • • • Paragard IUD Mirena IUD Skyla IUD Nexplanon implant Depot Provera Nuva ring Ortho Evra patch OCPs Natural family planning Condoms, Diaphragm Withdrawal • 46% of women discontinue contraception – side effects, partner complaint • Nexplanon implant and Progesterone IUD 84,80% continuation rate • Copper IUD – 78 % continuation rate • Pill, patch, ring – 67 % • Asymptomatic – no treatment needed • Symptomatic – Pessary – Surgical intervention • Apical support – traditional vs. mesh repair • Anterior repair – High rate of recurrence without apical support • Mesh repair – lower rate of recurrence • Poor surgical candidate • Le Forte colpoclesis