family planning (2) 부산백병원 산부인과 조인호. 2 health benefits of oral contraceptives

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Family Planning Family Planning (2) (2) 부부부부부 부부부부 부부부부부 부부부부 부부부 부부부

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Page 1: Family Planning (2) 부산백병원 산부인과 조인호. 2 Health Benefits of Oral Contraceptives

Family Planning (2)Family Planning (2)

부산백병원 산부인과부산백병원 산부인과조인호조인호

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Health Benefits of Oral Health Benefits of Oral ContraceptivesContraceptives

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Fertility after OC UseFertility after OC Use OC stopOC stop 후 수개월이 지나야 후 수개월이 지나야 ovulatory cycleovulatory cycle

이 되돌아 옴이 되돌아 옴 .. 66 개월이 지나도 돌아오지 않으면 개월이 지나도 돌아오지 않으면 pprolactin-ppprolactin-p

roducing pituitary tumorsroducing pituitary tumors 에 대한 에 대한 evaluationevaluation이 필요이 필요 ..

SexualitySexuality Menstual cycleMenstual cycle 에서 볼 때에서 볼 때 , ovulation time, ovulation time 에 에

가장 증가함가장 증가함 .. OCOC 복용과 복용과 SexualitySexuality 의 상관관계는 없음의 상관관계는 없음 ..

TeratogenicityTeratogenicity OCOC 복용과 상관관계 없음복용과 상관관계 없음 ..

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Interaction of Oral Contraceptives Interaction of Oral Contraceptives with Other Drugswith Other Drugs

OCOC 의 의 effectivenesseffectiveness 를 감소시키는 를 감소시키는 DrugsDrugs Phenytoin, phenobarbital rifampin Phenytoin, phenobarbital rifampin Antifungal agentsAntifungal agents Ampicillin, tetracyclineAmpicillin, tetracycline

OCOC 의 의 effectivenesseffectiveness 를 증가시키는 를 증가시키는 DrugsDrugs Vit C, AcetaminophenVit C, Acetaminophen

Benzodiazepine : OCBenzodiazepine : OC 로 인해 로 인해 half lifehalf life 증가증가

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Choice of Oral ContraceptivesChoice of Oral Contraceptives

11stst choice : Low-estrogen OC (20-35ug of EE) choice : Low-estrogen OC (20-35ug of EE) or very low-estrogen OC (20ug EE)or very low-estrogen OC (20ug EE)

Side effect (Common)Side effect (Common) Breakthrough bleeding and spottingBreakthrough bleeding and spotting

Tx : Tx : multiphasic -> monophasic (same estrogen level)multiphasic -> monophasic (same estrogen level) Estrogen Estrogen 용량 증가 용량 증가 -20ug of EE (daily for 7days)-20ug of EE (daily for 7days)

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Side effectSide effect Nausea, breast tenderness, mood changes aNausea, breast tenderness, mood changes a

nd weight gainnd weight gain ManagementManagement

Lowest-dose highly effective formulation-only Lowest-dose highly effective formulation-only 20ug of EE20ug of EE

Breast tenderness - more progestin activity ( 2Breast tenderness - more progestin activity ( 20-30ug EE + levonorgestrel)0-30ug EE + levonorgestrel)

Nasea – 20ug EENasea – 20ug EE

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Injectable Hormonal ContraceptivesInjectable Hormonal Contraceptives

Depomedroxyprgesterone acetate (DMPA)Depomedroxyprgesterone acetate (DMPA) Suspension of microcrystals of a synthetic proSuspension of microcrystals of a synthetic pro

gestingestin A single 150mg IM dose – 14wksA single 150mg IM dose – 14wks 동안 동안 ovulatiovulati

on supressionon supression 33 개월마다 한 번씩 –개월마다 한 번씩 – highly effectivehighly effective 작용작용 : Total amenorrhea: Total amenorrhea 를 일으킴를 일으킴 DisruptionDisruption 후 후 11 년내 년내 50%, 250%, 2 년내 년내 90%90% 에서 에서

fertilityfertility 회복함회복함 ..

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DMPADMPA 의 의 SafetySafety Lower bone densityLower bone density 유발 유발 ::

이유이유 : reflecting reduced estrogen level: reflecting reduced estrogen level But, not been associated with increased fractures.But, not been associated with increased fractures.

Bone densityBone density 의 의 Rapid increaseRapid increase 를 를 blockblock AdolescentsAdolescents 에 에 less disirableless disirable

LipidLipid 변화변화 Total Cholesterol, Triglycerides Total Cholesterol, Triglycerides 감소감소 HDL HDL 약간 감소약간 감소 , LDL , LDL 약간 증가 혹은 변화없음약간 증가 혹은 변화없음 .. But, not associated with MIBut, not associated with MI

Hemorrhage, teratogenesisHemorrhage, teratogenesis 유발시키지 않음유발시키지 않음 .. Mood changeMood change 를 일으키지 않음를 일으키지 않음

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DMPADMPA 의 의 BenefitsBenefits 감소시키는 것들감소시키는 것들

Anemia, PID, ectopic pregnancy, endometrial ca.Anemia, PID, ectopic pregnancy, endometrial ca. 연관성이 없는 것들연관성이 없는 것들

Cervical ca. , ovarian ca.Cervical ca. , ovarian ca. 증가시키는 것증가시키는 것

Breast ca.Breast ca.

최근에 나온 최근에 나온 DMPADMPA 제제제제 DMPA 25mg + 5mg long acting estrogen, estrDMPA 25mg + 5mg long acting estrogen, estr

adiol cypionate -adiol cypionate - 한달에 한번씩한달에 한번씩

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Subdermal ImplantsSubdermal Implants

Levonorgestrel implant (Norplant)Levonorgestrel implant (Norplant) 첫 첫 6-126-12 개월동안 개월동안 80mg/d release80mg/d release 이후 점점 감소하여 이후 점점 감소하여 35mg/d35mg/d 로 감소로 감소 55 년간 년간 plasma levelplasma level 을 을 25ng/mL25ng/mL 로 유지 로 유지 (20ng(20ng

/ml/ml 이상인 경우 효력이 있음이상인 경우 효력이 있음 )) 기전 기전 : :

LH surge block, LH surge block, cervixcervix 의 의 mucusmucus 를 를 scant, thickscant, thick 하게 만들어 하게 만들어 spermsperm

의 의 penetrationpenetration 방해방해 단점 단점 : : 체중이 체중이 70kg70kg 이상일때 이상일때 efficacyefficacy 가 가

떨어짐떨어짐 ..

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3-koto-desogestrel (Implanon)3-koto-desogestrel (Implanon) NorplantNorplant 보다 보다 effectiveeffective 33 년간 지속년간 지속

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Subdermal ImplantsSubdermal Implants

Bleeding PatternsBleeding Patterns ImplantImplant 는 는 Endometrial atropyEndometrial atropy 유발시킴유발시킴 .. Complete amenorrheaComplete amenorrhea 에 이르기 까지 에 이르기 까지 daily sdaily s

pottingpotting 에서 에서 regular monthly bleedingregular monthly bleeding 까지 까지 다양함다양함 ..

Low-dose oral estrogen, low-dose oral levonoLow-dose oral estrogen, low-dose oral levonorgestre or ibuprofenrgestre or ibuprofen

LactationLactation 과 무관함과 무관함 .. ImplantImplant 제거 후 즉시 제거 후 즉시 fertilityfertility 회복함회복함

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Metabolic effectMetabolic effect T-Chol, TG : T-Chol, TG : 감소감소 HDL : HDL : 변화 없거나 약간 감소변화 없거나 약간 감소 Atherosclerosis Atherosclerosis 촉진촉진 Bone densityBone density 변화 없음변화 없음

Side effectSide effect Irregular bleeding, headache, acne, weigh gaiIrregular bleeding, headache, acne, weigh gai

n or loss, mastalgia, mood change, depression or loss, mastalgia, mood change, depression, hyperpigmentation over the implnats, hirsutin, hyperpigmentation over the implnats, hirsutism, galactorrhea, symptomatic functional cystsm, galactorrhea, symptomatic functional cystss

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Emergency ContraceptionEmergency Contraception

EstrogenEstrogen Hige-dose estrogen : coitusHige-dose estrogen : coitus 후 후 7272 시간 이내시간 이내 작용기전 작용기전 : altered tubal motility, interference : altered tubal motility, interference

with corpus luteum function, alteration of the ewith corpus luteum function, alteration of the endometriumndometrium

용법용법 : 5mg of EE daily for 5days: 5mg of EE daily for 5days

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Estrogen and Progestin in CombinationEstrogen and Progestin in Combination EE 0.2mg + levonorgestrel 2mg (Ovral 2TEE 0.2mg + levonorgestrel 2mg (Ovral 2T

복용후 복용후 1212 시간내 다시 시간내 다시 2T)2T) Pregnancy rate : 1.2-1.8%Pregnancy rate : 1.2-1.8% Side effect : Nausea, vomittingSide effect : Nausea, vomitting

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Levonorgestrel AloneLevonorgestrel Alone 처음 처음 0.75mg0.75mg 복용 후 복용 후 1212 시간후 시간후 0.75mg 0.75mg

다시 복용다시 복용

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LNG : levonorgestrel 0.75mg X 2

Yuzpe : ethinyl estradiol 0.100mg + levonorgestrel 0.50mg X 2, 12hrs

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Copper Intrauterine DeviceCopper Intrauterine Device 방법 방법 : Coitus: Coitus 후 후 72hrs72hrs 내 삽입내 삽입

CoitusCoitus 후 후 77 일 이내 삽입하였을 때 임신되었는다는 일 이내 삽입하였을 때 임신되었는다는 보고는 없음보고는 없음

Danazol (weak androgen)Danazol (weak androgen) Pregnancy rate : 2%Pregnancy rate : 2%

Mifepristone (RU486)Mifepristone (RU486) 600mg 12hrs600mg 12hrs 이내에 반복 복용이내에 반복 복용

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SterilizationSterilization

Surgical sterilization is the most common Surgical sterilization is the most common method of fertility control used by couples imethod of fertility control used by couples in the US.n the US.

Tubal Sterilization at the time of laparotomyTubal Sterilization at the time of laparotomy Postpartum minilaparotomy soon after vaginal Postpartum minilaparotomy soon after vaginal

diverydivery Interval minilaparotomyInterval minilaparotomy LaparoscopyLaparoscopy

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Surgical TechniqueSurgical Technique

Pomeroy or modified Pomeroy techniquePomeroy or modified Pomeroy technique

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LaparoscopyLaparoscopy Trocar insert into the abdominal cavity through loTrocar insert into the abdominal cavity through lo

wer margin of umbilicus and suprapubic regionwer margin of umbilicus and suprapubic region General A. but local anesthesia with conscious sGeneral A. but local anesthesia with conscious s

edation is needed.edation is needed. Overnight hospitalization is rarely needed.Overnight hospitalization is rarely needed.

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Risks of Tubal SterilizationRisks of Tubal Sterilization General anesthesiaGeneral anesthesia Previous pelvic or abdominal surgeryPrevious pelvic or abdominal surgery Hx of PIDHx of PID ObesityObesity DMDM

MotalityMotality 9-10 deaths per 100,000 sterilization in US (19-10 deaths per 100,000 sterilization in US (1

979-1980)979-1980)

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Benefits of Tubal SterilizationBenefits of Tubal Sterilization Reduced risk for ovarian cancer (persists for aReduced risk for ovarian cancer (persists for a

s long as 20 years after surgery)s long as 20 years after surgery)

Sterilization failureSterilization failure 11 달 이내 달 이내 : : 대부분이 임신 후 대부분이 임신 후 sterilizationsterilization 을 을

시행한 경우시행한 경우 따라서 수술 전날까지도 따라서 수술 전날까지도 routineroutine 으로 으로 pregnapregna

ncy testncy test 시행할 것시행할 것

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Reversal of SterilizationReversal of Sterilization Success rate : Mechanical occlusion is better Success rate : Mechanical occlusion is better

than electrocoagulationthan electrocoagulation 75%75%

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VasectomyVasectomy

Excision of a portion of the vas deferens.Excision of a portion of the vas deferens.

Local anesthesiaLocal anesthesia Office settingOffice setting Dose not decrease sexual performanceDose not decrease sexual performance ComplicationComplication

Scrotal hematomas, wound infection, epididyScrotal hematomas, wound infection, epididymitismitis

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AbortionAbortion

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Safety IssuesSafety Issues

Risk for death from legal abortionRisk for death from legal abortion 0.7 per 100,000 (1996, US)0.7 per 100,000 (1996, US) Total maternal mortality : 7-8 /100,000 live birthsTotal maternal mortality : 7-8 /100,000 live births 16wks16wks 이후부터는 이후부터는 risk for deathrisk for death 가 이전보다 가 이전보다 1010 배 배

상승상승 11stst trimester abortion – vacuum curettage trimester abortion – vacuum curettage Mid trimester : variable methodsMid trimester : variable methods General Anesthesia :General Anesthesia :

Perforation of the uterus, visceral injury, Perforation of the uterus, visceral injury, hemorrhage, hysterectomy and deathhemorrhage, hysterectomy and death 의 위험성이 의 위험성이 증가됨증가됨

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Techniques for AbortionTechniques for Abortion

5-7wks ; vacuum curettage5-7wks ; vacuum curettage 5-6mm flexible plastic cannula and a modified 5-6mm flexible plastic cannula and a modified

50mL plastic syringe as vacuum source50mL plastic syringe as vacuum source

After 7wks : larger rigid plastic cannulas (8After 7wks : larger rigid plastic cannulas (8-12mm in diameter)-12mm in diameter)

General anesthesia is unnecessaryGeneral anesthesia is unnecessary Local anesthesia, IV sedatives and analgesicsLocal anesthesia, IV sedatives and analgesics

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Medical Means for AbortionMedical Means for Abortion

Mifepristone (RU486)Mifepristone (RU486) Progesteron antagonistProgesteron antagonist Early pregnancyEarly pregnancy 에서 에서 abortionabortion 유도유도 Misoprostol, prostaglandinMisoprostol, prostaglandin 과 병합하면 과 병합하면

효과높음효과높음 200mg mifepristone orally +800ug of vaginal 200mg mifepristone orally +800ug of vaginal

misoprostol => 98% complete abortionmisoprostol => 98% complete abortion 처음 처음 mifepristonemifepristone 투약 후 투약 후 1-31-3 일 지나도 효과 일 지나도 효과

없으면 다시 병원으로 와서 없으면 다시 병원으로 와서 misoprostolmisoprostol 투약투약 , , 이경우 절반이상에서 이경우 절반이상에서 4-54-5 시간안에 시간안에 expelexpel 됨됨

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Methotrexate (MTX)Methotrexate (MTX) Widely used to treat ectopic pregnancyWidely used to treat ectopic pregnancy MTX ,50mg/M2 IM + misoprostol 800ug PVMTX ,50mg/M2 IM + misoprostol 800ug PV 92% success rate (35days)92% success rate (35days) MTX+mifeprisoneMTX+mifeprisone 은 은 MTX + misoprostolMTX + misoprostol 과 과

비교하여 볼때 비교하여 볼때 efficacyefficacy 는 동일하나 보다 는 동일하나 보다 비싸다비싸다 ..

50mg IM50mg IM 과 과 50mg oral50mg oral 투여는 효과가 동일투여는 효과가 동일 ..

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Second-trimester AbortionSecond-trimester Abortion

D & ED & E Labor- induced MethodsLabor- induced Methods

Hypertonic solutionHypertonic solution ProstaglandinProstaglandin OxytocinOxytocin

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Hypertonic solutdionHypertonic solutdion Amnioinfusion of hypertonic salineAmnioinfusion of hypertonic saline Oldest methodOldest method ComlicationComlication

Serious Maternal DICSerious Maternal DIC

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ProstaglandinsProstaglandins

E & F series of Prostaglandins can cause UtE & F series of Prostaglandins can cause Uterine conraction at any stage of gestationerine conraction at any stage of gestation

Prostaglandin E2 and F2Prostaglandin E2 and F2αα are highly effectiv are highly effectivee

Side effectSide effect Vomiting, diarrheaVomiting, diarrhea

Vaginal minopristol(200ug every 2hrs) = PG Vaginal minopristol(200ug every 2hrs) = PG E2 (20mg every 3hrs)E2 (20mg every 3hrs)

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Misoprostol 200ug / 400ug / 600ug /q 12hr Misoprostol 200ug / 400ug / 600ug /q 12hr

-> abortion rate 70.6% / 82% / 96% (withi-> abortion rate 70.6% / 82% / 96% (within 48hrs)n 48hrs)

but, side effectbut, side effect 는 용량과 비례는 용량과 비례 임신 후반기에 고용량은 임신 후반기에 고용량은 uterine ruptureuterine rupture 의 의

위험성이 있으므로 조심할 것위험성이 있으므로 조심할 것 Ideal dose : misoprostol 400ug /q 6hrsIdeal dose : misoprostol 400ug /q 6hrs Body temperatureBody temperature 의 상승은 용량과 비례 의 상승은 용량과 비례 Retained placenta : PG abortionRetained placenta : PG abortion 에서 흔함에서 흔함

Instrumental extractionInstrumental extraction 이 이 half casehalf case 에서 필요에서 필요

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OxytocinOxytocin Very high doseVery high dose 에서 에서 PG E2PG E2 와 동일한 효과를 와 동일한 효과를

냄 냄 (17-24wks of pregnancy)(17-24wks of pregnancy) 50U in 5% D/W for 3hrs50U in 5% D/W for 3hrs

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ComplicatonComplicaton

Incomplete abortionIncomplete abortion Retained placentaRetained placenta

24-36hr24-36hr 까지 까지 expelexpel 되지 않으면 되지 않으면 D&ED&E 가 필요함가 필요함 HemorrhageHemorrhage InfectionInfection

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Selective ReductionSelective Reduction Multiple gestation -> preterm labor, major neonatMultiple gestation -> preterm labor, major neonat

al comlicationsal comlications 유발유발 Fetal intracardiac injection of KClFetal intracardiac injection of KCl

83% of the surviving fetuses delivered at 33wks or lat83% of the surviving fetuses delivered at 33wks or laterer

Rate of pregnancy loss after procedureRate of pregnancy loss after procedure 5.4% (9-12wks), 8.7% (13-18wks), 6.8% (19-24wks), 5.4% (9-12wks), 8.7% (13-18wks), 6.8% (19-24wks),

9.1% (25wks 9.1% (25wks 이상이상 )) No maternal DIC, No surviving neonates ischemiNo maternal DIC, No surviving neonates ischemi

c damage and coagulopathyc damage and coagulopathy 금기 금기 : monoanmionic twin, twin-twin transfusion : monoanmionic twin, twin-twin transfusion

syndromesyndrome