CLINICAL UPDATES
| NEWS AND CONTROVERSIES IN CONTRACEPTION —Carol E. Ball, MD, Assistant Professor of Obstetrics
and Gynecology, University of Minnesota Medical School, Minneapolis, and Medical Director, Planned Parenthood
of Minnesota, South and North Dakota
|
| Ethylene vinyl acetate and etonogestrel (Implanon): single-rod, subdermal implant; effective 3 yr; highly effective
and well accepted; etonogestrel crystals absorbed from solid rod of ethylene vinyl acetate; initially releases
60 µg of etonogestrel daily, decreasing over time; efficacy—6 pregnancies reported in 20648 cycles; 0.38 pregnancies
per 100 woman-years; mechanism of action—inhibits ovulation; trial data show no ovulation in first 30
mo of use; 2 of 31 participants ovulated in year 3, with no resulting pregnancies; increases viscosity of cervical mucus;
return to ovulation—etonogestrel levels undetectable within 5 days after removal; 90% of participants ovulated
within 3 mo after removal; bleeding patterns—unpredictable and irregular; counsel patient about variation
in bleeding patterns; no impact on hemoglobin levels; estradiol levels—no difference between women using Implanon
and women continuing to ovulate normally; causes for discontinuation—bleeding irregularities most common
reason for discontinuation; weight gain, emotional lability, headache, acne, and depression; mean weight gain
over 1 yr ≈2.8 lb, 3.7 lb over 2 yr (data also show weight loss among women using Implanon); implant site
reaction—pain, redness, swelling, and hematoma; no reports of expulsion from implantation site; problems at
removal—1.7% of women experienced problems at time of removal; implant not palpable, broken or damaged
implant, formation of fibrotic capsule, slight migration and difficult removal due to deep insertion (can be located
with high-frequency ultrasonography); health care provider must complete company-sponsored training program
before able to order implant
|
| Intrauterine devices (IUDs): CuT380A (ParaGard)—can be used 12 yr; nonhormonal; effect from copper; 0.8
failures per 100 woman-years; no noncontraceptive benefits; levonorgestrel-releasing (20 µg/day) intrauterine
system (LNG 20; Mirena)—0.1 failures per 100 woman-years; associated with lighter menses; infection problems
associated with Dalkon Shield cannot be applied to IUDs currently available; contraindications removed from
labeling—history of pelvic inflammatory disease (PID), or patient with multiple sexual partners (or partner has
multiple sexual partners); current IUDs do not increase risk for PID; acute PID or behaviors putting patient at risk
for PID current contraindication; unresolved abnormal Papanicolaou (PAP) test no longer contraindication (can be
inserted as long as low-grade changes followed); colposcopy can be performed with IUD in place, and IUD can remain
in place if excisional procedure required; vaginitis and cervicitis no longer contraindications (labeling
changed to read “mucopurulent cervicitis”); woman with yeast vaginitis or bacterial vaginosis does not need to be
rescheduled for IUD insertion (vaginitis can be treated at time of insertion); no longer contraindicated in immunocompromised
patients; asymptomatic genital actinomycosis does not require removal of IUD or prevent insertion;
nulliparous women—no contraindication; studies show no increase in tubal infertility in nulliparous women with
IUD, compared to multiparous women; well tolerated by nulliparous women; continuation rate 80% at 1 yr; safety
and efficacy same as in multiparous women; history of ectopic pregnancy—not contraindication; evaluate for ectopic
pregnancy if pregnancy occurs with IUD in place; screening requirements for insertion—woman who has
not had sexual intercourse since last menstrual period can have IUD inserted on day of appointment; woman who
has had intercourse within last 5 days can be administered emergency contraception and have IUD inserted; Pap
test can be performed at time of insertion; screen for sexually transmitted infections (STIs) if indicated by risk factors;
treatment for STIs can be initiated with IUD in place; CuT380A can be inserted 5 to 7 days after intercourse as
postcoital contraception; IUDs do not need to be inserted with menses; duration of use—LNG 20, 5 yr; CuT380A,
10 yr; study published in 1997 reported safe and effective for at least 12 yr, and pregnancy rate comparable to tubal
sterilization (in United States)
|
| Depomedroxyprogesterone acetate (DMPA) and bone mineral density (BMD): DMPA associated with
reduced estradiol levels; multiple studies confirm lower BMD in DMPA users; Cundy et al concluded short-term
skeletal changes observed during use of injections of DMPA do not predict long-term impact on skeletal health; no
evidence showing DMPA results in fractures; evidence does not support discontinuing DMPA after 2 yr, ordering
dual-energy x-ray absorptiometry (DEXA) on premenopausal women, or prescribing bisphosphonates; evidence
supports revising or rescinding 2004 “black-box” warning—studies show similar BMD in former adult DMPA
users, compared to never-users (similar study results in adolescent population); studies show recovery of BMD
complete by 12 mo after discontinuation; BMD ultimately higher in former DMPA users, compared to never-users;
duration of use had no effect on speed of recovery of BMD
|
| Transdermal patch and clotting: Food and Drug Administration (FDA) labeling change, November 2005—
states hormones from patches applied to skin are removed from body differently from hormones from oral contraceptives
(OCs), and patient using norelgestromin/ethinyl estradiol (EE) transdermal system (Ortho Evra) exposed
to ≈60% more estrogen than patient taking OCs containing 35 µg of estrogen; lay media failed to point out portion
of FDA labeling stating, “it is not known if there are differences in risk of serious side effects based on difference
between Ortho Evra and birth control containing 35 µg of estrogen”; subsequent industry-sponsored case-control
studies found no increase in risk for stroke or myocardial infarction (MI); Jick et al show no increased risk for
venous thromboembolism (VTE) in transdermal patch users and OCs users; unpublished data show relative risk of
2 for VTE with Ortho Evra (relative risk of 4 needed to make correlation); definitive association with serious side
effects unclear, more studies needed; recommendations—apply same contraindications for use of transdermal
patch as for OCs; use more caution in women with cardiovascular risk factors; do not use beyond 3 consecutive cycles
(because of slightly increased level of EE over time)
|
| Weight and contraceptive efficacy: top tier (more effective)—sterilization, implants, hormonal shots, IUDs;
middle tier (effective)—OCs, transdermal patch, ring, combination hormonal methods; lower tier (less effective)—
barrier methods, spermicides, and natural methods; Steiner et al found slightly higher failure rate with middle-tier
methods in obese women, compared to normal-weight women; difference translates to ≈2 to 4 more pregnancies
among obese women per 100 woman-years; choice of method should not be based on patient’s weight; contraception
in obese women always safer than pregnancy; no impact on efficacy with upper-tier methods and increased body
weight
|
| “Quick start” oral contraceptive initiation method: conventional instructions require waiting until next
menses before initiating to avoid hormone exposure in early pregnancy and to maintain appearance of regular cycle;
studies show no increase in congenital abnormalities or poor pregnancy outcome with hormone exposure in
early pregnancy; problems with conventional initiation method include risk of patient becoming pregnant while
waiting for menses, temporary decrease in motivation, and misunderstanding instructions; studies show 25% of
women never start method of contraception after leaving office; quick start increases chance for successful use of
OCs; patient takes first OC pill in health care provider’s office; continues taking one pill daily; data show quick
start initiation method more successful than conventional starts; simple approach, requiring no additional counseling;
requires health care provider to have packages of OCs readily available; no adverse events reported; high continuation
rate evidence of acceptability
|
| Conclusion: 49% of pregnancies in United States unintended; >50% of those end in abortion; United States has
highest rate of unintended pregnancy in developed world; important to provide patient with as many contraceptive
options as possible, to base limitations on good evidence, and to remove barriers to access to safe and highly effective
methods of contraception
|
| VULVAR DERMATOSES —Alison J. Bruce, MD, Assistant Professor of Dermatology, Mayo Clinic, College of
Medicine, Rochester, MN
|
| General considerations: wide spectrum of erythema in vulvar area, particularly in premenopausal women; normal
erythema often diagnosed as pathologic; medically insignificant lesions (eg, sebaceous glands, cysts) diagnosed as
warts; often >1 disease present simultaneously; group B streptococcus colonization common; initial treatment with
antibiotics provides relief from irritation and allows for further treatment of underlying problem; yeast usually not
sole cause of symptoms; goal to improve condition rather than to cure; ointments recommended; avoid creams (irritating
to genital area); gels not well tolerated (often contain alcohol; sting and burn genital area); use of multiple
products can result in contact dermatitis; avoid by using oral rather than topical medications; look for atrophy on
medial thighs and crural creases when using ultrapotent steroids; mild approach with steroids often not effective;
important to routinely reevaluate patient using steroids
|
| Lichen sclerosis et atrophicus (LS and A): typically affects postmenopausal women; vulvoperineal involvement;
itching, burning symptoms; even though asymptomatic in early stages, requires treatment because can
progress to scarring; generally isolated to genitalia; not associated with other skin diseases; scarring mimics other
disorders; biopsy reveals characteristic histopathology; negative on direct immunofluorescence (DIF) test; clinical
appearance—coalescing ivory plaques, erosion, inflammation, and some scarring, parchment-like wrinkling of
skin; atrophy part of disease, not caused by steroid medication; “figure-8” pattern classic feature (easily visible if
patient on side with buttocks spread); pathogenesis—autoimmune association; activation of proteolytic enzymes
proposed; treatment—ultrapotent topical steroids until disease in remission; clobetasol (eg, Temovate) twice
daily; reevaluate patient every 6 wk until stable; taper to 3 times weekly indefinitely (reevaluate patient in 3-6 mo);
use either hydrocortisone or trisinone if concerned about compliance; no benefit shown with topical testosterone or
topical estrogen; treat concurrently with antibiotic twice-daily for 1 wk and systemic antifungal at end of week; reevaluate
frequently; once patient stable, reevaluate regularly (risk of developing cancer in area); reports that tacrolimus
(Protopic) useful; recalcitrant patient—rebiopsy to rule out another disorder or squamous cell carcinoma;
intralesional injections of steroids; temporary effects with systemic steroids, but rebound can occur; retinoids irritating
to genital area; excision not recommended; risk for malignancy in area with phototherapy
|
| Lichen planus (LP): T cell-mediated inflammatory disorder; clinical features—white reticulate papules; significant
erosion possible; underrecognized and underdiagnosed; less common than LS and A; most common cause of
chronic erosive vulvitis; patient with only white striae often asymptomatic and may not require treatment; burning
and pain with erosive disease; erosive LP can affect mouth, esophagus, and outer ear canal; vulvovaginal-gingival
syndrome—erosive orogenital (penogingival syndrome in men) LP; patient generally middle-aged; severe desquamative
gingival stomatitis together with vaginitis; characterized by lichenoid infiltrate; often epidermis lifts off;
chronic disease; effective control challenging; biopsy essential to distinguish from other erosive diseases; positive
DIF; treatment—erosive disease challenging; topical steroids of appropriate potency; steroid foams or suppositories
developed for rectal use; topical tacrolimus probably more effective than steroids; long-term therapy necessary;
patient may develop resistance to medication; have high index of suspicion for Candida, bacterial infection,
or contact dermatitis; advise patient to use vaginal dilator regularly; topical cyclosporine (especially for oral disease);
oral solution can be used in vaginal area; burning on application; systemic agents—hydroxychloroquine
(Plaquenil) easily administered, well tolerated, and has minimal side effects; retinoids considered first- or second-
line systemic treatment for LP; use of systemic tacrolimus and methotrexate reported; speaker believes Protopic
relatively effective for mild to moderate cases
|
| Aphthous ulcers: canker sores; complex aphthosis—sore lasts 3 to 5 wk before healing; patient often has several
large, deep, and painful sores at same time; may be associated with genital aphthosis; oral and/or genital aphthosis
necessary, but insufficient, for diagnosis of Behçet’s syndrome (rare in United States); may be associated with inflammatory
bowel disease, deficiencies in iron, vitamin B12 , and folate; likely multifactorial autoimmune disease;
vulvar aphthae typically larger than those in mouth; oral and genital ulcers do not always occur synchronously; nonspecific
pathology, but not vasculitis; reactive pattern probably largely driven by neutrophils; rule out infective
causes (eg, herpes simplex virus, Epstein-Barr virus [EBV]); treatment—topical, intralesional, and systemic steroids
highly effective; colchicine and dapsone used as suppressive anti-inflammatory prophylactic therapy; supportive
therapy—topical analgesia; because of burning, advise patient to urinate into sitz bath or use funnel to relieve
burning sensation, and to avoid use of abrasive items; therapy depends on severity of problem; topical triamcinolone
ointment appropriate for occasional episode; rectal steroid suppositories and systemic steroids other treatment options
|
| Ulcus vulvae acutum: acute ulcer of vulva; associated with trigger factors (eg, influenza, enterocolitis, Yersinia
enterocolitis); recently associated with EBV; reactive process; spontaneous recovery; patients can develop canker
sores, suggesting predisposition; necrotic ulcer with desquamative base and surrounding area of erythema
|
| Plasma cell vulvitis: uncommon; more common in men; symptomatic in women (asymptomatic in men); occurs
inside labia minora; characterized by solitary orange-red plaque; atrophic, glistening, and mildly erosive; biopsy
necessary; referred to as plasma cell balanitis (Zoon balanitis) in men, and plasma cell vulvitis in women; plasma
cell mucositis (mouth) associated with allergies (eg, chewing gum); no malignant potential; usually stable; differential
diagnosis includes squamous cell carcinoma and Paget’s disease; infiltrate of plasma cells, red blood cells,
and hemosiderin seen on biopsy; treatment—topical and intralesional steroids and topical retinoids; recent reports
of use of imiquimod (Aldara)
|
| Common cutaneous diseases: psoriasis—commonly seen on body folds; characteristic scale may be absent;
dermatitis—can be caused by medications; scratch-itch cycle leads to neurodermatitis; patch test and culture necessary;
can evolve into lichen simplex chronicus (thickened skin with loss of pigment); stress or anxiety can play
role; treatment—topical corticosteroids with sufficient potency to achieve relief; treat underlying problems; ointments
preferable; antihistamines or antidepressesants to control itching; advise patient to avoid excessive scratching
or washing of area; tinea cruris rare in women; excessive use of steroids can lead to fungal infection
|
Suggested Reading
Barnes CJ et al: Epstein-Barr virus-associated genital ulcers: an underrecognized disorder. Pediatr Dermatol
24:130, 2007; Jick SS et al: Risk of nonfatal venous thromboembolism in women using a contraceptive transdermal
patch and oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol. Contraception 73:223,
2006; Kaunitz AM: Depo-Provera’s black box: time to reconsider? Contraception 72:165, 2005; Kennedy CM
et al: Erosive vulvar lichen planus: retrospective review of characteristics and outcomes in 113 patients seen in a vulvar
specialty clinic. J Reprod Med 52:43, 2007; Lotery HE et al: Erosive lichen planus of the vulva and vagina.
Obstet Gynecol 101(5 Pt 2):1121, 2203; Nelson AL: Contraindications to IUD and IUS use. Contraception 75(6
Suppl):S76, 2007; Westhoff C et al: Quick start: novel oral contraceptive initiation method. Contraception 66:141,
2002.
Educational Objectives
| The goal of this program is to present evidence supporting the use of contraceptive options and to improve the diagnosis
and management of vulvar dermatoses. After hearing and assimilating this program, the clinician will be better
able to:
|
 | 1. Assess data supporting the use of hormonal contraceptive implants, intrauterine devices (IUDs), and hormonal
contraceptive injections.
|
| 2. Counsel patients about contraceptive options.
|
| 3. Assess the feasibility of implementing the “quick start” oral contraceptive initiation method into clinical practice.
|
| 4. Recognize normal variants in assessing vulvar conditions.
|
| 5. Recognize and manage abnormal vulvar conditions.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgments
Dr. Ball was recorded at the 25th Annual OB/GYN Update, sponsored by HealthPartners Institute for Medical Education
and held April 12-13, 2007, in Oakdale, MN. Dr. Bruce was recorded at OB/GYN Clinical Reviews, sponsored
by the Mayo School of Continuing Medical Education and held November 2-3, 2006, in Rochester, MN.
|
