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#16
23.01.2007, 23:15
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#17
23.01.2007, 23:17
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С чего разговор и начался-прежде чем давать такие рекомендации, как дала Ника, необходимо выяснить, что там с цитологией, кольпоскопией и мазками, и пока нет данных, от советов воздержаться.
Еще раз обращаю внимание врачей-если нет полного анамнеза и обследования (например женщина ленится его написать или не видела наши рекомендации "как задать вопрос")-отвечать на такие вопросы-себе дороже, и у нас должна быть единая тактика в этом вопросе (сколько уже было ляпсусов в связи с этим). |
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#18
24.01.2007, 00:05
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Хорошо:-)
Вывод - впредь не буду доверять пациенткам на форуме, когда будут писать, что результаты анализов нормальные, учту, что надо просить детали. Но, следуя тому же принципу, верить ей на слово, что там безвредная эрозия, не требующая дальнейшего исследования, тоже не стоит. Насчет перлов на сайте (безотносительно разбираемого случая со спиралью) - знаете, просто вам посчастливилось работать в условиях, когда нормальная, достоверная диагностика есть под рукой в любое время. Но есть много мест, как, например, где я работаю, да и судя по отзывам в инернете, и в российских глубинках тоже, где просто нет нормальных лабораторий. И приходиться работать именно так - есть запах, нет запаха, есть зуд, нет зуда. К сожалению, это все еще реальность:-( |
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#19
24.01.2007, 00:13
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постановка спирали
Уважаемые коллеги!Осмелюсь высказать и свое мнение.Я спирали страюсь вообще не ставить и женщин отговариваю.Ну не нравиться мне повышенный риск инфекции,внематочной беременности.А обильные месячные это мягко сказано,многие женщины "сухие" только несколько дней в месяц.А гнойно- воспалительные образования?Мне кажется более уместным предлагать женщинам другие виды контрацепции.
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#20
24.01.2007, 01:10
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#21
24.01.2007, 01:12
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Ann Med. 1993 Apr;25(2):171-3. Links
Intrauterine contraceptive device and pelvic inflammatory disease. * Toivonen J. Department of Medical Chemistry, University of Helsinki, Finland. Comprehensive, mainly epidemiological data has helped us to recognize the strongest risk factors of pelvic inflammatory disease during intrauterine contraceptive device use. These are user's exposure to sexually transmitted diseases, young age and insertion of the device. Moreover, parity of the user and type of device may affect the risk of pelvic infection. PIP: Some people are concerned that IUD use increases the risk of pelvic inflammatory disease (PID), but the extent of the risk and the causal relationship between IUD use and PID are not clear. Two methodological problems with these studies are bias in selecting the comparison group and lack of standard diagnostic criteria for PID. Nonetheless, these studies have identified conditions which increase the risk of PID during IUD use. The woman's or her partner's sexual behavior determines exposure to sexually transmitted diseases (STDs). Regardless of IUD use, women with at least 4 sexual partners face a 3-fold higher risk of PID than those with only 1 partner. Among IUD users, increased coital frequency (5-8 times/month) increase the risk of PID. IUD insertion introduces temporary microbial contamination into the uterus, thereby bringing about a 6-fold increased risk of PID during the first 20 days after insertion. PID rarely occurs in women who have an IUD for more than 5 years, suggesting the need for less frequent replacement of IUDs. Young age alone is a risk factor for PID. For example, women less than 25 years old face a 2-3 fold increased risk of PID compared to women older than 25. Nulliparity appears to be a risk factor for PID, but not a strong factor. The Dalkon Shield IUD has been removed from the market because studies indicated that it significantly increased the risk of PID. Copper-releasing IUDs may have a lower risk of PID than does the Dalkon Shield. Studies show that women with the levonorgestrel-releasing IUD have a significantly lower rate of PID than do those with a copper-releasing IUD. Women in a mutually stable relationship are best suited for IUD use. Physicians should diagnose and treat STDs before insertion of an IUD. IUD replacement should be limited, if possible. Women less than 25 years old, particularly those who are nulliparous, should avoid using an IUD. [Ссылки доступны только зарегистрированным пользователям ] Lancet. 1992 Mar 28;339(8796):785-8. Links Intrauterine devices and pelvic inflammatory disease: an international perspective. * Farley TM, * Rosenberg MJ, * Rowe PJ, * Chen JH, * Meirik O. Special Programme of Research, Development, and Research Training in Human Reproduction, World Health Organisation, Geneva, Switzerland. The risk of pelvic inflammatory disease (PID) associated with use of an intrauterine device (IUD) has been an important concern that has dominated decisions on its use throughout the world, especially in the USA. Early research that suggested such an association led to both a dramatic decline in use of the method and its withdrawal from the US market by two manufacturers. However, factors other than use of an IUD are now thought to be major determinants of PID risk. To address these concerns, we have reviewed the World Health Organisation's IUD clinical trial data to explore the incidence and patterns of PID risk with use of an IUD. The overall rate of PID among 22,908 IUD insertions and during 51,399 woman-years of follow-up was 1.6 cases per 1000 woman-years of use. After adjustment for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times (unadjusted rates, 9.7 vs 1.4 per 1000 woman-years, respectively); the risk was low and constant for up to eight years of follow-up. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age. PID rates were lower among women who had IUDs inserted more recently. Our findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the first 20 days after insertion. Because of this increased risk with insertion, IUDs should be left in place up to their maximum lifespan and should not routinely be replaced earlier, provided there are no contraindications to continued use and the woman wishes to continue with the device. PIP: The risk of pelvic inflammatory disease (PID) associated with the use of an IUD has been an important concern that has dominated decisions on its use throughout the world, especially in the US. Early research that suggested such an association led to both a dramatic decline in the use of the method and its withdrawal from the US market by 2 manufacturers. However, factors other than use of an IUD are now thought to be major determinants of PID risk. To address these concerns, the authors reviewed the WHO's IUD clinical trial data to explore the incidence and patterns of PID risk with the use of an IUD. The overall rate of PID among 22,908 IUD insertions and during 51,399 woman-years of followup was 1.6 cases/1000 woman-years of use. After adjusting for confounding factors, PID risk was more than 6 times higher during the 20 days postinsertion than during later times (unadjusted rates, 9.7 vs 1.4/1000 woman-years, respectively); the risk was low and constant for up to 8 years of followup. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age. PID rates were lower among women who had IUDs inserted more recently. These findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the 1st 20 days after insertion. Because of this increased risk with insertion, IUDs should be left in place up to their maximum lifespan and should not routinely be replaced earlier, provided there are no contraindications to continued use and the woman desires to continue with the device. [Ссылки доступны только зарегистрированным пользователям ] Curr Opin Obstet Gynecol. 1993 Dec;5(6):829-32. Links The intrauterine device in the present and future. * Rivera R, * Chi IC, * Farr G. Family Health International, Research Triangle Park, Durham, North Carolina. Good counseling and better selection of candidates would result in the intrauterine device's (IUD) safer use. Age and parity of the IUD acceptor do not seem to be associated with an increased risk of pelvic inflammatory disease (PID). The newer generation of copper- and hormone-releasing IUDs are associated with improved safety and efficacy. PIP: The IUD is a very safe and effective contraceptive method for women in a mutually monogamous relationship. The 8-year pregnancy rates for the Copper T 380A IUD is 2.3%. Studies in the late 1960s and early 1970s suggested that IUDs caused pelvic inflammatory disease (PID). These studies may have been subject to methodological flaws (e.g., use of inadequate controls, such as users of methods protecting against PID [e.g. barrier methods] and failure to control for likely confounding variables [e.g., sexual behavior]). Recent large scale prospective studies tend to report low PID rates in IUD users (e.g., 7-year rate, 2.6% for the levonorgestrel releasing and a copper releasing IUDs). The risk of PID is highest within the first 20 days postinsertion, especially in women using a unmedicated IUD. The copper IUD has been modified to better conform to the uterine cavity throughout the menstrual cycle, thus, reducing the likelihood of bleeding and pain. Another new copper IUD likely to reduce bleeding and pain has 6 copper sleeves on 1 filament polypropylene thread. The knot at the thread's end is implanted into the myometrium at the fundus. The LNG-IUD releases a daily dose of 20 mcg levonorgestrel. It can be used effectively for 5 years. Amenorrhea and/or hormonal side effects contribute to its lower continuation rate than copper releasing IUDs. Providers must assess the risk of sexually transmitted diseases, conduct a pelvic exam, and counsel clients before IUD insertion. Only when IUD users experience symptoms do follow-up visits result in a significant cost saving. In the best interest of the client and to reduce discontinuation, counseling should address life style, user perspective, culture, possible increased risk of genital infection associated with nonmonogamous sexual behavior, and side effects. [Ссылки доступны только зарегистрированным пользователям ] |
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#22
24.01.2007, 01:34
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#23
24.01.2007, 01:42
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Ника!! Не сочтите, что я придираюсь. Но если нет признаков воспаления в мазках, цитология и кольпоскопия в пределах нормы-зачем ненужные обследования???
Она после постановки вмс может сменить полового партнера, и опять эту же самую хламидию подцепит, и опять она у нее будет жить бессимптомно, не вызывая воспаления. |
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#24
24.01.2007, 01:55
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Да что Вы - нормальная дискуссия:-)
А разве она про кольпоскопию что-то писала? Тогда я что-то пропустила, я думала, речь шла только о мазке на цитологию. А почему я именно о хламидии озаботилась в данном случае - из-за ее любви поражать трубы, что при ВМС не очень благоприятный фактор. Но вы, конечно, правы, что она и потом может подцепить хламидиоз и жить с этим, но это уже не в силах врачей предугадать и предусмотреть. |
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#27
24.01.2007, 02:22
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#28
26.01.2007, 19:43
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продолжим дискуссию :) ?
... к вопросу о "никому не нужных" обследованиях (в частности на хламидиоз):
Sexually Transmitted Diseases Treatment Guidelines, 2006 Chlamydial Infections Some women who have uncomplicated cervical infection already have subclinical upper reproductive tract infection. Asymptomatic infection is common among both men and women, and to detect chlamydial infections health-care providers frequently rely on screening tests. Annual screening of all sexually active women aged <25 years is recommended (124), as is screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners). The benefits of C. trachomatis screening in women have been demonstrated in areas where screening programs have reduced both the prevalence of infection and rates of PID (125,126). Вот самери: [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] ИМХО применительно к ВМК: - ВМК не есть методом выбора для женщин, часто меняющих половых партнёров. Но такова се ля ви (С) , всякое бывает.- и если уж произошла реинфекция от нового полового партнёра у женщины с ВМК, то удалять контрацептив (без веских оснований) нет необходимости. Тем более что сама манипуляция удаления будет в таком случае ВЗОМТ провоцирующим мероприятием. Достаточно провести повторное лечение (тем же азитромицином однократно). З.Ы.: согласно тому же источнику, женщины, получавшие лечение по поводу хламидиоза, при смене полового партнёра подлежат повторному обследованию. |
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#29
26.01.2007, 20:43
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Как раз в недавно выпущенном руководстве ВОЗ настоятельно рекомендуют как можно реже менять ВМС (до 10 лет спокойно можно носить, ведутся исследования и по сроку 15 лет), так как именно с установкой ВМС и связан наибольший риск ВЗОМП.
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#30
26.01.2007, 22:39
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В тему
Если вдруг кто еще не добрался до этих ссылок, делюсь
(рекомендации ВОЗ по контрацепции)[Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] |
Линейный вид
