Oral Contraceptive Medication Research Articles

Comparison of dienogest or combinations with ethinylestradiol/estradiol valerate on the pain score of women with endometriosis: A prospective cohort study.

Endometriosis is one of the most frequent gynecologic disorders. The pathognomonic symptom of endometriosis is pelvic pain. The recommended pain medications are oral hormonal contraceptives, progestin therapy, danazol, gonadotropin-releasing hormone analogs, nonsteroidal anti-inflammatory drugs, and aromatase inhibitors. In this study, we aimed to compare the efficiency of costing dienogest (DNG) and low-cost oral contraceptives regarding visual analog scores (VAS) score of pelvic pain and also cancer antigen-125 (CA-125), anti-Mullerian hormone (AMH) levels, and size of endometrioma in the patients with endometriosis which is a chronic disease that requires a lifelong management plan. In our study, 18 to 45-year-old patients presented to our institution's gynecology and obstetrician department for various complaints over 2 years, and endometriosis diagnoses were included. Patients were divided into 3 groups (20 patients in each medication group) according to the given medication: cyclic DNG (Visanne) or 0.03 mg ethinylestradiol combined with 2 mg DNG (Dienille) or estradiol valerate combined with 2 mg DNG (Qlarista). We recorded all patients' CA-125/AMH values and VAS scores of pelvic pain. All patients gave informed consent. There was no statistically significant difference between pre-medication and post-medication levels of CA-125, AMH, VAS score, and cyst size in all groups. However, statistically, significant decreases were seen in the cyst size and VAS score, indicating response to therapy in all groups. In conclusion, we think it is more reasonable to use cost-effective oral contraceptive medications, which also cause common side effects, instead of costing DNG since all drugs have the same efficiency and success.

The Effects of Different Forms of Contraceptives on the Coagulation Profile

Background: The association between combined oral contraceptive pills and increased risk of venous thromboembolism has been extensively researched but little has been reported on its effects on all haematological parameters and coagulation factors. This study aimed to evaluate the effects of different forms of oral contraceptives on the coagulation profile of female subjects in Enugu metropolis. This case-control study was conducted among women attending the Family planning unit of University of Nigera Teaching Hospital, Ituku Ozalla, Enugu State. Methods: The subjects were 36 women undergoing oral contraceptive medication and the control were 36 healthy women not taking this medication. ABO blood grouping and Full blood count (FBC) were carried out while prothrombin time (PT) and activated partial thromboplastin time (APTT) of test subjects were determined using test kits from Technoclone Austria. Most of the test subjects were found to be of the O + blood group. The haematological profile of test subjects showed a statistically significant increase in Red blood cell (RBC), packed cell volume (PCV), neutrophil, eosinophil, mean platelet volume (MPV) and plateletcrit while showing statisticallysignificant reductions in mean cell volume (MCV), mean cell haemoglobin (MCH), mean cell haemoglobin concentration (MCHC), lymphocyte, basophil, platelet volume distribution width (PDW) and red cell distribution widths in comparison to the control group. There was a significant decrease in the PT of test subjects (16.06±1.35 secs) in comparison to the control group (19.63±1.28 secs) while the slight increase in their APTT values was not significant. Conclusion: Thrombotic markers such as increased Red cell markers; RBC, haematocrit and platelet indices; MPV, PCT were increased along with decreased PT levels and prolonged APTT values though not significant can link oral contraceptives medication use to a hypercoagulable state in subjects thereby increasing their risk to venous thromboembolism.

Link between Two Decades of Oral Contraceptives and Bowel Infarction: A Case Report

Abstract Objectives: Partial or total necrosis of the bowel is a frequent cause of obstruction of the mesenteric artery or vein. Mesenteric infarction is usually the consequence of other associated pathologies of the patient and most often revealed by acute intestinal obstruction. Thus, it is of utmost importance to recognize the risk factors and treat all conditions that might have a link with a hypercoagulability state. Acute mesenteric ischemia is pathology difficult to treat due to the nonspecific symptomatology and late diagnosis consequently. Moreover, the majority the patients have other comorbidities resulting a mortality in over 50% of the cases. Methods and results: Identified risk factors in our patient’s case for the thrombus formations were oral contraceptive medication, hypertension, and obesity. Other secondary causes of Superior Mesenteric Vein (SMV) and Portal Vein (PV) thrombosis were investigated but all tests were negative leading to the incrimination of obesity and chronic use of oral contraceptives for over two decades. Conclusion: Rare, life-threatening complications of associated pathologies such as venous mesenteric thrombosis and bowel obstruction are unanticipated. Thus, it is of utmost importance to diagnose complications and risk factors as soon as possible whose resolutions will make it possible to prolong survival of many patients. Identification of populations at risk and screening of asymptomatic patients are therefore crucial imperatives.

Exploration of Menarche, Dietary Iron, and Additional Risk Factors on the Development of Iron Deficiency in Adolescent Girls

Background: Iron deficiency (ID) is estimated to affect between 9 and 16% of adolescent girls in the United States. It occurs during a critical time of increased iron demands related to blood volume expansion, muscle mass increase, and menstrual blood loss. Black girls are disproportionately affected, likely due to social determinants of health. ID is associated with decreased cognitive function, exercise capacity, and fatigue. Unrecognized ID can progress to complications of severe anemia. Despite readily available therapies including both oral and intravenous iron, no universal screening recommendations or evidence-based prediction tools exist to identify adolescent girls at risk for ID. Our objective was to determine the prevalence of, timing of, and clinical risk factors for ID in a large, biracial cohort of adolescent girls. Methods: Existing clinical data and stored serum specimens were obtained from the National Heart Lung and Blood Institute (NHLBI) Growth and Health Study (NGHS). The NGHS was a 10-year longitudinal study initiated in 1985 that enrolled 2,379 girls (51% Black, 49% White) from three cities (San Francisco, Cincinnati, Washington DC). Subjects participated in annual visits with serum samples obtained at Years 1, 3, 5, 7, and 10 with a retention rate of 89% at the 10th annual visit. Clinical data included socioeconomic data, body mass index (BMI), age at menarche, menstrual and pregnancy history, use of oral contraceptive medications, and dietary iron intake. We hypothesized that >10% of NGHS subjects would meet criteria for ID. We further hypothesized that longer duration from onset of menarche, low dietary iron intake, history of pregnancy, and obesity (defined as BMI >30) would be associated with ID. Available serum samples at Year 10 (n=692) were analyzed with Q-Plex Human Micronutrient Array ELISA kits (Quansys Biosciences) to measure iron-related parameters including serum ferritin, soluble transferrin receptor (sTfR1), sTfR1:ferritin index, and C-reactive protein. Subjects with ferritin >150 ng/mL and CRP >5 mg/L were excluded. ID was defined as serum ferritin <15 ng/mL, sTfR1 >5 mg/L, and sTfR1:ferritin index >2. Univariate logistic regression models assessed for the association of ID with established clinical risk factors. Results: Clinical and laboratory data from 510 subjects were included in the final analysis (median age 19 years, 51.4% Black). Of those, 83 (n=16.3%) were found to be iron deficient. ID was not associated with racial group, poverty threshold, BMI, age at menarche, history of pregnancy, oral contraceptive pill use, or average daily iron intake (TABLE). Subjects with later onset of menarche tended to have lower ferritin (OR 1.27 [1.05-1.54], p<0.015, FIGURE). Conclusion: The prevalence of ID in subjects 18 to 19 years of age enrolled in the NGHS was consistent with higher values of previously published prevalence estimates in adolescent girls. Established risk factors for the development of ID, such as earlier onset of menarche, were not clearly associated with ID in this cohort. These findings suggest that universal screening, rather than targeted screening, may be important for the early identification of all girls with ID. Additional clinical data and serum samples from Years 5 and 7 of the NGHS will be obtained to determine the prevalence of ID in the same cohort of subjects at earlier ages and determine changes in iron status over time. The results from this study will inform the development of a risk prediction tool as well as evidenced-based screening recommendations for ID in adolescent girls. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

RF32 | PSUN65 Effect of Oral Contraceptive Medication on Blood Pressure, Plasma Renin, and Aldosterone Levels

Abstract Background Combination oral contraceptive medications may cause elevations of plasma renin activity and aldosterone levels. Clinical Case A 20-year-old female with a past medical history of chronic migraines and allergic rhinitis was referred to endocrinology for evaluation of secondary hypertension after she was found to have elevated renin levels by her primary care physician. The patient was noted to be hypertensive during a tonsillectomy 4 months prior and had also experienced an increased frequency of headaches prompting an evaluation for secondary hypertension and the initiation of lisinopril 10 mg daily. Her other medications included levocetirizine, biotin, and the combined oral contraceptive pill (OCP) norgestimate-ethinyl estradiol (0.25 mg/0.035 mg). Physical examination was remarkable for blood pressure 130/85mmHg, Pulse rate 77, BMI 30 kg/m2, pale striae on upper arms, lower back and abdomen, and a slight fat pad on the posterior nape of her neck. Initial lab results revealed normal plasma sodium, potassium, metanephrines and normetanephrines, plasma renin activity (PRA) 70.657 ng/mL/h (0.167-5.380 ng/mL/h), aldosterone 18.9 ng/dL (0.0-30.0 ng/dL), and 8: 00 amcortisol 30.3 mcg/dL (6.2-19.4mcg/dL). Doppler ultrasound and magnetic resonance angiography excluded renal artery stenosis and abdominal renin-secreting tumors. Owing to concern about OCP interference with the measurements of PRA and aldosterone levels, these tests were repeated at the end of a seven-day OCP placebo pills and biotin withdrawal. Lab results revealed: PRA &amp;gt;178 ng/mL/h, aldosterone 15.3 ng/dL, 1 mg overnight dexamethasone suppression test cortisol 1.1 mcg/dL, and 24-hour urinary cortisol 22.4 mcg/L (normal value &amp;lt;24mcg/L). Subsequently, the patient agreed to discontinue OCP and biotin and have labs redrawn 6 weeks later, which revealed PRA of 0.9 ng/mL/h and aldosterone of 5.9 ng/dL. Her blood pressure also normalized off the oral contraceptive and lisinopril was successfully discontinued. Conclusion This case report demonstrates the clinically significant impact of oral contraceptive medication on blood pressure, plasma renin activity and aldosterone levels. It's well known that oral contraceptives may cause elevations in PRA and aldosterone1 likely due to an upregulation of angiotensin mediated by the effect of ethinyl estradiol on the hepatocytes1, albeit not previously reported of the magnitude found in our patient. The extreme elevations of PRA and aldosterone in our patient suggested a diagnosis of either renovascular hypertension, renin secreting neoplasm or coarctation of aorta all of which were excluded. The subsequent normalization of blood pressure, PRA and Aldosterone off oral contraception×6 weeks confirmed that the OCP was the source of her hypertension and lab abnormalities. This case highlights the importance of identifying and omitting interfering medications when evaluating patients for secondary causes of hypertension. References Oelkers WK. Effects of estrogens and progestogens on the renin- aldosterone system and blood pressure. Steroids 1996;61: 166–71. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:36 p.m. - 12:41 p.m.

The Canadian Gynecologic Oncology Peri-operative Management Survey: re-examining Enhanced Recovery After Surgery (ERAS) recommendations

ObjectiveEnhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study...

Prediction model of persistent ovulatory dysfunction in Korean women with polycystic ovary syndrome.

There is no validated tool to predict persistent ovulatory dysfunction after medication with oral contraceptives in women with polycystic ovary syndrome (PCOS), which is the most severe subtype of PCOS. We aimed to build a model to predict persistent ovulatory dysfunction after medication of oral contraceptives in women with PCOS. A total of 286 patients with PCOS were treated with and without oral contraceptives at a tertiary academic medical center. Data were obtained from the electronic medical record system between January 2016 and March 2019. A risk prediction model was developed using multivariable logistic regression. Model 1 was based on age and chief complaints and Model 2 further included predictors evaluated during a clinic visit. Model 3 additionally included laboratory findings. Of the study population, ovulatory dysfunction was persistent in 117 patients (40.9%). Compared with the simple model (Models 1 and 2), the full prediction model (Model 3) had better Akaike's information criterion (286, 244 vs. 225) and the area under the curve (AUC) increased from 0.74 and 0.79 to 0.84. The full model included 7 covariates measured during the evaluation of PCOS, and two covariates were significant predictors of persistent ovulatory dysfunction in PCOS: age (OR 0.91; 95% CI 0.84-0.97), and anti-Müllerian hormone (OR 1.17; 95% CI 1.09-1.26). This model demonstrated good discrimination (AUC, 0.84) and calibration (Hosmer-Lemeshow goodness of fit test, p=0.74). This prediction model was shown to be a useful method for predicting persistent ovulatory dysfunction after oral contraceptive medication in patients with PCOS.

Association of COVID-19 vaccines ChAdOx1 and BNT162b2 with major venous, arterial, or thrombocytopenic events: A population-based cohort study of 46 million adults in England.

Thromboses in unusual locations after the Coronavirus Disease 2019 (COVID-19) vaccine ChAdOx1-S have been reported, although their frequency with vaccines of different types is uncertain at a population level. The aim of this study was to estimate the population-level risks of hospitalised thrombocytopenia and major arterial and venous thromboses after COVID-19 vaccination. In this whole-population cohort study, we analysed linked electronic health records from adults living in England, from 8 December 2020 to 18 March 2021. We estimated incidence rates and hazard ratios (HRs) for major arterial, venous, and thrombocytopenic outcomes 1 to 28 and >28 days after first vaccination dose for ChAdOx1-S and BNT162b2 vaccines. Analyses were performed separately for ages <70 and ≥70 years and adjusted for age, age2, sex, ethnicity, and deprivation. We also prespecified adjustment for anticoagulant medication, combined oral contraceptive medication, hormone replacement therapy medication, history of pulmonary embolism or deep vein thrombosis, and history of coronavirus infection in analyses of venous thrombosis; and diabetes, hypertension, smoking, antiplatelet medication, blood pressure lowering medication, lipid lowering medication, anticoagulant medication, history of stroke, and history of myocardial infarction in analyses of arterial thromboses. We selected further covariates with backward selection. Of 46 million adults, 23 million (51%) were women; 39 million (84%) were <70; and 3.7 million (8.1%) Asian or Asian British, 1.6 million (3.5%) Black or Black British, 36 million (79%) White, 0.7 million (1.5%) mixed ethnicity, and 1.5 million (3.2%) were of another ethnicity. Approximately 21 million (46%) adults had their first vaccination between 8 December 2020 and 18 March 2021. The crude incidence rates (per 100,000 person-years) of all venous events were as follows: prevaccination, 140 [95% confidence interval (CI): 138 to 142]; ≤28 days post-ChAdOx1-S, 294 (281 to 307); >28 days post-ChAdOx1-S, 359 (338 to 382), ≤28 days post-BNT162b2-S, 241 (229 to 253); >28 days post-BNT162b2-S 277 (263 to 291). The crude incidence rates (per 100,000 person-years) of all arterial events were as follows: prevaccination, 546 (95% CI: 541 to 555); ≤28 days post-ChAdOx1-S, 1,211 (1,185 to 1,237); >28 days post-ChAdOx1-S, 1678 (1,630 to 1,726), ≤28 days post-BNT162b2-S, 1,242 (1,214 to 1,269); >28 days post-BNT162b2-S, 1,539 (1,507 to 1,572). Adjusted HRs (aHRs) 1 to 28 days after ChAdOx1-S, compared with unvaccinated rates, at ages <70 and ≥70 years, respectively, were 0.97 (95% CI: 0.90 to 1.05) and 0.58 (0.53 to 0.63) for venous thromboses, and 0.90 (0.86 to 0.95) and 0.76 (0.73 to 0.79) for arterial thromboses. Corresponding aHRs for BNT162b2 were 0.81 (0.74 to 0.88) and 0.57 (0.53 to 0.62) for venous thromboses, and 0.94 (0.90 to 0.99) and 0.72 (0.70 to 0.75) for arterial thromboses. aHRs for thrombotic events were higher at younger ages for venous thromboses after ChAdOx1-S, and for arterial thromboses after both vaccines. Rates of intracranial venous thrombosis (ICVT) and of thrombocytopenia in adults aged <70 years were higher 1 to 28 days after ChAdOx1-S (aHRs 2.27, 95% CI: 1.33 to 3.88 and 1.71, 1.35 to 2.16, respectively), but not after BNT162b2 (0.59, 0.24 to 1.45 and 1.00, 0.75 to 1.34) compared with unvaccinated. The corresponding absolute excess risks of ICVT 1 to 28 days after ChAdOx1-S were 0.9 to 3 per million, varying by age and sex. The main limitations of the study are as follows: (i) it relies on the accuracy of coded healthcare data to identify exposures, covariates, and outcomes; (ii) the use of primary reason for hospital admission to measure outcome, which improves the positive predictive value but may lead to an underestimation of incidence; and (iii) potential unmeasured confounding. In this study, we observed increases in rates of ICVT and thrombocytopenia after ChAdOx1-S vaccination in adults aged <70 years that were small compared with its effect in reducing COVID-19 morbidity and mortality, although more precise estimates for adults aged <40 years are needed. For people aged ≥70 years, rates of arterial or venous thrombotic events were generally lower after either vaccine compared with unvaccinated, suggesting that either vaccine is suitable in this age group.

A case-control study on factor V Leiden: an independent, gender-dependent risk factor for venous thromboembolism

BackgroundActivated protein C resistance (APCR) due to factor V Leiden (FVL) mutation (R506Q) is a major risk factor in patients with venous thromboembolism (VTE). The present study investigated the clinical manifestations and the risk of venous thromboembolism regarding multiple clinical, laboratory, and demographic properties in FVL patients.Material and methodsA retrospective cross-sectional analysis was conducted on a total of 288 FVL patients with VTE according to APCR. In addition, 288 VET control samples, without FVL mutation, were also randomly selected. Demographic information, clinical manifestations, family and treatment history were recorded, and specific tests including t-test, chi-square and uni- and multi-variable regression tests applied.ResultsAPCR was found to be 2.3 times significantly more likely in men (OR: 2.1, p < 0.05) than women. The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in APCR patients was 4.5 and 3.2 times more than the control group, respectively (p < 0.05). However, APCR could not be an independent risk factor for arterial thrombosis (AT) and pregnancy complications. Moreover, patients were evaluated for thrombophilia panel tests and showed significantly lower protein C and S than the control group and patients without DVT (p < 0.0001).ConclusionFVL mutation and APCR abnormality are noticeable risk factors for VTE. Screening strategies for FVL mutation in patients undergoing surgery, oral contraceptive medication, and pregnancy cannot be recommended, but a phenotypic test for activated protein C resistance should be endorsed in patients with VTE.

Toplum Tabanlı Kanser Taraması: Hedef Topluma Ulaşmak

Objective: The aim of this study is to determine the risk factors and the results of the community-based screening program of the women who attended the Cancer Early Diagnosis, Screening, and Education Center between 2005-2011. Methods: This study was planned on a descriptive design. Data of the women who attend to cancer screening center between 2005-2011 years for breast cancer and cervical cancer screening program were collected retrospectively and evaluated. Incomplete forms were excluded. Results: Research has been completed by the records of 3162 women. The age of the study group was between 25-69 years old. The majority of them has been educated for 5 years and/or less, or not educated (89%), more than one-third of patients had more than four birth (38%), the breastfeeding rate was high (93.6%), the oral contraceptive drugs and HRT medication usage ratios were low (7.2%, 7.2%), respectively), the smoking rate was low (14.9%). The number of women who consulted for cervix cancer screening was 215 in 2008 and 142 for breast cancer screening; by the end of June 2011. Those numbers increased to 1271 and 1012, respectively. Conclusion: Community-based cancer screening programs are much more successful to reach the target population although single women, LGBT individuals, “working class” are still the missing parts of the puzzle.

Anticoagulation in pulmonary arterial hypertension: a decision analysis.

Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43–0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66–1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.

SAT-210 Autoimmune Progesterone Dermatitis: A Rare Case Report in a Young Woman with Chronic Dermatitis

Back ground: Autoimmune progesterone dermatitis (APD) or progesterone hypersensitivity (PH) is a rare hypersensitivity reaction to progestogen that exclusively occur in women of childbearing age of which is the underlying mechanism remains not well understood. Clinical case: A 44 years old lady was referred to our endocrine outpatient clinic by her dermatologist for treatment of a recently diagnosed autoimmune progesterone dermatitis. She was initially evaluated for a skin rash that started during the second trimester of her second pregnancy in 2009. Her initial diagnosis was pregnancy induced eczema which was treated with topical steroid with no significant improvement. Her rash worsens after delivery and had persisted since then. She failed chronic systemic steroid treatment and multiple immunosuppressive medications over the years. She had regular menstrual period since her menarche at age of 11 years old. She was on oral contraceptive medication prior to her second pregnancy which she resumed after delivery. She then switched to IUD. Her rash typically gets worse 7-10 days before the onset of her menstrual period with some improvement after her period. Her initial clinical exam showed erythematous papules over her extensor elbows, thighs and genital area with scattered eczematous excoriated plaques over her extremities and trunk. She underwent skin patch test which showed that she is allergic to class A, B, and D1 steroids PH was suspected based on her history and confirmed by a positive progesterone skin test. She was referred to reproductive endocrinology for consideration of ovulation suppression using GnRH agonist. Conclusion: APD is a rare hypersensitivity reaction that can be triggered by endogenous progesterone (menses, pregnancy) or exogenous progestin (OCP, IUD, IVF) exposure. Women between menarche and menopause can be affected with the average age of onset to be in the third decade of life. The underlying mechanism is not well known with several hypotheses being postulated (e.g hypersensitivity reaction type I and IV, hormone cross reactivity and autoimmunity) Clinical presentation is variable and can range from mild dermatitis to life threatening anaphylaxis with some extra dermal manifestations have been described. Detailed history taking is the key to diagnosis as the most consistent features is the presentation of symptoms during the luteal phase of the menstrual cycle. The goal of treating APD is to suppress ovulation which can be achieved by the use of GnRH agonist, selective estrogen receptor modulator or oophorectomy. Progesterone desensitization has been tried in women desiring pregnancy.

A young woman presenting a kikuchi-fujimoto’s disease associated with induced lupus

Introduction: Kikuchi-Fujimoto’s disease (KFD) or histiocytic necrotizing lymphadenitis is a benign and self-limited disease of unknown etiology mainly affecting young women. Although the association with systemic lupus erythematosus (SLE) is well described, no case of drug-induced lupus erythematosus (DILE) associated KFD has not been reported so far. Case report: We herein report a 25-year old Caucasian woman, with no medical history and no medication except for oral estrogen-progestin contraception (levonorgestrel-ethinylestradiol), who presented with cervical lymphadenopathy, fever and arthralgia without weight loss, night sweats or skin involvement. An exhaustive infectious disease screening was negative and lymph node biopsy revealed histiocytic necrotizing lymphadenitis suggesting KFD. Autoimmune screening tests evidenced high titers of anti-histone antibodies suggesting DILE induced by estrogen-progestin medication. The patient received a short course of non-steroidal anti-inflammatory treatment for painful lymphadenitis and arthralgia. Oral levonorgestrel-ethinylestradiol contraceptive medication was stopped and KFD and DILE completely recovered with a long-term disappearance of anti-histone antibodies. Conclusion: We report the first case of KFD associated-DILE following oral levonorgestrel-ethinylestradiol medication. Even though levonorgestrel-ethinylestradiol induced lupus is well known, the association with KFD has never been reported and the physiopathology remained unknown. Keywords: Kikuchi-Fujimoto disease, Lupus, Levonorgestrel-ethinylestradiol

A young woman presenting a kikuchi-fujimoto’s disease associated with induced lupus

Introduction: Kikuchi-Fujimoto’s disease (KFD) or histiocytic necrotizing lymphadenitis is a benign and self-limited disease of unknown etiology mainly affecting young women. Although the association with systemic lupus erythematosus (SLE) is well described, no case of drug-induced lupus erythematosus (DILE) associated KFD has not been reported so far. Case report: We herein report a 25-year old Caucasian woman, with no medical history and no medication except for oral estrogen-progestin contraception (levonorgestrel-ethinylestradiol), who presented with cervical lymphadenopathy, fever and arthralgia without weight loss, night sweats or skin involvement. An exhaustive infectious disease screening was negative and lymph node biopsy revealed histiocytic necrotizing lymphadenitis suggesting KFD. Autoimmune screening tests evidenced high titers of anti-histone antibodies suggesting DILE induced by estrogen-progestin medication. The patient received a short course of non-steroidal anti-inflammatory treatment for painful lymphadenitis and arthralgia. Oral levonorgestrel-ethinylestradiol contraceptive medication was stopped and KFD and DILE completely recovered with a long-term disappearance of anti-histone antibodies. Conclusion: We report the first case of KFD associated-DILE following oral levonorgestrel-ethinylestradiol medication. Even though levonorgestrel-ethinylestradiol induced lupus is well known, the association with KFD has never been reported and the physiopathology remained unknown. Keywords: Kikuchi-Fujimoto disease, Lupus, Levonorgestrel-ethinylestradiol

Insult to Injury: A Multifactorial Etiology of Ischemic Colitis

Ischemic Colitis (IC) is a common cause of intestinal tract ischemic injury and is caused by transient hypoperfusion to the gut. Ischemic colitis is associated with female and elderly patients but can occur in younger patients with a precipitating cause. Contributors include vascular abnormalities, coagulation disorders and medications, including oral contraceptives and antibiotics. Typical presentation includes sudden onset cramping lower abdominal pain and bright red blood per rectum with blood clots. Endoscopic evaluation and histology is the gold standard to diagnose colon ischemia, but this may be time consuming and invasive. Our patient is a 24-year old woman with abdominal pain and bloody diarrhea. She was in her normal state of health until experiencing two days of sudden onset left sided abdominal pain, cramping, tenesmus and multiple episodes of bloody diarrhea. She denied fevers or chills, weight loss, foreign travel, abnormal food intake or family history of IBD. She later endorsed intermittent hematochezia for the past two years. Medications included chronic combined estrogen-progesterone oral contraceptive and new medication of doxycycline po bid this year. She had no previous endoscopies. Labs were notable for leukocytosis, negative pregnancy test, positive fecal leukocytes and CT scan w/o contrast indicating a nonspecific colitis in the sigmoid and descending colon. The patient was given empiric antibiotics and supportive care with initial resolution of leukocytosis and symptom improvement. Stool studies were negative and antibiotics were discontinued, but recurrence of bloody diarrhea and blood clots in her stool prompted further workup. Sigmoidoscopy was performed showing ishemic colitis, confirmed on pathology. Patients may undergo unnecessary treatment and testing for other pathologies such as infection, IBD or malignancy. Our patient improved with conservative management but surgery may be required in cases of gangrene colitis or stricture. Associations between ocp, antibiotics and acute ischemic colitis have been described previously. Our patient endorsed intermittent hematochezia prior to starting doxycycline, suggesting chronic colonic ischemia due to ocp prior to developing acute ischemic colitis from doxycycline sensitivity. Our case illustrates the need for a high index of suspicion for IC in young patients and further research is needed to determine potential synergistic mechanisms of medications that may cause ischemic colitis.1595_A Figure 1. Images from the sigmoid colon showing loss of vascularity and as well as erythema and edema consistent with ischemic colitis.1595_B Figure 2. Images from the sigmoid colon showing loss of vascularity and as well as erythema and edema consistent with ischemic colitis.1595_C Figure 3. Demonstration of colonic mucosa with mucosal hemorrhage and detachment of surface epithelial cells from the basement membrane. Necrosis of the superficial crypts with hyalinization of the lamina propria is noted. Findings are consistent with acute ischemic colitis.

Expect the Unexpected in a Colonoscopy: A Case of Colonic Endometriosis

Endometriosis is defined by the presence and the proliferation of endometrial tissue outside the uterus. Estimate prevalence is nearly 10-15% in women of reproductive age group. Symptoms vary according to location where endometrial tissue is implanted. Intestinal endometriosis can occur in up to 37% of all cases of endometriosis, mainly affecting recto sigmoid part of colon. Our patient is a 32-year-old female with past history of infantile cerebral palsy, seizure disorder and chronic constipation presented to our gastroenterology clinic with abdominal pain. Symptoms have been waxing and waning for years, described as diffuse abdominal pain, cramping in nature and associated with severe constipation. Patient denied any other symptoms, including hematemesis, hematochezia or melena. Patient reported family history of unknown cancer. Physical exam was remarkable for scars from previous cesarean sections. No abdominal tenderness, guarding or rigidity was appreciated. Basic laboratory testing was unremarkable. Colonoscopy visualized a 1 cm sessile polyp (figure 1) in descending colon that was snared, cauterized and retrieved (figure 2). Histology of the polyp revealed benign endometrial glands and stroma, consistent with diagnosis of endometriosis. Patient was started on oral contraceptive medication with dramatic improvement of abdominal pain before patient preferentially stopped it due to weight gain. A follow up colonoscopy for recurrent abdominal pain visualized diminutive polyp in the sigmoid colon that was removed by snare polypectomy. Pathology was consistent with hyperplastic polyp. On outpatient follow up, patient denied any more symptoms of abdominal pain. Endometriosis is a hormone responsive pathological implanting of endometrial tissue outside the uterus. Symptoms of endometriosis vary. Intestinal endometriosis usually manifests as alteration in bowel habits, rectal bleeding and dyschezia. Our patient presented with non-specific abdominal pain that initially responded with oral contraceptive medication. Although patient with diagnosis of endometriosis usually tend to be infertile unless treated, our patient had delivered more than once before she was diagnosed with endometriosis. We present this case so we as gastroenterologist and internists would have low index of suspecion of this rare pathology.Figure: Colonoscopy visualized a 1 cm sessile polyp in the descending colon.Figure: Appearance of bleeding polyp after it was snared and cautarized.

A Review of hormone-based therapies to treat adult acne vulgaris in women.

Hormone-based therapies including combined oral contraceptive medications and spironolactone are considered effective therapies to treat adult acne in women. Our objective is to provide a concise and comprehensive overview of the types of hormonal therapy that are available to treat acne and comment on their efficacy and safety profiles for clinical practice. A systematic search using the PubMed Database was conducted to yield 36 relevant studies for inclusion in the review and several conclusions were drawn from the literature.Treatment with oral contraceptive pills leads to significant reductions in lesion counts across all lesion types compared with placebo. There were no consistent differences in efficacy between the different combined oral contraceptive formulations. In terms of risk, oral contraceptive pill users had three-times increased odds of venous thromboembolism versus non-users according to a recent meta-analysis (95% confidence interval 2.46-2.59). Data on oral contraceptive pill use and breast cancer risk are conflicting but individual patient risk factors and histories should be discussed and considered when prescribing these medications. However, use of these medications does confer measurable protection from endometrial and ovarian cancer. Spironolactone was also shown to be an effective alternative treatment with good tolerability.Combined oral contraceptive medications and spironolactone as adjuvant and monotherapies are safe and effective to treat women with adult acne. However, appropriate clinical examinations, screening, and individual risk assessments particularly for venous thromboembolism risk must be conducted prior to initiating therapy.

Recurrent pulmonary embolism associated with oral hormonal contraceptive use

Pulmonary embolism (PE) is a dramatic and life-threatening complication of deep vein thrombosis, and thus, its prevention, diagnosis, and treatment are of special importance. One of the more common acquired risk factor of PE is the use of oral contraceptive (OCP) medications. We report a case of PE secondary to OCP use. A 30-year-old female patient presented with PE following OCP use. Diagnosis was confirmed with computed tomography angiography and treatment was started with thrombolytics. Although appropriate treatment was initiated and offending drug was withdrawn, patient succumbed to her illness. Thus, treatment with OCPs requires careful and thorough evaluation of patient history and regular follow-up, focusing on likely complications.

Oral contraceptive consumption and cerebral venous sinuses thrombosis

Introduction: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and the clinical presentation is variable. One of the more common acquired risk factors of venous sinus thrombosis is oral contraceptive medications. While the prognosis for CVST is favorable, it is important to identify and treat early to prevent neurologic deficits. CVST accounts for 0.5% of strokes and most commonly presents with headaches and in many cases focal neurologic deficits. Diagnosis is confirmed with neuroimaging including CT angiography or MR angiography. Treatment consists of anticoagulation and in some cases, thrombolytic therapy is beneficial. The overall prognosis of CVST is favorable.The objective of the study is to describe the features of a series of patient with CVST due to consumption of OCPs, treated in the department of Neurosurgery, Bir hospital and OM hospital, and to discuss the risk factors associated with consumption of OCPs, its presentation, and outcome.Methods: This is a retrospective case series carried out in the department of Neurosurgery, Bir hospital and OM hospital during the year September 2012 to September 2014. Demographic features like age, presenting symptoms, clinical findings and outcome were analyzed. All cases received heparin or LMWH followed by Warfarin.Results: Nine patients were identified over a period of 2 years. The presenting symptoms included headache, vomiting, loss of consciousness, focal neurological deficit, seizure and neck pain. Signs found included papilloedema, fever, slurring of speech and focal neurological signs.Conclusion: Dural sinus thrombosis is a rare and under-recognized cause of headache that should be considered in women with recent introduction of hormonal contraception. The absence of papilledema and a negative CT brain should not halt further workup. MRI/venogram is mandatory to confirm the diagnosis.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 2-5

Risk factors related to aggressive condylar resorption after orthognathic surgery for females: retrospective study

Objective: The aim of the present study was to identify the risk factors for aggressive condylar resorption (ACR) after orthognathic surgery.Methods: A total of 25 female patients with osteoarthritis (OA) scheduled for orthognathic surgery were divided into two groups: those who exhibited ACR (ACR (+), n = 8) and those who did not exhibit ACR (ACR (−), n = 17) after surgery. Clinical indices were used to determine the extent of mandibular advancement, the presence of temporomandibular disorder (TMD), and relevant medical treatment histories (including the use of oral contraceptive (OC) medication. TMJ dysfunction was clinically evaluated in terms of pain, the presence of sounds (clicks or crepitus), and disc displacement, joint effusion (JE), and synovial hyperplasia (SH); these were further investigated with the aid of magnetic resonance imaging (MRI). The cephalographic findings were compared with the normal profiles of Japanese subjects.Results: The mean (with SD) extent of mandibular advancement was 11.4 mm (2.4) in ACR (+) and 4.1 mm (1.8) in ACR (−). The TMD medical history of ACR (+) was much more extensive than that of ACR (−); all patients in ACR (+) had a history of OC use. More patients in ACR (+) than in ACR (−) had TMJ dysfunction and disc displacement, JE, and SH on MRI. Preoperative cephalograms showed that ACR (+) patients exhibited counterclockwise rotation of the mandible and retrognathism that was attributable to a small sella–nasion–B (SNB) angle, a wide mandibular plane angle, and a negative inclination of the ramus.Conclusions: The present findings suggest that the development of ACR after orthognathic surgery to treat mandibular retrognathism may be associated with coexisting TMJ pathologic abnormality.