simple question

[jok200]

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Bit confused, have been looking around a lot but I haven't been able to find a clean answer. If a woman is on an OCP and she starts having withdrawal bleeding, which I know is common I have been told if it persists you can give a higher dose of estrogen like norinyl 1/50 for a couple of days and the bleeding should stop? Confused because everywhere I read states that the decreasing progesterone levels lead to involution of the spiral arteries and the functional layer starts to become ischemic and sloughs away, so why wouldn't i give progesterone instead of estrogen to maintain the endometrium? I was thinking it was because the estrogen is what stabilzes the endometrium forming the lattice that holds it together, but if that is the case then it is the combination of sudden cessation of progesterone from the corpus luteum and decreasing levels of estrogen that together cause menstruation, and if that is the case why would I only give estrogen and not both?

lots of questions, but I couldn't find a straight answer anywhere.

thanks again-

 

[jok200]

also.. does anyone know where I can find an algorithm for dealing with irregular bleeding with a woman on OCP ?

 

[THP]

I'm not quite sure I understand exactly what your question is. The hormone mechanisms you described are not contradictory. Women who come in with severe bleeding will sometimes get high dose IV estrogen and what it does is stabilize the endometrium for short periods of time. This is a quick fix, not a long term solution.

You actually can also give progesterone to slow bleeding. Medroxyprogesterone acetate (Provera) is classically used in women who can't take estrogen to slow bleeding for periods of time, along with some other progestins. The mirena IUD for example. The problem with extended progesterone only regimens is that over time the endometrium can become thin and atrophic and will slough unpredictably.

Similarly, extended periods of estrogen only leads to a thickened hyperplastic endometrium which will break down and bleed heavily over extended periods of time as we see in obese women with PCOS when they finally do have a period.

Because of both mechanisms, this is why combined OCPs is a good regimen to control dysfunctional uterine bleeding.

In a normal menstrual cycle it is the sudden cessation of progesterone that leads to menstruation.

 

[THP]

also.. does anyone know where I can find an algorithm for dealing with irregular bleeding with a woman on OCP ?

There is no such algorithm, nor should there be. This is part of the art of medicine. Women have very different responses to OCPs and a big part of it is trial and error. What works for one woman certainly does not work for another and the different progestins are tolerated differently. Sometimes we have to give up on OCPs entirely because it doesn't always work.