Postponement of withdrawal bleeding in women using low-dose combined oral contraceptives.

Postponement of menses is widely practised by women using oral contraceptives. One-hundred volunteers, consisting of three groups of women, each group using a different extensively used contraceptive regimen, were tested and compared. The test period consisted mainly of a double (monophasics) or extended (triphasics) pill cycle without a tablet-free interval. Based on daily records of vaginal bleedings as well as on the results of a questionnaire, it could be concluded that postponement of the withdrawal bleeding for twenty extra days was generally effective; the occurrence of the bleedings was related to the duration of postponement of menses and to the contraceptive regimen that was used. However, the introduction of a seven-week cycle pill is not yet a promising alternative since the majority of the volunteers preferred the inconvenience of a monthly withdrawal bleeding.

PIP: Women who already were using 1 of the 3 most widely prescribed combined oral contraceptives (OCs) for more than 6 months without experiencing any pill-related problems were asked to participate in an investigation to determine what would be the percentage of regular users of low-dose combined OCs that could effectively postpone the withdrawal bleeding for 21 days (20 in case of triphasic preparation) by skipping the tablet-free interval. It was assumed that if 1 or more bleeding days occurred in the total period of tablet intake, the woman would consider the attempt to have failed. 100 women who responded to announcements in daily newspapers, student weeklys, and information boards at universities in Amsterdam fulfilled the inclusion criteria. The women were asked to maintain a daily record of vaginal bleedings on a specially designed card where a distinction was made between "spotting" and "bleeding." The total study period lasted 12 weeks. It started with the tablet-free interval after a preceding pill cycle, followed by 42 days of daily tablet intake and a 7-day tablet-free interval, and was completed by a regular 21-day tablet cycle and a 7-day tablet-free period. For the triphasic levonorgestrel-containing pill, the scheme was somewhat more complicated. In the 1st 21 days of the 2 consecutive OC cycles, spotting and bleeding episodes were rare. After day 21, there was a rapid increase in the number of women with bleeding episodes in the group using the extended triphasic regimen. This was observed also in women using the consecutive monophasic regimens but to a considerably smaller degree. The difference between the triphasic and the monophasic preparations in the extended cycle (day 21-42) was statistically significant. No statistical difference was observed when spotting included. The extended period of tablet intake was followed by a withdrawal bleeding in the 7-day tablet-free interval in all but 1 case; this woman remained amenorrheic until the next tablet-free interval. The bleeding pattern in the cycle following the prolonged tablet cycle showed minimal irregular bleeding, followed by a normal withdrawal bleeding. 98 women completed a questionnaire on side effects and acceptability of the regimen. Of the 56 women who experienced a bleeding or a period of spotting during the extended period of pill intake, 16 considered the method to be acceptable despite the bleeding or spotting. Of these 16 women, 13 experienced spotting only. 48 of the 98 women would favor a bleeding at 3 or 6 months only, while for the other half this was unacceptable of the 98 women would desire total amenorrhea, if possible.

[Problem-oriented pharmacotherapeutical education]. / Farmacotherapie-onderwijs: van concluderen naar redeneren.

Teaching pharmacotherapy to students of medicine is concerned with knowledge and understanding, skills and attitudes. These elements can be communicated by using a problem-oriented decision-making process. Learning the logical steps from problem to diagnosis, treatment and result and the feedback to the diagnosis, improves the future capacity of adequately solving the individual patient's problems.

Curriculum development in pharmacotherapy: testing the ability of preclinical medical students to learn therapeutic problem solving in a randomized controlled trial.

AIMS: To determine whether preclinical medical students are able to learn therapeutic problem solving simultaneously with gaining knowledge of pharmacology. METHODS: A randomized controlled pre/post-test study among 85 3rd year preclinical medical students from two medical faculties in Amsterdam. In addition to the normal curriculum, the study group followed a course, which was a copy of the obligatory training in cognitive therapeutic skills for 5th year students who had gained knowledge first, followed by applying the knowledge. Before, immediately after and 9 months after the training both the study group and a control group took a test (T0, T1, T2). The level of knowledge and cognitive therapeutic skills were assessed. As a reference, 38 5th year students also took the tests. RESULTS: On T0 the levels of cognitive therapeutic skills of the study and control groups were similar (26.7% and 27.4% of the required level for graduation, respectively). On T1 and T2, the study group scored significantly higher compared with the control group: 46.0/36.7% and 41.3/36.3%, respectively (P<0.05). In comparison with T0, the scores of the study group on T1 increased significantly and showed no significant decline on T2. There were no differences between the groups with respect to the level of knowledge in any of the three tests. The level of cognitive therapeutic skills in the 5th year reference group increased slightly but not significantly from 40.3% to 44.5% after the training; the level of knowledge increased significantly from 48.8% to 68.0%. CONCLUSIONS: Preclinical medical students are able to learn cognitive therapeutic skills simultaneously with gaining knowledge of pharmacology.

Evaluation of a pharmacotherapy context-learning programme for preclinical medical students.

AIM: To evaluate a context-learning pharmacotherapy programme for approximately 750 2nd, 3rd and 4th year preclinical medical students with respect to mastering cognitive pharmacotherapeutic skills, i.e. choosing a (drug) treatment and determining patient information. METHODS: The context-learning pharmacotherapy programme consists of weekly organized role play sessions in the form of consulting hours. Fourth year students sit for a therapeutic Objective Structured Clinical Examination (OSCE) in the form of consulting hours at the outpatient clinic. Sixty-one 2nd, 74 3rd and 49 4th year medical students who attended the role play sessions and the OSCE were randomly selected. Their performances were assessed by clinical examiners and clinical experts and compared with a reference group of 6th year graduated students. Additionally, the scores of a questionnaire on study load and appreciation were collected. RESULTS: The level of the pharmacotherapeutic skills of the 4th year students who followed the pharmacotherapy context-learning programme was not far below that of 6th year graduates who had finished their clinical clerkships, but had not followed the pharmacotherapy programme. The time spent on the programme was about 1% of the total study load per year. The students appreciated the role play sessions and OSCE by around 80% and 99% of the maximum possible scores. CONCLUSIONS: Preclinical pharmacotherapy context learning has a modest but positive effect on learning cognitive pharmacotherapeutic skills, i.e. choosing a drug treatment and determining patient information. This effect has been obtained with role play sessions, a suboptimal form of context learning, with a minimal study load and a high appreciation by students.