220

12. kombinirebuli oraluri da saineqcio kontraceptivebi

kombinirebuli oraluri kontraceptivebi (kok)

ganmarteba

kombinirebuli oraluri kontraceptivebi warmoadgens maRalefeqtur,

sinTezur estrogen-progestagenur preparatebs, romlebic icavs qals

arasasurveli orsulobisagan.

kok-i, masSi Semavali estrogenisa da progestagenis kombinaciis mixedviT

iyofa or ZiriTad tipad: monofazuri da mravalfaziani.

• monofazuri _ 21 aqtiuri tabletidan TiToeuli Seicavs estrogenisa

da progestagenis Tanabar raodenobas;

• mravalfaziani: orfaziani (bifazuri) da samfaziani (trifazuri).

• orfaziani (bifazuri) _ 21 aqtiuri tabletidan TiToeuli Seicavs

estrogenis ucvlel dozas, xolo progestagenis doza izrdeba

ciklis meore fazaSi;

• samfaziani (trifazuri) _ 21 aqtiuri tableti Seicavs estrogenisa

da progestagenis sam sxvadasxva kombinacias: estrogenis Semcveloba

izrdeba mxolod meore fazaSi, progestagenis Semcveloba izrdeba

safexurebrivad sam etapad.

estrogenuli komponentis Semadgenlobis mixedviT kok-i iyofa:

• maRaldoziani _ 1 tableti Seicavs 50 mkg e. e.*

• dabaldoziani _ 1 tableti Seicavs 30-35 mkg e. e.

• mikrodozirebuli _ 1 tableti Seicavs 15-20 mkg e. e.

(3, 6 _ xarisxi A)

moqmedebis meqanizmi

kok-is moqmedebis meqanizmi vlindeba reproduqciuli sistemis sxvadasxva

doneze: hipoTalamusi _ hipofizi _ sakvercxeebi _ saSvilosno _

saSvilosnos milebi.

• Trgunavs ovulacias. kok-is moqmedebiT mcirdeba hipoTalamusis mier

rilizing-hormonis da hipofizis mier gonadotropuli hormonebis

sekrecia, ris Sedegadac sakvercxeSi estrogenis gamomuSaveba orjer

mcirdeba da ovulacia iTrguneba. sakvercxeebi mcirdeba zomebSi da

Seicavs mraval atreziul folikuls.

* e.e. _ eTinilestradioli

221

• endometriumi proliferaciul fazaSi ganicdis swraf regress da

naadrev sekreciul transformacias. zogjer aRiniSneba atrofiuli

cvlilebebic, romelsac aqvs antiimplantaciuri efeqti.

• mcirdeba saSvilosnos milebis peristaltika, rac aqveiTebs maTSi

spermatozoidebis moZraobas.

• icvleba cervikaluri lorwos bioqimiuri Semadgenloba _ qveiTdeba

sialis mJava. aseve cikluri cvlilebebis ararsebobis gamo

cervikaluri lorwo sqeldeba da masSi spermatozoidebis SeRweva

Zneldeba.

(3, 5 _ xarisxi A)

efeqturoba

kok-is efeqturoba Seadgens:

0,3 orsulobas 100 qalze/weliwadSi, praqtikulad, sworad da

regularulad gamoyenebis SemTxvevaSi;

6-8 orsulobas qalze/weliwadSi usistemod, araregularulad gamoyenebis

SemTxvevaSi.

(2 _ xarisxi A)

kontracepciuli upiratesobebi

• maRali da swrafi efeqturoba;

• meTodis Seqcevadoba;

• qals eZleva SesaZlebloba akontrolos fertiloba;

• gverdiTi movlenebis simcire;

• gamoyenebis simartive;

• gamoyenebis win ar aris aucilebeli saSosmxrivi gasinjva;

• ar ukavSirdeba sqesobriv aqts;

• SedarebiT iafia (Tu SevadarebT abortis xarjebs);

• SeiZleba gavrceldes arasamedicino personalis mier;

• menstrualuri ciklis adeqvaturi kontroli.

(3, 5, 6 _ xarisxi A)

arakontracepciuli upiratesobebi

samedicino praqtikaSi kok gamoiyeneba ara marto kontracepciuli, aramed

arakontracepciuli mizniTac, romelsac aqvs Tavisi upiratesobebi:

• mcirdeba saSvilosnosgare orsulobis sixSire;

• mcirdeba mcire menjis Rrus organoebis anTebiTi daavadebebis

sixSire;

222

• mcirdeba menstrualuri gamonadeni;

• mcirdeba sarZeve jirkvlebis keTilTvisebiani daavadebis (fibrozul-

kistozuri mastopaTia) riski;

• mcirdeba sakvercxis, endometriumisa da koloreqtaluri kibos

ganviTarebis riski;

• qreba, an mcirdeba premenstrualuri daZabuloba da dismenoreis

simptomebi;

• mcirdeba rkinadeficituri anemiis riski (menstrualuri gamonadenis

Semcirebis xarjze);

• dadebiTad moqmedebs endometriozis mimdinareobaze;

• mcirdeba saSvilosnos miomis ganviTarebis riski;

• mcirdeba sakvercxis retenciuli warmonaqmnebis sixSire;

• xasiaTdeba samkurnalo efeqtiT hiperandrogenuli (akne, hirsutizmi,

seborea) mdgomareobebisas;

• gamoiyeneba saSvilosnodan disfunqciuri sisxldenebis, uSvilobis

samkurnalod;

• izrdeba Zvlis simkvrive;

• ixsneba `arasasurveli orsulobis SiSi~;

• SesaZlebelia morigi menstruaciis `gadaweva~ gamocdis, Sejibrebis,

dasvenebis dros, an samedicino CvenebiT.

(3, 5, 6, 7 _ xarisxi A)

naklovanebebi

• miRebis wesis darRveva zrdis arasasurveli orsulobis risks;

• saWiroebs kvalificiur konsultacias;

• yoveldRiuri gamoyeneba _ saWiroebs mudmiv motivacias. gulmaviwyoba

zrdis orsulobis risks;

• efeqturoba qveiTdeba zogierT wamalTan erTdrouli miRebisas

(barbituratebi, antituberkulozuri preparatebi);

• ar icavs sqesobrivi gziT gadamdebi daavadebebisagan (maT Soris B hepatitis virusi da aiv/Sidsi);

• SesaZloa fertilobis aRdgenis Seferxeba (1-2% SemTxvevaSi);

• Zalian iSviaTad SesaZlebelia seriozuli garTulebebi: infarqti,

insulti, filtvis an Tavis tvinis Trombozi (Sesabamisad 1, 3 an da

11 SemTxveva 100 000 qalze, romlebic iyeneben kok-s)

• aucilebelia uwyveti momarageba

(3, 5, 6, 7 _ xarisxi A)

223

mdgomareobebi, romlebic kok-is gamoyenebis dawyebamde moiTxovs winaswar

samedicino Sefasebas

janmos klasifikacia:

kategoria 1: kok-i SeuzRudavad gamoiyeneba nebismieri

situaciaSi.

kategoria 2: kok-i umetes SemTxvevaSi SeuzRudavad

gamoiyeneba, radganac sargebloba metia, vidre

Teoriuli da/an dadasturebuli riski.

kategoria 3: kok-is gamoyeneba rekomendebuli ar aris,

radganac Teoriuli an dadasturebuli riski metia

vidre sargebloba. kok-i gamoiyeneba mxolod im

SemTxvevaSi, Tu sxva meTodi ar aris xelmisawvdomi.

kategoria 4: kok-is gamoyeneba ar SeiZleba.

(2 _ xarisxi A)

kok-is gamoyenebis ukuCvenebebia:

• orsuloba;

• mSobiarobis Semdeg 6 Tve ZuZuTi kvebis dros;

• mSobiarobis Semdeg 3 kvira ara meZuZur dedebSi;

• sasqeso gzebidan daudgeneli genezis sisxldena;

• gul-sisxlZarRvTa daavadebis mravlobiTi risk-faqtorebis arseboba;

garTulebebiT mimdinare gulis sarqvlebis daavadebebi;

• Tromboflebiti, Tromboemboliuri daavadebebi, Tavis tvinis sisxlis

mimoqcevis darRveva, cerebro-vaskuluri insultebi, miokardiumis

infarqti (anamnezSi);

• Trombogenuri mutacia _ sisxlis Sededebis darRvevebi;

• Sakiki nevrologiuri simptomebiT;

• 35 wlis zeviT sigaretis moweva (dReSi 15 Reri da meti sigareti);

• arteriuli hipertonia;

T/A sistoluri ≥ 160 diastoluri ≥ 100 mm vwy sv (me-4 kategoria) an sistoluri ≥ 140-159 diastoluri ≥ 90-99 mm vwy sv (me-3 kategoria);

• Saqriani diabeti sisxlZarRvovani garTulebebiT, an sxva

sisxlZarRvovan daavadebebTan erTad, an 20 wlis xangrZlivobiT;

• ZuZus kibo amJamad;

• RviZlis mwvave daavadeba (hepatiti);

ki

meTodis

gamoyeneba

SeiZleba

ara

meTodis

gamoyeneba

rekomendebu-

li ar aris

224

• RviZlis keTilTvisebiani an avTvisebiani simsivne, RviZlis cirozi,

dekompensaciis stadiaSi;

• qirurgiuli operacia xangrZlivi imobilizaciiT.

(2 _ xarisxi A)

orsuloba (dadasturebuli an saeWvo)

kategoria 4. kok-i ar gamoiyeneba orsulobis dros. Tu preparatis miRebis

fonze orsuloba dadasturda saSvilosnos RruSi, kok-is miReba unda

Sewydes. Tanamedrove monacemebiT kok-is miReba ar zrdis

mkvdradSobadobis, TviTnebiTi abortisa da Tandayolili mankis

ganviTarebis risks. miuxedavad amisa, orsulobis adreul vadazec ki

rekomendebuli araa preparatebis gamoyeneba.

Tu menstruaciis dagvianebisas orsulobis gamoricxva ver xerxdeba, kok-is

miReba unda gadavaddes Semdeg menstruaciamde. am SualedSi qalma unda

gamoiyenos kontracepciis sxva meTodi (mag. barieruli).

ZuZuTi kveba

kategoria 4. Tu qali ZuZuTi kvebavs bavSvs da ar iyenebs lam-s,

mSobiarobidan 6 Tvis ganmavlobaSi mizanSewonili araa kok-is miReba,

radganac masSi Semavali estrogeni gadis dedis rZeSi da axalSobilze

SesaZlebelia mavne zegavlena iqonios. aseve cnobilia, rom mSobiarobidan

pirveli 6 kviris ganmavlobaSi estrogeni amcirebs laqtaciis process. Tu

qali ar iyenebs lam-s, mSobiarobidan 6 Tvemde sasurvelia gamoiyenos

kontracepciis sxva meTodi (mag: sSs, barieruli, sufTa progestagenuli

abebi da sxva).

kategoria 3. Tu qali mSobiarobis Semdgom periodSi ar kvebavs ZuZuTi,

kok-is dawyeba SeuZlia mSobiarobidan mxolod 3 kviris Semdeg, radganac,

pirveli 3 kviris ganmavlobaSi estrogenuli komponenti zrdis Trombis

warmoqmnis risks. aseve, mSobiarobidan pirveli 3-6 kviris ganmavlobaSi

ovulaciis naklebi albaTobaa da amdenad qalebi orsulobis dabali

riskis qveS imyofebian.

sasqeso gzebidan daudgeneli genezis sisxldena

kategoria 4. Tu qals aReniSneba sisxldena saSodan, sanam sisxldenis

swori diagnozi ar dadgindeba, rekomendebuli araa kok-is gamoyeneba,

radganac kok-s SeuZlia menstruaciebs Soris periodSi sisxldena SeaCeros

da SeniRbos ZiriTadi problema (mag: saSvilosnos Rrus an saSvilosnos

gare orsuloba, mcire menjis Rrus sxva paTologia da iSviaTad

genitaluri traqtis kibo). saWiroa Catardes srulyofili ginekologiuri

gamokvleva da kategoria ganisazRvros mxolod amis Semdeg.

kategoria 2. diagnozis dadgenis Semdeg Tu dadasturda disfunqciuri

sisxldena saSvilosnodan, kok-is miReba mizanSewonilia samkurnalo

mizniTac.

225

gul-sisxlZarRvTa daavadebebi

kategoria 4. gul-sisxlZarRvTa daavadebebis dros _ gulis iSemiuri

daavadeba (amJamad da adre), stenokardia, garTulebuli gulis sarqvlebis

daavadeba (filtvismieri hipertenzia, winagulebis fibrilaciis riski,

qvemwvave baqteriuli endokarditi anamnezSi), lipiduri metabolizmis

aTerogenuli darRvevebi, arteriuli an venuri Trombozi, Trombogenuri

mutacia (magaliTad: leidenis V faqtori, proTrombinis mutacia, protein

S, protein C da antiTrombinis ukmarisoba) _ rekomendebuli araa kok-is

miReba, radgan man SeiZleba Seqmnas daavadebebis ganviTarebis damatebiTi

riski (estrogenis efeqti).

Tavis tvinis sisxlZarRvebis dazianeba

kategoria 4. Tu qals anamnezSi aReniSneba insulti da Tavis tvinis

sisxlZarRvebis sxva dazianeba, rekomendebuli araa kok-is miReba.

sisxlis Sededebis darRvevebi

kategoria 4. Tu qals aReniSneba Rrma venebis Trombozi an filtvis

embolia amJamad an anamnezSi, an didi qirurgiuli operacia da xangrZlivi

imobilizacia, rekomendebuli araa kok-is miReba.

kategoria 2. Rrma venebis Trombozi / filtvis emboliis ojaxuri anamnezi,

didi operacia araxangrZlivi imobilizaciiT, `mcire~ qirurgia

imobilizaciis gareSe.

Sakiki (Tavis tkivili)

kategoria 4. Tu qals aReniSneba Sakiki kerovani nevrologiuri

simptomebiT (mag: metyvelebis unaris droebiTi dakargva, mxedvelobis

velebis gamovardna da a.S.), nebismier asakSi, rekomendebuli ar aris kok-is

miReba. misma gamoyenebam SeiZleba Seqmnas insultis damatebiTi riski

(estrogenis efeqti).

gamokvlevebiT damtkicda, rom qalebis is jgufi, romelTac aReniSnebaT

aura, imyofebian insultis ganviTarebis ufro maRali riskis qveS vidre

isini, visac aura ara aqvs. auris mqone pacientebSi kok-is gamoyenebisas 2-4-

jer izrdeba insultis riski, vidre im qalebSi, romlebic kontracepciis

am meTods ar iyeneben.

kategoria 3. Sakiki kerovani nevrologiuri simptomebis gareSe ≥ 35 wlis

asakSi.

kategoria 2. Sakiki kerovani nevrologiuri simptomebis gareSe < 35 wlis

asakSi.

35 wlis da meti asakis mweveli qalebi

kategoria 4. aRniSnuli asakis qalma ar unda miiRos kok-i, Tu eweva dReSi

≥ 15 sigarets.

226

35 wlis da ufro meti asakis mweveli (intensiuri, an araintensiuri) qalebi

imyofebian infarqtis, insultis da sisxlis Sededebis sxva problemebis

gazrdili riskis qveS. aseT SemTxvevebSi kok-is miReba qmnis Trombis

warmoqmnis damatebiT risks (estrogenis efeqti)

kategoria 3. asaki ≥ 35 _ sigareti <15 dReSi

kategoria 2. asaki < 35

maRali arteriuli wneva

kategoria 4. qalebma, romelTac aReniSnebaT arteriuli wneva ≥160/100 mm.vwy.sv. (sisxlZarRvovani problemebiT, an maT gareSe), ar unda miiRon

kok-i.

kategoria 3. Tu eqimTan orjer ganmeorebiTi vizitis dros qals

arteriuli wneva aReniSna 140-159/90-99 mm.vwy.sv., man ar unda miiRos kok-i.

sasurvelia SeirCes kontracepciis sxva meTodi (spermicidi, kondomi da

a.S.). janmrTel qalebSi kok-is miReba iwvevs arteriuli wnevis mxolod

umniSvnelo cvlilebas. hipertenziis dros ki, is qmnis insultis,

miokardiumis mwvave infarqtis da periferiuli arteriebis dazianebis

damatebiT risks (estrogenis efeqti). wamlis miReba unda Sewydes, Tu

pirveli ramdenime Tvis ganmavlobaSi vlindeba arteriuli wnevis

mniSvnelovani mateba, an arteriuli sisxlZarRvebis daavadeba.

kategoria 2. anamnezSi maRali arteriuli wneva orsulobis dros, Tumca

amJamad arteriuli wneva normis farglebSia.

Saqriani diabeti

kategoria 3/4. progresuli da didxans mimdinare (>20 welze) Saqriani

diabeti, sxvadasxva garTulebebiT: sisxlZarRvovani, neiropaTia,

retinopaTia, nefropaTia.

aRniSnuli mdgomareobebis dros qalebma ar unda miiRon kok, radganac

masSi Semavali estrogeni zrdis Trombis warmoqmnis damatebiT risks.

kategoria 2. qalebs, insulin damokidebuli an insulin damoukidebeli

Saqriani diabetiT seriozuli garTulebebis gareSe, ZiriTadad SeuZliaT

kok-is miReba.

kategoria 1. anamnezSi diabeti orsulobis dros.

ZuZus kibo

kategoria 4. Tu qals aReniSneba ZuZus kibo amJamad an anamnezSi, ar unda

miiRos kok-i. cnobilia, rom sarZeve jirkvelis kibo hormondamokidebuli

simsivnea da kok-is miRebam SeiZleba gazardos simsivnis progresirebis

riski.

kategoria 1. sarZeve jirkvlebis keTilTvisebiani daavadeba.

kategoria 1. sarZeve jirkvlebis kibos ojaxuri anamnezi. kok-is gamoyeneba

aRniSnuli kategoriis qalebSi ar iwvevs sarZeve jirkvlebis kibos

gazrdil risks imaTTan SedarebiT, visac analogiuri anamnezi hqonda da

227

kok-s ar iyenebda. Tu aRiniSneba sarZeve jirkvlis kibos ganmapirobebuli

genis BRCA1 tipis mutacia, kok-is gamoyenebam SeiZleba umniSvnelod

gazardos zemoT aRniSnuli kibos riski.

RviZlis daavadebebi

kategoria 4. simptomuri siyviTle, virusuli hepatiti, dubin-jonsonis

sindromi, rotoris sindromi warmoadgens kok-is miRebis ukuCvenebas,

radganac aRniSnuli mdgomareobis dros kok-Si Semavali steroidebi

mTlianad ver metabolizdeba RviZlSi, ramac SeiZleba damatebiTi ziani

moutanos qalis janmrTelobas.

qalebma hepatitis dros ar unda miiRon kok manam, sanam ar moxdeba RviZlis

funqciuri maCveneblebis normalizeba (uxSiresad siyviTlis gaqrobidan 3-5

Tvis Semdeg).

RviZlis simsivneebi, cirozi

kategoria 4. RviZlis keTilTvisebiani (adenoma) da avTvisebiani (hepatoma)

simsivne, cirozis mZime (dekomepensirebuli) forma _ warmoadgenen kok-is

miRebis ukuCvenebas, radganac preparatis miRebam SeiZleba gaauaresos

zemoT aRniSnuli mdgomareobebi.

naRvlis buStis daavadebebi

kategoria 3. Tu qals amJamad aReniSneba naRvlis buStis daavadeba da

imyofeba medikamenturi mkurnalobis qveS, man sasurvelia kok-i ar miiRos,

garda im SemTxvevebisa, roca kontracepciis sxva ufro Sesaferisi

meTodebi xelmisawvdomi ar aris.

kok-ma SeiZleba gamoiwvios naRvlis buStis daavadebis riskis mcire

gazrda. arsebobs agreTve mosazreba, rom kok-s SeuZlia gamoiwvios

naRvlis buStis arsebuli daavadebebis gauareseba.

kategoria 2. qolecisteqtomiis Semdeg kok-is gamoyeneba SeiZleba.

kategoria 2. asimptomuri mdgomareobis dros, kok-is gamoiyeneba SeiZleba.

qirurgiuli operacia xangrZlivi woliTi reJimiT

kategoria 4. xangrZlivi imobilizacia zrdis venuri sisxlis Sededebis

momatebis risks. Tu SesaZlebelia, kok-is miReba unda Sewydes qirurgiuli

Carevidan (roca saWiroa xangrZlivi imobilizacia) 4 kviriT adre da mis

Semdeg 2 kviris ganmavlobaSi.

kategoria 3. antikonvulsantebis (fenitoini, barbituratebi, karbamazepini,

primidoni) valprois mJavas garda da antituberkulozuri (rifampicini)

preparatebis miReba

aRniSnuli preparatebis miRebis fonze dabaldoziani kok-is efeqturoba

mcirdeba, radgan maTi didxans miReba iwvevs RviZlis fermentebis

228

aqtiurobis momatebas, rac iwvevs estrogenisa da progestagenis

metabolizmis daCqarebas da preparatebis efeqturobis Semcirebas.

menstruaciebs Soris periodSi sisxliani gamonadeni SeiZleba miuTiTebdes

estrogenis da progestagenis daqveiTebul doneze. am SemTxvevaSi saWiroa

maRaldoziani (estrogenis maRali done) kok-is gamoyeneba, an unda SeirCes

kontracepciis sxva meTodi.

antimikozuri preparatis (grizeofulvini) miReba

kategoria 2. ramdenadac grizeofulvini, romelic iwvevs estrogenis da

progestagenis metabolizmis gazrdas, Cveulebriv mxolod xanmokle

periodis ganmavlobaSi (2-4 kvira) gamoiyeneba, qalebs, romlebic mas

sokovani infeqciis samkurnalod iyeneben, SeuZliaT kok-is miRebis

gagrZeleba da paralelurad damatebiTi meTodis (mag: kondomi) gamoyeneba

momdevno menstruaciis dawyebamde.

(2 _ xarisxi A)

kok-is miRebis dawyeba da gamoyenebis reJimi

kok-is miRebis dawyeba SesaZlebelia regularuli menstrualuri ciklis

dros:

• menstrualuri ciklis dawyebidan 5 dRis ganmavlobaSi;

• menstrualuri ciklis nebismier dros, Tu sakmarisi safuZveli

arsebobs imisi, rom qali orsulad ar aris;

• Tu kok-is miReba iwyeba menstrualuri ciklis dawyebidan 5 dRis

Semdeg, qals rekomendacia eZleva Tavi Seikavos sqesobrivi

kavSirisagan, an gamoiyenos kontracepciis damatebiTi meTodi 7 dRis

ganmavlobaSi (kondomi / spermicidi).

(1 _ xarisxi A, 12, 13 _ xarisxi B)

amenoreis dros:

• kok-is miRebis dawyeba SeiZleba nebismier dros, Tu sakmarisi

safuZveli arsebobs imisi, rom qali orsulad ar aris. aseT

SemTxvevaSi qalma sasurvelia Tavi Seikavos sqesobrivi kavSirisagan

an gamoiyenos kontracepciis damatebiTi meTodi 7 dRis ganmavlobaSi

(kondomi / spermicidi)

(1 _ xarisxi A, 8, 9 _ xarisxi B)

mSobiarobisa da abortis Semdeg:

• mSobiarobidan 6 Tvis Semdeg, Tu qali ZuZuTi kvebavs bavSvs;

• mSobiarobidan 3 kviris Semdeg, Tu qali ZuZuTi ar kvebavs bavSvs;

• abortis Semdeg kok-is gamoyeneba SeiZleba maSinve. amasTan

kontracepciis damatebiTi meTodis gamoyeneba saWiro ar aris.

(1 _ xarisxi A, 12, 13 _ xarisxi B)

229

gamoyenebis reJimi:

• qali Rebulobs TiTo tablets yoveldRe 21 dRis ganmavlobaSi

(erTsa da imave dros). isvenebs 7 dRe da me-8-e dRidan iwyebs axal

firfitas.

• Tu firfita Seicavs 28 tablets (bolo 7 tableti arahormonulia da

SeiZleba Seicavdes rkinas an vitamins), qali kok-s Rebulobs uwyveti

reJimiT, anu 28 tabletis damTavrebis Semdeg qali Sesvenebis gareSe

tabletebis miRebas iwyebs axali firfitidan.

(1 _ xarisxi A, 12, 13 _ xarisxi B)

• prof. a. xomasuruZis mier SemuSavebuli modifikaciis mixedviT

monofazuri tabletebis raodenoba unda gaizardos an Semcirdes

menstrualuri ciklis xangrZlivobis mixedviT. mag: 30 dRiani

menstrualuri ciklis SemTxvevaSi qali Rebulobs TiTo tablets

yovel dRe 23 dRis ganmavlobaSi; 26 dRiani menstrualuri ciklis

SemTxvevaSi – TiTo tableti erTxel dReSi 19 dRis ganmavlobaSi da

a.S. 7 dRiani Sesvenebis wesi SenarCunebulia.

sxva hormonuli meTodidan kok-ze gadasvla

• SeiZleba Sualedis gakeTebis gareSe, mxolod im pirobiT, rom wina

meTodi gamoyenebuli iyo rekomendaciis mixedviT. aseT SemTxvevaSi

Semdgom menstruaciamde mocda aucilebeli ar aris.

• Tu wina meTodi warmoadgenda ineqcias, kok-is dawyeba SeiZleba

Semdgomi ineqciis savaraudo dRes. aseT SemTxvevaSi kontracepciis

damatebiTi meTodis gamoyeneba saWiro ar aris.

(1 _ xarisxi A, 12, 13 _ xarisxi B)

arahormonuli kontracepciidan (sSs-s garda) kok-ze gadasvla

• kok-is miRebis dawyeba SeiZleba menstrualuri ciklis dawyebidan 5

dRis ganmavlobaSi. kontracepciis damatebiTi meTodis gamoyeneba

saWiro ar aris.

• aseve, kok-is miRebis dawyeba SeiZleba wina meTodis Sewyvetidan

maSinve, an nebismier dros, Tu sakmarisi safuZveli aris imisa, rom

qali orsulad ar aris. Tu kok-is miRebis dawyeba xdeba

menstrualuri ciklis dawyebidan 5 dRis Semdeg, qals rekomendacia

eZleva Semdgomi 7 dRis ganmavlobaSi Tavi Seikavos sqesobrivi

kavSirisagan, an gamoiyenos kontracepciis damatebiTi meTodi.

(1 _ xarisxi A, 12, 13 _ xarisxi B)

sSs-dan (levonorgestreliani sSs-s CaTvliT) kok-ze gadasvla

• kok-is miRebis dawyeba SeiZleba menstrualuri ciklis dawyebidan 5

dRis ganmavlobaSi. kontracepciis damatebiTi meTodebis gamoyeneba

saWiro ar aris, sSs amoRebuli unda iyos am periodSi.

230

• aseve kok-is miRebis dawyeba SeiZleba nebismier dros, Tu sakmarisi

safuZveli aris imisa, rom qali orsulad ar aris.

_ Tu aRniSnuli menstrualuri ciklis ganmavlobaSi qali aqtiuri

sqesobrivi cxovrebiT cxovrobda da menstruaciis dawyebidan

gasulia 5 dReze meti, aseT SemTxvevaSi amoReba rekomendebulia

Semdgomi menstrualuri ciklis dros.

_ Tu aRniSnuli menstrualuri ciklis ganmavlobaSi qali

sqesobrivi cxovrebiT ar cxovrobda da menstruaciis dawyebidan

gavida 5 dReze meti, qals rekomendacia eZleva Semdgomi 7 dRis

ganmavlobaSi Tavi Seikavos sqesobrivi kavSirisagan, an gamoiyenos

kontracepciis damatebiTi meTodi. Tu zemoT xsenebul kontracepciis

damatebiT meTodad sSs iTvleba, maSin misi amoReba unda moxdes

Semdgomi menstrualuri ciklis dros.

• Tu qals aqvs araregularuli menstrualuri gamonadeni an amenorea,

kok-is miRebis dawyeba SeiZleba im rekomendaciiT, romelic

miTiTebulia: `kok-is miRebis dawyebaSi amenoreis dros~.

(1 _ xarisxi A, 12, 13 _ xarisxi B)

kok-is miRebis Semdeg fertilobis aRdgena

kok-is did upiratesobas warmoadgens misi miRebis Semdeg fertilobis

swrafi aRdgena. hipoTalamus – hipofiz – sakvercxeebis funqcionireba 90%-

Si aRdgeba 2-6 Tvis ganmavlobaSi. SemTxvevaTa 2%-Si SeiZleba adgili

hqondes hipofizis gonadotropuli funqciis hiperdamuxruWebis sindroms

da Sesabamisad amenoreas. aRniSnuli mdgomareoba ZiriTadad gvxvdeba

maRaldoziani preparatebis gamoyenebisas 6 da meti Tvis ganmavlobaSi.

amenorea SeiZleba ganviTardes endometriumis atrofiuli cvlilebebis

Sedegad, romelic Seqcevadi procesia. endometriumis funqciuri Sris

aRdgenis Semdeg menstruacia TavisTavad aRdgeba an SesaZlebelia saWiro

gaxdes estrogenebiT mkurnaloba.

(1, 3 _ xarisxi A)

preparatebiT momarageba

• eqimma qals unda misces kok-is wliuri maragi (damokidebulia qalis

survilze, ramden xans gegmavs igi kok-is miRebas) Tu eqims gaaCnia

kontraceptivebiT (kok-iT) programuli uzrunvelyofa. an urCios mas,

TviTon izrunos maragis Seqmnaze.

• maragis Sevsebis sistema moqnili unda iyos, romelic qals

saSualebas miscems, Tavisuflad miiRos kontracepciis saWiro

raodenoba misTvis mosaxerxebel dros.

• janmo-s eqspertebis monacemebiT eqimis mier qalisTvis kok-is gacema

raodenobis TvalsazrisiT SezRuduli ar unda iyos, radganac

hormonuli kontracepciis gamoyenebis dros arasasurveli (an

iZulebiTi) Sesveneba zrdis daugegmavi orsulobis risks

(1 _ xarisxi A)

231

meTvalyureoba _ ganmeorebiTi viziti

• kok-is gamoyenebisas qali eqimTan unda mivides yovelwliurad.

• kok-is miRebis dawyebidan 3 Tvis Semdeg aucilebelia eqimTan

ganmeorebiTi viziti.

• qalma eqims unda mimarTos nebismier dros kontracepciasTan

dakavSirebuli romelime gverdiTi movlenis, an sxva raime problemis

warmoqmnis SemTxvevaSi, an Tu qals surs kontracepciis aRniSnuli

meTodis Secvla.

(1 _ xarisxi A)

konsultireba

kontracepciis meTodis SerCeva xdeba: reproduqtologis, mean-ginekologis

da ojaxis eqimis mier.

qals unda mieces zusti instruqcia kok-is:

• moqmedebis meqanizmze

• gverdiT movlenebze (ix. gverdiTi movlenebi)

• sayuradRebo niSnebze (ix. sayuradRebo niSnebi)

• kok-is miRebis dawyebaze (ix. kok-is miRebis dawyeba)

• reJimze (ix. gamoyenebis reJimi)

• gamotovebul abebze (ix. protokoli gverdiTi movlenebi, Sefaseba,

marTva)

• ganmeorebiT vizitze (ix. meTvalyureoba _ ganmeorebiTi viziti)

• fertilobis aRdgenaze

232

kok-is gverdiTi movlenebis klasifikacia

estrogendamokidebuli efeqti progestagendamokidebuli efeqti

• Tavis tkivili

• T/A-is momateba (arteriuli

wnevis momateba)

• gaRizianeba

• gulisreva, Rebineba

• Tavbrusxveva

• mastodinia (sisavsis SegrZneba

sarZeve jirkvlebSi)

• qloazma (orsulobis msgavsi

laqebi saxeze)

• varikozuli venebis

mdgomareobis gauareseba

• kontaqturi linzebis

autanloba

• sxeulis wonaSi momateba

• Tavis tkivili

• depresia

• advilad daRla

• akne

• libidos daqveiTeba

• saSos lorwovani garsis

simSrale

• varikozuli venebis

mdgomareobis gauareseba

• sxeulis wonaSi momateba

estrogenuli efeqtis ukmarisoba

(estrogenis SefardebiT mcire doza)

progestagenuli efeqtis ukmarisoba

(progestagenis SefardebiT

mcire doza)

• Tavis tkivili

• depresia

• gaRizianeba

• sarZeve jirkvlebis zomaSi

Semcireba

• libidos daqveiTeba

• saSos lorwovani garsis

simSrale

• menstruaciaTa Soris

sisxliani CamonaSali ciklis

dasawyisSi da/an SuaSi

• mcire menstrualuri

gamonadeni

• Warbi menstruacia

• menstruaciaTa Soris

sisxliani CamonaSali ciklis

meore fazaSi

• menstruaciis Seferxeba

233

kok-is miRebis dawyebamde rekomendebuli gamokvlevebi da analizebi,

pacientis saWiroebebisa da moTxovnilebebis mixedviT:

klasi

• sarZeve jirkvlebis gamokvleva _ C

• mcire menjis Rrus/sasqeso organoebis gamokvleva _ C

• saSvilosnos yelis kiboze skriningi _ C

• standartuli laboratoriuli analizebi _ C

• hemoglobinis gansazRvra sisxlSi _ C

• sggi-iT daavadebis riski

anamnezis Sekreba da saerTo gasinjva _ C

• sggi/Sids-is gamovlenis skrininguli

laboratoriuli analizebi _ C

• arteriuli wnevis gazomva _ *

klasi _ `C~ _ aRniSnuli gamokvlevisa da analizis Catareba ar

uzrunvelyofs kontracepciis am konkretuli meTodis uSiSrad

gamoyenebas da efeqturobas.

* _ gamokvlevis Catareba rekomendebulia.

sayuradRebo niSnebi kok-is miRebisas

qalma unda mimarTos samedicino dawesebulebas maSinve, Tu

SeamCnia qvemoT aRwerili romelime niSani:

• Zlieri tkivili gulmkerdSi, an qoSini;

• Zlieri Tavis tkivili, an mxedvelobis darRveva, metyvelebis

moSla;

• Zlieri tkivili qvemo kidurebSi;

• Zlieri tkivili muclis areSi;

• siyviTle ;

• sisxliani gamonadenis ararseboba: 21 tabletiani firfitis

damTavrebis SemTxvevaSi an 7 araaqtiuri tabletis miRebis

periodSi, romelic SeiZleba iyos orsulobis niSani.

(3, 7 _ xarisxi A)

234

kombinirebuli saineqcio kontraceptivebi (ksk)

ganmarteba

kombinirebuli saineqcio kontraceptivebi Seicavs xanmokle moqmedebis

(bunebriv) estrogens da xangrZlivi moqmedebis progestagens. saineqcio

preparatebi TandaTanobiT Seiwoveba ineqciis Semdeg 28 dRis ganmavlobaSi.

erTi ineqcia keTdeba TveSi erTxel.

ksk-s tipebi

• 25 mg depo-medroqsiprogesteron acetati da 5 mg estradiol

cipionati (ciklofemi, cikloprovera, lunela da novafemi)

• 50 mg noreTisteron enantati da 5 mg estradiol valerati (mesijina

da noriginoni)

radganac ksk-Si Semavali estrogeni ufro fiziologiuria da naklebad

Zlieri, vidre kok-Si Semavali sinTezuri estrogeni, ksk-s gamoyenebisas

gamovlenili estrogendamokidebuli gverdiTi movlenebi SeiZleba

gansxvavdebodes kok-is gverdiTi movlenebisagan. ksk-s moklevadianma

gamokvlevebma aCvena, rom kok-Tan SedarebiT igi umniSvnelod moqmedebs

arteriul wnevaze, hemostazze, sisxlis Sededebaze, lipidebis

metabolizmze da RviZlis funqciaze.

ksk-i warmoadgens kontracepiis SedarebiT axal meTods, amdenad maTi

xangrZlivi gamoyenebis epidemiologiuri monacemebi am etapze mcirea.

amasTan, kok-is miRebisas hormonuli datvirTvis moxsna SeiZleba

preparatis miRebis SewyvetiT, xolo ksk-s gamoyenebisas hormonis

zemoqmedeba grZeldeba xangrZlivad.

janmo-s samuSao jgufis daskvniTi masala, romelic kok-is gamoyenebaze

arsebobs, umetes SemTxvevaSi misaRebia ksk-ze, magram ara yvela SemTxvevaSi.

amitom ksk-s gamoyenebisas pacientebis mdgomareobis kvalifikaciis dros

janmo-s samuSao jgufi orinetirebuli iyo kok-is da pk-s (progestagenuli

kontraceptivebi) kategoriebze da SearCia saSualo maT Soris. Tumca mZime

formis paTologiebis dros (mag: gulis iSemiuri daavadeba) klasifikacia

aris igive, rac kok-is dros. amitom aRniSnuli kategoriebi aris winaswari

da axali monacemebis mixedviT eqvemdebareba gadasinjvas.

(2 _ xarisxi A)

ksk-s moqmedebis meqanizmi (ix. kok-i)

efeqturoba

ksk-s efeqturoba Seadgens 0,05 orsuloba 100 qalze/weliwadSi, sworad da

regularulad gamoyenebis SemTxvevaSi. 3 orsuloba 100 qalze/weliwadSi

araregularulad gamoyenebis SemTxvevaSi.

(2 _ xarisxi A)

235

kontracepciuli upiratesobebi

• maRali efeqturoba

• meTodis Seqcevadoba

• SeiZleba daculi iyos kontracepciis meTodis gamoyenebasTan

dakavSirebuli konfedencialoba

• gamoyenebis simartive

• gamoyenebis win ar aris aucilebeli saSosmxrivi gasinjva

• ar moiTxovs maragis gakeTebas

(3 _ xarisxi A)

naklovanebebi

• zogierT SemTxvevaSi iwvevs menstrualuri ciklis xasiaTis

Secvlas (adreul stadiaze araregularuli _ mcire raodenobiT

sisxliani gamonadeni)

• damokidebulia gamomyenebelze (pacienti klinikaSi unda movides

30 dReSi erTxel)

• ar icavs sqesobrivi gziT gadamdebi daavadebebisagan (maT Soris B hepatitis virusi da aiv/Sidsi)

(3 _ xarisxi A)

ksk-is gamoyenebis Cvenebebi

ksk SeiZleba gamoiyenon im qalebma, romlebsac:

• aviwydebaT tabletebis yoveldRe miReba

• progestagenuli saineqcio kontraceptivebis fonze aReniSnebodaT

araregularuli sisxliani CamonaSali

(7 _ xarisxi A)

ksk-s gverdiTi movlenebi

• menstrualuri ciklis cvlilebebi. ufro naklebad gvxvdeba, vidre

progestagenuli saineqcio kontraceptivebis gamoyenebis dros.

pirveli cikli aris mokle (10-20 dRe), romlis Semdeg aRiniSneba

yovelTviuri sisxldena. araregularuli sisxldena aRiniSneba

SemTxvevaTa 30%-Si pirveli 3 Tvis ganmavlobaSi. ksk-s

gamomyeneblebis umravlesobas pirveli wlis bolos aReniSnebaT

regularuli menstrualuri cikli

• amenorea ar aRiniSneba

• sxva mcire gverdiTi movlenebia: wonaSi momateba, Tavis tkivili

(3 _ xarisxi A)

ukuCvenebebi, kategoriebi, urTierTqmedeba sxva medikamentebTan da

gegmiuri gamokvlevebi ix. kok-is Sesabamis nawilSi

236

ksk-s gamoyenebis dros gansxvavebuli kategoriebi mocemulia qvemoT:

sigaretis moweva

kategoria 2. asaki < 35 w.

kategoria 2. asaki ≥ 35 w. sigareti < 15 dReSi

kategoria 3. asaki ≥ 35 w. sigareti ≥ 15 dReSi

naRvlis buStis daavadeba

kategoria 2. qolecisteqtomiis Semdeg

kategoria 2. medikamenturi mkurnalobis Semdeg

kategoria 2. daavadeba amJamad

kategoria 2. usimptomod mimdinare

RviZlis cirozi

kategoria 2. msubuqi forma (kompensirebuli)

kategoria 3. mZime forma (dekompensirebuli)

(2 _ xarisxi A)

ksk-s ineqciis gakeTebis vadebi

regularuli menstrualuri ciklis dros:

• menstrualuri ciklis dawyebidan 7 dRis ganmavlobaSi.

kontracepciis damatebiTi meTodis gamoyeneba saWiro ar aris;

• menstrualuri ciklis nebismier dros, Tu sakmarisi safuZveli

arsebobs imisa, rom qali orsulad ar aris;

• Tu ineqcia keTdeba menstrualuri ciklis dawyebidan 7 dRis

Semdeg, qals eZleva rekomendacia Tavi Seikavos sqesobrivi

kavSirisagan, an gamoiyenos kontracepciis damatebiTi meTodi 7

dRis ganmavlobaSi.

amenoreis dros:

• ksk-s ineqcia SeiZleba nebismier dros, Tu sakmarisi safuZveli

arsebobs imisi, rom qali orsulad ar aris. aseT SemTxvevaSi,

qalma sasurvelia Tavi Seikavos sqesobrivi kavSirisagan, an

gamoiyenos kontracepciis damatebiTi meTodi ineqciidan 7 dRis

ganmavlobaSi.

237

mSobiarobisa da abortis Semdeg:

• Tu mSobiarobidan gavida 6 Tveze meti, qali agrZelebs bavSvis

ZuZuTi kvebas da aqvs amenorea, ksk-s ineqcia keTdeba `amenoreis~

Sesabamisi rekomendaciis mixedviT.

• Tu mSobiarobidan gavida 6 Tveze meti, qali ZuZuTi kvebavs bavSvs

da aqvs regularuli menstrualuri cikli, ksk-s ineqcia keTdeba

`regularuli menstrualuri ciklis~ rekomendaciis mixedviT.

• Tu mSobiarobidan gavida 3 da meti kvira, qali ZuZuTi ar kvebavs

bavSvs da aqvs amenorea, ksk-s ineqciis gakeTeba SeiZleba nebismier

dros, Tu sakmarisi safuZveli arsebobs imisa, rom qali orsulad

ar aris. amasTan qals eZleva rekomendacia Tavi Seikavos

sqesobrivi kavSirisagan, an gamoiyenos kontracepciis damatebiTi

meTodi ineqciidan 7 dRis ganmavlobaSi.

• Tu mSobiarobidan gavida 3 da meti kvira, qali ZuZuTi ar kvebavs

bavSvs da menstrualuri cikli aRdga, ksk-s ineqcia keTdeba

`regularuli menstrualuri cikli~-s rekomendaciis mixedviT.

• abortis Semdeg maSinve SeiZleba ksk-s ineqciis gakeTeba. amasTan

kontracepciis damatebiTi meTodis gamoyeneba saWiro ar aris.

ksk-s gamoyenebis reJimi:

• ksk-s ganmeorebiT ineqciebs Soris Sualedi Seadgens 4 kviras.

• Tu rekomendebuli intervalis dacva ver xerxdeba, ineqciis

gakeTeba SeiZleba vadaze 1-7 dRiT adre. Tumca aseT SemTxvevaSi

SesaZlebelia dairRves menstrualuri cikli.

• Tu rekomendebuli intervalis dacva ver xerxdeba, ineqciis

gakeTeba SeiZleba 1-7 dRiT gvian. 7 dReze meti gadacilebis

SemTxvevaSi SeiZleba mxolod im pirobiT, Tu sakmarisi safuZveli

arsebobs imisi, rom qali orsulad ar aris. aseT SemTxvevaSi qals

eZleva rekomendacia Tavi Seikavos sqesobrivi kavSirisagan, an

gamoiyenos kontracepciis damatebiTi meTodi 7 dRis ganmavlobaSi.

(1 _ xarisxi A, 10, 11 _ xarisxi B)

sxva hormonuli meTodidan ksk-ze gadasvla _ ix. kok-is Sesabamis nawilSi.

arahormonuli kontracepciidan (sSs-s garda) ksk-ze gadasvla

• ksk-s ineqciis gakeTeba SeiZleba ukve gamoyenebuli meTodis

SewyvetisTanave, Tu sakmarisi safuZveli aris imisa, rom qali

orsulad ar aris. aseT SemTxvevaSi kontracepciis damatebiTi

meTodis gamoyeneba saWiro ar aris.

• Tu menstruaciis dawyebidan ar gasula 7 dReze meti, aseT

SemTxvevaSi kontracepciis damatebiTi meTodis gamoyeneba saWiro

ar aris.

238

• Tu ksk-s ineqcia keTdeba menstrualuri ciklis pirveli 7 dRis

Semdeg, qals eZleva rekomendacia Tavi Seikavos sqesobrivi

kavSirisagan, an gamoiyenos kontracepciis damatebiTi meTodi 7

dRis ganmavlobaSi.

sSs-dan (levonorgestrel-sSs-s CaTvliT) ksk-ze gadasvla

• ksk-s ineqciis gakeTeba SeiZleba menstrualuri ciklis dawyebidan

pirveli 7 dRis ganmavlobaSi. sSs amoRebuli unda iyos am

periodSi. kontracepciis damatebiTi meTodis gamoyeneba saWiro ar

aris.

• nebismier dros, Tu safuZveli arsebobs imisa, rom qali orsulad

ar aris.

• Tu qals aqvs araregularuli menstrualuri gamonadeni an

amenorea, ksk-s ineqcia keTdeba `amenoreis~ rekomendaciiT.

(1 _ xarisxi A, 8, 9 _ xarisxi B)

fertilobis aRdgena

• ksk-s ineqciis Semdeg fertilobis aRdgenis Sesaxeb gamokveTili

monacemebi amJamad ar aris.

(1, 2 _ xarisxi A)

konsultireba

ksk-s ineqciis gakeTebamde qalTan unda Catardes konsultireba,

romelic moicavs:

• meTodis upiratesobebs da naklovanebebs, efeqturobas, risks da

sargebels, gverdiT movlenebs da Rirebulebas;

• ojaxis dagegmvis alternatiul meTodebs;

• sigaretis mowevas da masTan dakavSirebul sisxlZarRvovan

garTulebebs;

• ineqciebis vadebs.

239

sayuradRebo niSnebi ksk-s gamoyenebis dros

• Zlieri tkivili muclis areSi;

• Zlieri tkivili gulmkerdis areSi, xvela, sunTqvis

ukmarisoba;

• Zlieri Tavis tkivili;

• mxedvelobis dakargva an dabindva;

• mZafri tkivili barZayis an wvivis areSi;

• kanis da Tvalebis siyviTle;

• Zlieri sisxliani gamonadeni;

• diskomforti an sxva problemebi ineqciis adgilze.

(3, 7 _ xarisxi A)

240

ksk-s ineqciis dawyebamde skrininguli kiTxvari

anamnezis Sekrebis mizania sxvadasxva risk faqtorebis aRmoCena da maTi

gaTvaliswineba ksk-s ineqciis dawyebamde

qals dausviT Semdegi kiTxvebi:

ara ki

1. menstruacia dagvianebulia an fiqrobT, rom orsulad

xarT?

2. ZuZuTi kvebavT 6 Tvemde asakis axalSobils?

3. eweviT sigarets (dReSi ramdens) da xarT >35 welze?

4. gaqvT Tavis tkivili, xSirad erT mxareze, pulsirebadi,

Tavbrusxveva, diskomforti sinaTlesa da xmaurze?

5. gaqvT xolme maRali arteriuli wneva?

6. Tu gqoniaT rodesme mwvave sisxlZarRvovani moSla

(insulti, stenokardiuli Seteva, barZayis an filtvis

arteriis Trombozi)?

7. gaqvT Tu ara Saqriani diabeti?

8. gqoniaT (an amJamad gaqvT) sarZeve jirkvlis kibo?

9. gqoniaT (an amJamad gaqvT) RviZlis raime seriozuli

daavadeba an siyviTle?

10. amJamad xom ar iRebT antituberkulozur an

antiepilefsiur wamlebs?

11. gaqvT sisxldena sqesobrivi kavSiris Semdeg an

menstruaciebs Soris periodSi?

Tu qali

Tundac erT

kiTxvaze

pasuxobs "diax",

CautareT

gamokvleva.

mieciT kondomi

kontracepciis

sxva meTodis

SerCevamde.

Tu qali yvela

aRniSnul

kiTxvaze

pasuxobs -

"ara"-mas

SeuZlia ksk-is

gamoyeneba

241

gamoyenebuli literatura

1. Фонд народонаселения Организции Объединенных Нации в области; Репродуктивное здоровье и исследования Всемирная Организация Здравоохранения //«Свод Практических Рекомендаций по применению средств контрацепции»//, Женева, Издание второе, 2005г. `xarisxi A.~

2. Фонд Организции Объединенных Нации в области народонаселения; Репродуктивное здоровье и исследования Всемирная Организация Здравоохранения //«Медицинские критерии приемлемости для использования методов контрацепции»//, Женева, Третье издание, 2004г. `xarisxi A.~

3. Руководство по Контрацепции / Под ред. Прилепской В. Н. – М.: МЕД пресс, 2006. – 399с. `xarisxi A.~

4. Elomaa K., Ranta S., Tuominen J., Lahteenmaki P. Charcoal treatment and risk of escape ovulation in oral contraceptive users. Human Reproduction, 2001. `xarisxi A.~

5. Hatcher R. A., Trussell J, Stewart F. et all. Contraceptive Technology. Eighteenth Revised Edition. N Y, Ardent Media, 2004. `xarisxi A.~.

6. IPPF Guidlines –Medical and Service delivery Guidlines 2004/ 254-268. `xarisxi A.~.

7. Paul D. Blumental, Noel Mclntosh. Краткое руководство по репродуктивному здоровью и контрацепции. Второе издание, 1996, стр. 404. `xarisxi A.~.

8. Petta CA et al. Delayed first injection of the once-a-month injectable contraceptive containing 25 mg of medroxyprogesterone acetate and 5 mg E (2) cypionate: effects on ovarian function. Fertility & Sterility, 2001. `xarisxi B.~.

9. Petta CA et al. Delayed first injection of the once-a-month injectable contraceptive containing 25 mg of medroxyprogesterone acetate and 5 mg estradiol-cypionate: effects on cervical mucus. Contraception, 2001. `xarisxi B.~.

10. Wilcox AJ, Dunson D, Baird DD. The timing of the “fertile window” in the menstrual cycle: day specific estimates from a prospective study. British Medical journal, 2000. `xarisxi B.~.

11. Wilcox AJ, Dunson DB, Weinberg CR, Trussell J, Baird DD. Likelihood of conception with a single act of intercourse: providing benchmark rates for assessment of post-coital contraceptives. Contraception, 2001. `xarisxi B~.

12. Westhoff C et al. Quick start: novel oral contraceptive initiation method. Contraception 2002. `xarisxi B.~.

13. Westhoff C et al. Bleeding patterns after immediates vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertility and Sterility, 2003. `xarisxi B.~.

242

avtorTa jgufi

saqarTvelos reproduqtologTa asociacia

⇒ a. xomasuriZe _ profesori, medicinis mecnierebaTa doqtori;

i.Jordanias sax. adamianis reproduqciuli janmrTelobis s/k

institutis direqtori;

⇒ n. marsagiSvili _ medicinis doqtori. i.Jordanias sax. adamianis

reproduqciis s/k institutis Sobadobis regulaciis ganyofileba;

⇒ g. cercvaZe _ medicinis doqtori. i.Jordanias sax. adamianis

reproduqciis s/k instituti. Sobadobis regulaciis ganyofilebis

ufrosi;

⇒ T. maRularia _ medicinis doqtori.

eqspertebi:

⇒ n. parunaSvili – medicinisAdoqtori;

⇒ j. qristesiaSvili _ iv. javaxiSvilis saxelobis Tbilisis

saxelmwifo universitetis, reproduqtologia-meanoba-gienkologiis

departamentis asocirebuli profesori; i.Jordanias sax. adamianis

reproduqciis samecniero kvleviTi instituti, med. mecn. doqtori,

profesori;

⇒ saojaxo medicinis profesionalTa kavSiri _ i. qarosaniZe.

243

protokoli

kok-i (reproduqtologebisaTvis, mean-ginekologebisaTvis da ojaxis

eqimebisaTvis)

kok-is miRebis dawyebamde skrininguli kiTxvari

anamnezis Sekrebis mizania sxvadasxva risk faqtorebis aRmoCena da maTi

gaTvaliswineba kok-is miRebis dawyebamde

dausviT qals Semdegi kiTxvebi:

ara ki

1. menstruacia dagvianebulia an fiqrobT, rom orsulad

xarT?

2. ZuZuTi kvebavT 6 Tvemde asakis axalSobils?

3. eweviT sigarets (dReSi ramdens) da xarT >35 welze?

4. gaqvT Tavis tkivili, xSirad erT mxareze, pulsirebadi,

Tavbrusxveva, diskomforti sinaTlesa da xmaurze?

5. gaqvT xolme maRali arteriuli wneva?

6. Tu gqoniaT rodisme mwvave sisxlZarRvovani moSla

(insulti, stenokardiuli Seteva, barZayis an filtvis

arteriis Trombozi)?

7. gaqvT Tu ara Saqriani diabeti?

8. gqoniaT (an amJamad gaqvT) sarZeve jirkvlis kibo?

9. gqoniaT (an amJamad gaqvT) RviZlis raime seriozuli

daavadeba an siyviTle?

10. amJamad xom ar iRebT antituberkulozur, an

antiepilefsiur wamlebs?

11. gaqvT sisxldena sqesobrivi kavSiris Semdeg an

menstruaciebs Soris periodSi?

12. ramdeni dRis win dagewyoT ukanaskneli menstruacia?

Tu qali

Tundac erT

kiTxvaze

pasuxobs "diax",

CautareT

gamokvleva.

mieciT kondomi

kontracepciis

sxva meTodis

SerCevamde.

Tu qali yvela

aRniSnul

kiTxvaze

pasuxobs -

"ara"-mas

SeuZlia kok-is

gamoyeneba da

gadadiT me-12-e

kiTxvaze

244

• Tu qals ukanaskneli menstruacia daewyo bolo 5 dRis ganmavlobaSi,

SeuZlia exlave daiwyos kok-is miReba.

• Tu qals ukanaskneli menstruacia daewyo 5 dReze meti xnis win da am

periodSi iyenebda kontracepciis romelime meTods (TavSekavebis

CaTvliT), mieciT kok da uTxariT - axlave daiwyos misi miReba da

auxseniT, rom uaxloesi 7 dRis ganmavlobaSi kondomi da/an

spermicidi gamoiyenos.

• Tu qals ukanaskneli menstruacia daewyo 5 dReze meti xnis win da am

periodSi ar iyenebda kontracepciis romelime meTods (TavSekavebis

CaTvliT), mieciT kok da uTxariT, rom misi miReba daiwyos momdevno

menstruaciis pirveli 5 dRis ganmavlobaSi.

245

gverdiTi movlenebi, maTi Sefaseba, marTva

gverdiTi

movlena

Sefaseba marTva

gulisreva,

Rebineba,

Tavbrusxveva

• daadgineT, tabletebs xom

ar Rebulobs diliT an

uzmoze.

• SeamowmeT orsulobaze

(testi orsulobaze).

• urCieT qals tabletebi

miiRos Zilis win vaxSmis

Semdeg, an vaxSmis dros.

• orsulobis dadgenis

SemTxvevaSi qalma

tabletebis miReba unda

Sewyvitos da gagzavnili

unda iyos specialistTan

(ginekologi, reproduqto-

logi). Tu orsuloba ar

dadasturda, auxseniT

qals, rom es movlenebi

gaivlis 1-2 Tvis

ganmavlobaSi, kok-is

miRebis fonze, an mieciT

Zalian mcire doziani

kok-i (20mkg.e.e.).

• Tu problema

autanelia, Sewyvitos kok-

is miReba. daexmareT mas

kontracepciis sxva

meTodis SerCevaSi.

• amenorea

• hkiTxeT qals, rogor

iRebda tabletebs, xom ar

daaviwyda erTi an

ramodenime tabletis miReba?

• SeamowmeT orsulobaze

(saSvilosnos RruSi,

saSvilosnosgare): anamnezi,

testi orsulobaze, gasinjva.

• tabletebis gamotoveba

zrdis orsulobis risks.

Tu qalma gamotova an

daagviana tabletis (erTi

an ramodenime) miReba, is

gamokvleuli unda iyos

orsulobaze.

• orsulobis dadgenis

SemTxvevaSi qali

gaagzavneT ginekologTan

an reproduqtologTan. Tu

qali gadawyvitavs

orsulobis SenarCunebas,

man tabletebis miReba

unda Sewyvitos. qals

unda aexsnas, rom kok-Si

Semavali estrogeni da

progestageni xanmokle

miRebisas orsulobis

adreul stadiaze nayofze

uaryofiT gavlenas ar

246

axdens.

• Tu pacienti iRebda 21

tabletian firfitas,

daaviwyda erT kviriani

Sesvenebis gakeTeba

menstruaciisaTvis da

uwyveti reJimiT miiRo

tabletebi, ganuviTardeba

amenorea. mieciT axsna-

ganmarteba, rom es saSiSi

ara aris. Tu qali

ukmayofiloa, dauniSneT

mas maRaldoziani kok-i

(50 mkg e.e.).

• Tu qali swori reJimiT

iRebda tabletebs da

aReniSneba amenorea,

auxseniT, rom amenoreis

SemTxvevaSi mis sxeulSi

an saSvilosnoSi sisxli

ar grovdeba.

progestagenis mcire

dozis mudmivi moqmedebiT

endometriumis sisqe

mcirdeba, rac iwvevs

sisxldenis Semcirebas an

mTlianad Sewyvetas. Tu is

ganagrZobs dabaldoziani

kok-is (30-35 mkg e.e.)

miRebas, amenorea

Cveulebriv SenarCundeba.

urCieT qals, ganmeorebiT

momarTos klinikas, Tu

amenorea kvlav

Semawuxebeli iqneba.

247

• vaginaluri

sisxldena/

CamonaSali

• hkiTxeT qals rogor

iRebda tabletebs, xom ar

daaviwyda erTi an ramodenime

tabletis miReba?

• kok-s miReba axali

dawyebulia

• SeamowmeT ginekologiur

daavadebebze (menjis Rrus

anTebiTi daavadeba),

orsulobaze (saSvilosnos

RruSi, eqtopiuri), arasrul

abortze (teqsti

orsulobaze)

• ginekologiur

daavadebebze eWvis

SemTxvevaSi ojaxis eqimi

qals agzavnis Sesabamis

specialistTan

(ginekologTan,

reproduqtologTan)

• kok-is fonze qalma daiwyo

axali medikamentebis miReba

(mag. rifampicini)

• Tu qals aviwydeba

tabletebis miReba,

SeaxseneT wamlis miRebis

wesebi da auxseniT, rom

tabletebis gamotoveba

zrdis orsulobis risks.

Tu SemdgomSi mas kvlav

aviwydeba tabletebis

miReba, SeurCieT

kontracepciis sxva

meTodi.

• daamSvideT, uTxariT,

rom sisxldena/CamonaSali

SesaZlebelia kok-is

gamoyenebis pirveli sami

Tvis ganmavlobaSi da

umravles SemTxvevaSi

mcirdeba gamoyenebis

meoTxe Tvidan. Tu

sisxldena/CamonaSali

Semawuxebelia,

gadaiyvaneT SedarebiT

maRaldozian kok-ze, an

daexmareT qals

kontracepciis sxva

meTodis SerCevaSi.

• Tu saxezea

ginekologiuri

problemebi, CaatareT

Sesabamisi mkurnalobis

kursi.

• mieciT maRaldoziani

kok-i (50 mkg.e.e.), an

daexmareT qals

kontracepciis sxva

meTodis SerCevaSi.

248

• maRali

arteriuli

wneva ≥160/100 _ me-4 kategoria

≥140-159/90-99 _ me-3 kategoria

• Tu arteriuli wnevis

momateba ganpirobebulia

kok-is gamoyenebiT, qalma

unda Sewyvitos

preparatebis miReba.

daexmareT qals

kontracepciis sxva

meTodebis SerCevaSi.

• kok-is miRebis

Sewyvetis Semdeg 3 Tvis

ganmavlobaSi Tu ar

moxda arteriuli wnevis

normalizeba, qali

gaagzavneT Sesabamis

specialistTan

gamokvlevaze.

• tkivili

gulmkerdis

areSi

(gansakuTrebiT

Tu is

dakavSirebulia

fizikur

datvirTvasTan)

• SeamowmeT gul-

sisxlZarRvTa daavadebebze,

arteriuli wneva, guliscemis

sixSire.

• Tu gamoikveTa gsd-is

niSnebi, gaagzavneT

gamokvlevaze. qals mieciT

rekomendacia Sewyvitos

kok-is gamoyeneba,

daexmareT kontracepciis

sxva meTodis SerCevaSi.

• Tavis

tkivili

(mxedvelobis

darRveviT)

• daadgineT, Seicvala Tu

ara Tavis tkivilis xasiaTi

da intensivoba kok-is

miRebis dawyebis Semdeg.

• CaatareT fizikuri

gasinjva, SeamowmeT

arteriuli wneva.

aucileblobis SemTxvevaSi

gamoikvlieT: Tvalis fskeri

da nevrologiuri statusi

• Tu Tavis tkivili susti

xasiaTisaa da iSviaTia,

mieciT

tkivilgamayuCebeli

wamali. 1 Tvis Semdeg

mdgomareoba SeafaseT

ganmeorebiT.

• Tu kok-is miRebis

dawyebis Semdeg Seicvala

Tavis tkivilis

intensivoba (tkivilis

gaZliereba, mxedvelobis

cvlileba, metyvelebis

unaris darRveva an

dakargva), SewyviteT kok-

is gamoyeneba da

daexmareT qals

kontracepciis sxva

(arahormonuli) meTodis

SerCevaSi.

249

• sarZeve jirkvlebis

daWimuloba an

mtkivneuloba

(mastalgia)

• SeamowmeT orsulobaze

• orsulobis SemTxvevaSi

imoqmedeT ise, rogorc es

zemoTaa aRniSnuli (ix.

amenorea).

• gasinjeT s/jirkvali: _

kvanZi an kista -gamonadeni an

galaqtorea (Tu ar kvebavs

ZuZuTi)

• Tu qali orsulad ar

aris, sarZeve jirkvlebis

mtkivneuloba gaivlis 3

Tvis Semdeg.

• Tu fizikuri gasinjviT

gamovlinda kvanZi an

gamonadeni, romelic

saeWvoa kiboze (mag:

mkvrivi, palpaciis dros

umtkivneulo an

moZraobaSi SezRuduli

kvanZi, romelic ar

icvleba mensturaciis

dros), qali gaagzavneT

Sesabamis gamokvlevaze.

• hkiTxeT qals, Tu amCnevs

s/jirkvlebis daWimulobas

Tvis mxolod garkveul

dros (mag. menstruaciis

dawyebamde)

• urCieT qals, moeridos

kofeins, Sokolads da a.S.

da auxseniT, rom

s/jirkvlebSi mimdinare

cikluri cvlilebebi

(daWimuloba,

mtkivneuloba)

damokidebulia

estrogen/progestagenis

dozis cvlilebaze. qali

gadaiyvaneT ufro

dabaldozian kok-ze.

magram Tu ukve imyofeba

yvelaze dabaldozian

kok-ze da preparatis

miRebis dawyebidan gavida

3 Tveze meti, daexmareT

mas kontracepciis sxva

meTodis SerCevaSi.

• depresia • ganixileT xasiaTis

cvlilebebi

• Tu qals depresia

gauRrmavda kok-is miRebis

Semdeg, daexmareT

kontracepciis sxva,

arahormonuli meTodis

SerCevaSi, an kok-i

SearCieT progestagenis

dabali doziT.

250

• Tu xasiaTis cvlileba

kok-s ar gamouwvevia,

SeiZleba maTi miRebis

gagrZeleba.

• SesaZlebelia

piridoqsinis (B6)-s miReba

50 mg dReSi 2 Tve.

• libidos

daqveiTeba

• ganixileT libidos

cvlilebebi

• Tu kok-s ar gamouwvevia

libidos daqveiTeba,

SeiZleba maTi miRebis

gagrZeleba. Tu qali

fiqrobs, rom libidos

daqveiTebis mizezi

preparatebia, daexmareT

mas kontracepciis sxva

meTodis SerCevaSi.

• akne • hkiTxeT, rogor da ra

sixSiriT iwmends saxes?

• xom ar imyofeba amJamad didi stresis qveS?

• Cveulebriv kok-is

miRebis dros akne

umjobesdeba da qreba.

Tumca, zogierT

SemTxvevaSi, man SeiZleba

ar imoqmedos da misi

gauaresebac ki

gamoiwvios. qali

gadaiyvaneT naklebi

androgenuli efeqtis

mqone progestagenis

Semcvel kok-ze.

rekomendebulia saxis

gawmenda dReSi orjer da

saxis cximiani kremebis

gamoyenebisagan Tavis

Sekaveba. Tu mdgomareoba

ar Seicvala, daexmareT

qals sxva meTodis

SerCevaSi (ara

hormonuli).

• siyviTle • Tu siyviTle gamovlinda

kok-is miRebis dawyebis

Semdeg, SeamowmeT qali

hepatitze, RviZlis

keTilTvisebian an

avTvisebian simsivneze,

cirozze, naRvlis buStis

daavadebaze.

• kok-Si Semavali

hormonebi, praqtikulad

ar moqmedebs RviZlis

funqciaze. Tu siyviTle

ganpirobebulia virusuli

hepatitiT, SewyviteT

hormonuli preparatebis

miReba da daexmareT qals

sxva arahormonuli

meTodis SerCevaSi srul

gamojanmrTelebamde (anu

simptomebis gaqrobidan an

251

RviZlis funqciis

normalizaciidan 3 Tve).

• Tu siyviTle

ganpirobebulia RviZlis

simsivniT an ciroziT,

SewyviteT kok-is

gamoyeneba, gagzavneT qali

Sesabamis gamokvlevaze,

daexmareT mas

kontracepciis sxva

meTodis SerCevaSi.

• Tu siyviTle

ganpirobebulia naRvlis

buStis daavadebiT,

SewyviteT kok-is

gamoyeneba da daexmareT

qals sxva Sesaferisi

meTodis SerCevaSi.

• Rebineba kok-is miRebidan 2

saaTis

ganmavlobaSi

• aseT SemTxvevaSi qalma

unda miiRos kidev erTi

aqtiuri tableti

(1, 4 _ xarisxi A, 10, 11 _ xarisxi B)

252

rodis SeiZleba kok-is miRebis dawyeba

regularuli menstrua-

luri ciklis dros

amenoreis

dros

abortis

Semdeg

mSobiarobis

Semdeg

_ menstrualuri ciklis

dawyebidan 5 dRis

ganmavlobaSi.

_ menstrualuri ciklis

nebismier dros, Tu sakmarisi

safuZveli arsebobs imisi,

rom qali orsulad ar aris.

_ Tu kok-is miReba iwyeba

menstrualuri ciklis daw-

yebidan 5 dRis Semdeg, qals

rekomendacia eZleva Tavi

Seikavos sqesobrivi

kavSirisagan, an gamoiyenos

kontracepciis damatebiTi

meTodi 7 dRis ganmavlobaSi

(kondomi /spermicidi).

_ kok-is miRebis dawyeba

SeiZleba nebismier

dros, Tu sakmarisi

safuZveli arsebobs

imisa, rom qali

orsulad ar aris. aseT

SemTxvevaSi qalma

sasurvelia Tavi

Seikavos sqesobrivi kav-

Sirisagan, an gamoiyenos

kontracepciis

damatebiTi meTodi 7

dRis ganmavlobaSi

(kondomi/spermicidi).

_ abortis Semdeg

kok-is gamoyeneba

SeiZleba maSinve.

amasTan

kontracepciis

damatebiTi

meTodis

gamoyeneba saWiro

ar aris.

qali ZuZuTi

kvebavs

bavSvs

qali ZuZuTi

ar kvebavs

bavSvs

_

mSobiarobi

dan 6 Tvis

Semdeg

_

mSobiarobi

dan 3 kviris

Semdeg

(1, 2 _ xarisxi A)

253

kok-is gamoyenebis reJimi

21 tabletiani

firfita

28 tabletiani

firfita

_ erTi tableti erTxel

dReSi 21 dRis ganmavlobaSi

(erTsa da imave dros).

Sesveneba 7 dRe, me-8 dRidan

saWiroa axali firfitis

dawyeba.

_ erTi tableti erTxel

dReSi (erTsa da imave dros)

28 dRis ganmavlobaSi (bolo

7 tableti arahormonulia da

SeiZleba Seicavdes rkinas an

vitamins). anu erTi firfitis

damTavrebis Semdeg Sesvenebis

gareSe saWiroa axali

firfitis dawyeba.

(1, 2 _ xarisxi A)

254

kok-is urTierTqmedeba sxva medikamentebTan

xSirad gamoyenebuli an

daniSnuli wamlebi

gverdiTi efeqtebi komentarebi da

rekomendaciebi

tkivilgamayuCeblebi _

acetaminofeni

(tailenoli,

paracetamoli da sxv.).

tkivilgamayuCebeli

efeqtis SesaZlo

daqveiTeba (wamlebis

eqskreciis gaZliereba).

Tvalyuri adevneT

tkivilgamayuCebel

efeqts.

antibiotikebi * -

grizeofulvini da

rifampicini.

ar arsebobs klinikurad

dadasturebuli efeqti

penicilinebisTvis,

tetraciklinebisTvis,

cefalosporinebisTvis

da sxva xSirad

gamoyenebuli

antibiotikebisaTvis.

aRniSnuli

antibiotikebis miRebisas

SeiZleba kontracepciis

hormonuli meTodis

miReba da Cveulebriv

saWiro aRar aris

kontracepciis

damatebiTi meTodis

gamoyeneba.

kok-is kontracepciuli

efeqtis daqveiTeba,

gansakuTrebiT

dabaldoziani kok-is

SemTxvevaSi 30-35 mkg

eTinil estradioli (ee).

daexmareT qals,

aarCios

kontracepciis sxva

meTodi, an

gamoiyeneT abebi

estrogenis ufro

maRali

SemcvelobiT (50 mkg

ee) an kontracepciis

damatebiTi meTodi

(mag. kondomi).

antidepresantebi

(elavili, norpramini,

tofranili da sxv.).

SesaZloa

antidepresantuli

efeqtis gaZliereba.

gamoiyeneT

sifrTxiliT.

antidepresantebis

dabali dozebi

praqtikulad

usafrTxoa.

255

hipotenziuri preparatebi

meTildopa (dopegiti),

aldometi da sxv.

SesaZloa hipotenziuri

efeqtis Sesusteba.

gamoiyeneT kok da

ksk sifrTxiliT,

gaakontroleT

arteriuli wneva.

krunCxvis sawinaaRmdego

barbituratebi

(fenobarbitali da sxv.)

karbamazepini

(tegretoli) fenitoini

(dilantini) primidoni

(misolini).

kok da ksk

kontracepciuli efeqtis

Semcireba,

gansakuTrebiT

dabaldoziani kok-is

miRebis SemTxvevaSi.

SesaZloa fenitoinis

efeqtis gazrda.

daexmareT qals

aarCios

kontracepciis sxva

meTodi an

gamoiyeneT

maRaldoziani kok

(50 mkg ee) an

kontracepciis

damatebiTi meTodi

(mag. kondomi).

beta blokatori

(korgardi, inderali,

lopresori, tenormini).

SesaZloa beta

blokatoruli efeqtis

gazrda.

akontroleT gul-

sisxlZarRvTa

mdgomareoba.

bronqodilatatorebi

Teofilini (bronkotabsi,

maraqsi, primateni,

quibron tedrali, Teo-

duri da sxv.).

Teofilinis efeqtis

gaZliereba.

akontroleT

Teofilinis dozis

gadaWarbebis

simptomebi.

hipoglikemiuri

(diabineze, orinaze,

tolbutamidi, tolinaze).

SesaZloa

hipoglikemiuri efeqtis

daqveiTeba.

akontroleT Saqari

sisxlSi iseve,

rogorc nebismier

diabetian qalSi.

trankvilizatorebi

benzodiazepini (ativani,

libriumi, seraqsi,

tranqseni, valiumi,

qsanaqsi da sxva).

SesaZloa

trankvilizatorebis

efeqtis gaZliereba an

Sesusteba, maT Soris

fsiqomotoruli

darRvevebi.

gamoiyeneT

sifrTxiliT.

Cveulebrivi dozebi,

rogorc wesi,

mniSvnelovan

efeqtebs ar iwvevs.

* ramdenadac grizeofulvini, romelic iwvevs estrogenisa da

progestagenis metabolizmis gazrdas, Cveulebriv mxolod xanmokle

periodis ganmavlobaSi (2-4 kvira) gamoiyeneba, qalebs, romlebic iReben mas

mikozuri infeqciis samkurnalod, SeuZliaT gaagrZelon kok-is miReba. maT

unda gamoiyenon kontracepciis damatebiTi meTodi grizeofulvinis miRebis

periodSi da misi Sewyvetis Semdeg momdevno menstruaciis dawyebamde.

(7 _ xarisxi A)