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MODERN MEDICINE CPD ARTICLE NUMBER TWO: 1 point Soft tissue rheumatism Part 2: tendinitis, tenosynovitis, ligament sprains and muscle strains R O D G E R L A U R E N T , MB ChB, MD, F R A C P Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) The recurrence of soft tissue injuries can be minimised by finding the precipitating cause, and adequately stretching and strengthening the involved structure before returning to the offending activity. Causes The causes of tendinitis are overuse of the tendon and abnormal biomechanics. paratenon surrounds the tendon and epitenon and is a series of thin membranes that allows movement of the tendon over adjacent tissues. When it becomes inflamed, it thickens and reduces the movement of the tendon. Symptoms and signs The symptoms and signs of tendinitis include: • pain over the involved part of the tendon • swelling and tenderness over the involved region • pain on isometric contraction of the relevant muscle. Tendinitis involves the tendon and paratenon. It usually commences in the tendon, with the paratenon then becoming inflamed, thickened and adherent to the tendon. Central degeneration is usually the primary cause in older people, with secondary involvement of the paratenon. The problem can also begin in the paratenon, with inflammation Dr Laurent is Senior Staff Specialist in and thickening of the paratenon Rheumatology and Musculoskeletal and minimal involvement of the Medicine, Department of Rheumatology, tendon. This is the pattern of tenRoyal North Shore Hospital, Sydney, Australia. dinitis associated with overuse. Treatment Prolonged rest or immobilisation of a tendon after an injury is detrimental to the tendon because there is a rapid loss of collagen. It is important to prevent this, even though the exercises in the initial stages are minimal. Treatment of tendinitis involves: • reducing or stopping the activity responsible for the pain • nonsteroidal anti-inflammatory drugs (NSAIDs) - can be used for the first few days, although they usually provide only minimal benefit • applying cold packs for ten to 15 minutes over the involved area, two or three times a day - this should be done after exercise, including stretching exercises • a course of ultrasound - sometimes relieves pain • beginning concentric muscle exercises as the pain resolves ^ This two-part article is a guide to identifying the involved structure in soft tissue rheumatism, isolating and correcting the precipitating cause, and treating and preventing soft tissue injuries. Last month, Part 1 provided an overview of diagnosis and management, as well as describing features specific to enthesitis and bursitis. This month, the author focuses on tendinitis, tenosynovitis, ligament sprains and muscle strains. Tendinitis Site of injury A tendon consists of collagen fibres with occasional tenocytes. The main blood supply is from the epitenon, which is the vascular connective tissue surrounding the tendon. The ends of the tendon also receive a blood supply from the muscle and bone attachments. However, there may be a relatively avascular area that is often subject to tendinitis. The S E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A 25 Soft tissue rheumatism: part 2 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) continued I • starting eccentric muscle exercises after the tendinitis has become asymptomatic with concentric muscle exercises • sport- or work-specific exercises, to achieve maximum strength of the musculotendinous unit involved • correcting any precipitating causes, eg sports technique or repetitive movements in the workplace. Common examples of tendinitis Common examples of tendinitis include: • Achilles tendinitis • shoulder rotator cuff tendinitis. Achilles tendinitis Site of injury The Achilles tendon commences at about midcalf and consists of a superficial layer from the gastrocenemius muscle and a deep layer from the soleus muscle. The tendon inserts into the posterior calcaneum. The gastrocnemius muscle crosses two joints. The area from two to six centimetres above the insertional site is the area with the poorest blood supply and is the region where tendinitis usually begins (Figure 1). 26 Tendinitis should not be confused with Achilles tendon enthesitis which occurs at the insertional site of the tendon. Figure 2. The anatomy of the rotator Tendinitis should not be confused with Achilles tendon enthesitis which occurs at the insertional site of the tendon. Cause The most common cause of Achilles tendinits is overuse. There are several predisposing factors, including biomechanical abnormalities of the hip, knee and foot (especially overpronation), that produce abnormal movement of the tendon. A tight Achilles tendon with limited ankle dorsiflexion increases the stress on the tendon, as do training errors, inadequate warmup, a sudden increase in activity and inadequate footwear with poor heel support. Symptoms and signs Symptoms and signs of Achilles tendinitis include: • pain over the lower part of the tendon • swelling and tenderness over the involved region (Figure 1) M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002 cuff tendons • pain on stretching the Achilles tendon by dorsifexion at the ankle • pain on isometric contraction of the gastrocnemius and soleus muscles. Treatment The general measures for treating tendinitis outlined earlier apply to the treatment of Achilles tendinitis. In addition, a heel raise, usually a sponge insert, may be helpful by reducing the stretch on the tendon. Corticosteroids should not be injected around the Achilles tendon because of the risk of tendon rupture. Shoulder rotator cuff tendinitis Rotator cuflf tendinitis is probably the most common cause of shoulder pain, and usually involves the supraspinatus and infraspinatus tendons. Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) alternative low dose mQyp T h i n k 'te 28 levonorgestrel 100 |Llg/ethinyloestradiol 20 |ig Proven efficacy with the most widely utilised progestogen in oral contraception world-wide - levonorgestrel(4 5) Lowest dose levonorgestrel/EE OC Lower dose doesn't compromise cycle control<5) Wyeth South Africa (Pty) Ltd Tel: (011) 655-2600 • Fax: (011) 655-2686 • W e b address: w w w . w y e t h . c o m fS3l Minesse: 24 Yellow tablets each containing: gestodene 60 ng, ethinyloestradiol 15 ng; 4 white placebo tablets. Reg. no.: 33/18.8/0341 [55] Loette 28:21 Pink tablets each containing: levonorgestrel 100 ng, ethinyloestradiol 20 ng; 7 green placebo tablets. Reg. no.: 33/18.8/0054 Refs: (1) Norambuena J, Bierschwaie H. Clinical assessment of the effectiveness, cycle control and side-effects of Minulet® as an oral contraceptive. Gynaecol. Endocrinol. 1996; 10 (5):13-20.(2) Guillebaud J. A new paradigm for low-dose oral contraception. Introduction. Eur J Contracept Reprod Health Care 1999:4:1-2. (3) Gestodene Study Group 324, Cycle control, safety and efficacy of a 24-day regimen of gestodene 60 ug/ethinylestradiol 15jig and a 21-day regimen of desogestrei 150(ig/ethinylestradiol 20 |ig. Eur J Contracept Reprod Health Care 1999:4;17-25JM) IMS Data, Qtr. 3,2000. (5) Archer DF-et al. A New Low-Dose Monophasic Combination Oral Contraceptive (Alesse™) with Levonorgestrel 100 ng and Ethinylestradiol 20 tig. Contraception 1997; 55:139-144. Wyeth Pharmaceuticals World Leaders in Women's Health Soft tissue rheumatism: part 2 continued I I • Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) I Tenosynovitis can result in fibrin deposition on the tendon and the producing thickness and nodule formation. It may also be associated with any swelling due to previous tears of Site of injury The rotator cuff consists of the tenthe tendon, and loss of the normal inflammatory arthritis (eg rheumatoid arthritis or psoriatic arthritis). dons of the supraspinatus, infrahumeral head depression mechspinatus, subscapularis and teres anism. minor muscles. These tendons Symptoms and signs form a broad band and insert into Tenosynovitis The symptoms and signs of the greater and lesser tuberosity tenosynovitis include; and the ligament that covers the Site of injury • pain on active movement; if the bicipital groove. The supraspina- In areas where there is considerproblem is severe, there will also tus tendon passes between the able movement of the tendon, espebe pain at rest head of the humerus and the coraco- cially over ligaments and bone, the • tenderness over the involved acromial arch. The subacromial bursa tendon runs through afibrous tunarea of the tendon facilitates movement between the • swelling - this is usually mild if nel that allows easy movement and subacromial arch and the rotator the injury is related to overuse reduces friction on the tendon. The cuff tendons of the supra- and (Figure 4); however, if the fibrous tunnel and tendon sheath infraspinatus muscles (Figure 2). tenosynovitis is due to infection The rotator cuff functions to sta- are covered with synovium which or sodium urate crystals, swelling bilise the shoulder joint and add also forms synovial fluid. may be marked, with surroundTenosynovitis is inflammation of power to glenohumeral rotation ing oedema and erythema the tendon sheath and is distinct and elevation. • pain on stretching the tendon or from tendinitis which is inflammaThe primary problem in the tion of the tendon and the on isometric contraction of the rotator cuff is probably central musculotendinous unit paratenon. degeneration with swelling • in chronic tenosynovitis, of the tendons. This causes crepitus can be felt over impingement of the tendon the tendon; this is the between the humeral head New low dose oestrogen only therapy: result of fibrin deposition and coracoacromial arch, within the tendon sheaths which is the main cause of • restricted movement the pain. Weakness of the this may occur in both rotator cuff can lead to furacute and chronic ther impingement because tenosynovitis. of a reduction in the ability Because it should be natural for you to 1 to depress the humeral prescribe hormone replacement cherapy Treatment head during abduction. Treatment of tenosynovitis Subacromial bursitis is due to repeated use or \ J B L usually secondary to the excessive stress involves: tendinitis. • identification of the precipitating Tenosynovitis can result in fibrin activity, particularly if the Causes deposition on the tendon and the tenosynovitis is due to overuse Causes of rotator cuff tendinitis sheath, producing thickness and these movements should be include: nodule formation. These may result reduced or stopped until the • overuse or trauma - rotator cuff in the tendon catching as it passes tenosynovitis has resolved tendinitis is more common in through afibrous pulley. This is the • injection of a mixture of local people who use their shoulders cause of 'trigger finger', when the anaesthetic and corticosteroid in an abducted position of finger flexor tendons are involved into the tendon sheath, but not greater than 90° (eg swimmers) the tendon, when there is signifi(Figure 4). • advancing age - in the middlecant pain or restriction of moveThe most common tendons aged and elderly there is often ment involved are the abductor pollicis no obvious precipitating cause • ultrasound and NSAIDs, longus and the extensor pollicis (the tendons degenerate with although they provide only miniage, especially in the middle, brevis tendons at the wrist, the mal benefit in this situation and the tendinitis can become finger flexor tendons, and the tib- • a regimen of stretching and genialis posterior and common perchronic) tle exercises - this is important for maintaining a full range of • structural abnormalities - these oneal tendons at the ankle. movement of the musculotendican cause increased impingeCauses nous unit. ment on the tendon (examples The same treatment is used for include abnormal scapula posi- The most common cause of tion associated with thoracic tenosynovitis is repeated use or tenosynovitis associated with inflammatory arthritis. Treatment excessive stress on the tendon. kyphosis, chronic tendon esti*$fem 28 M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002 Ligaments are usually damaged when there is a sudden stress that does not allow sufficient time for muscle support. Figure 3. Rotator of abduction. cuff Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) of the inflammatory arthritis will also control the tenosynovitis. An example of tenosynovitis: de Quervain's tenosynovitis De Quervain's tenosynovitis involves the abductor poilicis longus and the extensor poilicis brevis tendons at the wrist. It occurs at the radial styloid where the tendons, invested in a common synovial sheath, run along a groove in the bone (Figure 5). With repeated use of the wrist and thumb, there can be increased friction on the tendon. Signs and symptoms The symptoms and signs of de Quervain's tenosynovitis include: • pain felt over the radial border of the wrist and possibly radiating down to the thumb • pain produced by thumb movements, particularly the pinch grip • swelling and tenderness over the radial styloid • pain reproduced on ulnar deviation of the wrist, with the thumb held flexed and adducted so that it is across the palm of the hand (Figure 6). Treatment Treatment of de Quervain's tenosynovitis involves: • a resting splint or an appropriately applied crepe bandage to reduce movement of the thumb in the acute stage tendinitis: the painful arc is Figure from index • corticosteroid injections, particularly in the early inflammatory phase • stretching and strengthening exercises to restore normal movement; if exercise is not commenced early, there can be fibrosis and restriction of thumb movement • surgical decompression - may occasionally be required; however, it can usually be prevented by early commencement of an exercise programme. about 60° to tenosynovitis 12ff 4 Flexor in the finger - the result of overuse. ament complex of the ankle, particularly the talofibular component of the ligament (Figure 7). Sprain of the lateral ligament of the ankle Symptoms and signs The symptoms and signs Ligament sprains Site of injury Ligaments are structurally similar to tendons, being predominantly made up of type 1 collagen and fibrocytes. Ligaments provide stability to the joint and determine the limits of its range of movement. Ligaments slowly elongate under pressure and support the joint until muscle support takes over. Ligaments are usually damaged when there is a sudden stress that does not allow sufficient time for muscle support. The level of injury can range from a simple stretch of the ligament, through varying degrees of tearing, to a complete rupture. Ligaments are important in proprioception and contain nociceptors that can be damaged when the ligament is injured. The most common ligament injury is a sprain of the lateral ligS E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A 29 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) I H D operates one of the most technologically advanced distribution systems which enables batch control and tracking, thereby combatting the distribution of fraudulent products and the incidence of theft. W e distribute on behalf of o u r highly innovative principals and utilise the best technology t o guarantee the integrity of their products. So, w h e n you obtain product from I H D you are assured that y o u r patient will receive the intended medicine. International H e a l t h c a r e D i s t r i b u t o r s . L i n b r o Business Park, J o h a n n e s b u r g , S o u t h Africa.Tel: ( O i l ) 458-2222 Fax: ( O i l ) 458-2299. F o r m o r e i n f o r m a t i o n visit o u r w e b s i t e w w w . i h d . c o m . , C liampion distributors. Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) i S A I A H A D Bccausc the patient should always get what is prescribed. Soft tissue rheumatism: part 2 continued Exercises must be continued after symptoms have resolved, as it probably takes nine months for ligaments to return to normal strength. Anterior talofibular Fibula Posterior talofibular ligament Calcaneum Talus ligament Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) Figure 6. Pain in de Ouervain's reproduced by flexion and adduction ulnar deviation of the wrist. indicating a sprain of the lateral ligament of the ankle include: • pain over the region of the ligament, made worse on inversion and supination of the foot • swelling over the ligament • tenderness over the ligament and its attachments • restriction of movement of the ankle and the subtalar joint, usually due to muscle spasm. Treatment Treatment of a lateral ligament strain of the ankle involves: • for the acute injury, the standard regimen of rest, ice, compression and elevation • NSAIDs - may be helpful • commencing exercise as soon as possible - prolonged rest results in significant loss of collagen (exercise and stretches should be within the limits of pain) • gentle mobilising exercises for the ankle and the subtalar joint • strengthening exercises for the peroneus longus and brevis muscles • strapping of the ankle with adhesive tape which restricts inversion and eversion of the hindfoot, supporting the ligament and helping proprioception 32 Figure tenosynovitis of the thumb 7. Diagram is and • proprioceptive exercises, including balance boards and different stepping activities, to correct functional instability • exercises must be continued after symptoms have resolved, as it probably takes nine months for ligaments to return to normal strength. of lateral ankle ligaments. Ischial Musculotendinous junction injuries Muscle strains occur most frequently at the musculotendinous junction. The most common muscle strain is that of the hamstring muscles. This muscle lies across two joints, which may be why it is more susceptible to strain. Semitendinosus Hamstring strain Site of injury The hamstrings consist of three muscles: semitendinosus, semimembranosus and biceps femoris (Figure 8). At the musculotendinous junction, the muscle cells connect directly to the tendon. The muscle cell membrane at this site is folded so that the muscle cell and extracellular collagen interdigitate. This folding increases the surface area, M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002 Musculotendinous junctions Figure string 8. Anatomy muscles of the ham- THE SELECTIVE COX-2 I N H I B I T O R Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) WITH A WELL BALANCED EFFICACY AND SAFETY PROFILE. Inflammatory pain relief and mobility in any body's language. ® , . meloxicam 7,5 mg:15mg E 3 Mobic 7,5 mo tablet. Each tablet contains 7,5 mg meloxicam . Reg. No. 29/3.1/421. Mobic 15 mg tablet. Each tablet contains 15 mg meloxicam. Reg. No. 29/3.1/422. Applicant details: HKdlteim Pharmaceuticals IPty) Ltd. Co. Reg. No. 66/08618/07. 407 Pine Avenue, Randburg, Tel 10111 886-1075, Fax lOtll 787-376B/8B6-JJ05. RfiteTtTirej: I Uiwity, C. el al. Gaslrointesunftf ttferaWfity ol meloxicam compared to diclofenac in osteoarthritis patients. Br J Rheumatology 1998; Vol. 37 (No. 91:937 945. 1. l^lqueker, J ci al. Improvement in gastrointestinal (tiierability of Hie Sdtective cyclooxygenase (COXJ-2 inhibitor, meloxicam, compared with piiowum:results ol the safety and cHu.jn,1 large-scate evaluation ol KIKurihritis. fcsr i Bheumjuilogy 1998; Vol. 37 iNoJir. 946-951. D Boenringer Ingelheim therades SELECT) trial in 341567 Soft tissue rheumatism: part 2 continued, I I | reducing the stress per unit area at the musculotendinous junction. Causes Causes of hamstring include: strain Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) • eccentric contraction - injuries are more likely to occur during eccentric contraction because the force generated then is greater than that generated during concentric contraction • muscle crossing two joints injuries are more common in muscles that cross joints (eg hamstring or gastrocnemius muscles) • muscle weakness, which predisposes to injury • weakness of a muscle relative to its antagonist, which results in strength imbalance - imbalance between the strengths of the Returning to the precipitating activity before the muscle has healed i e a c [ s fQ recurrence of injury. quadriceps and hamstring muscles is important, and can be secondary to exercise programmes that emphasise quadriceps exercises but do not include adequate hamstring exercises • fatigue, which results in physiological shortening of the muscle • poor warm-up technique, wliich reduces flexibility and makes the muscle more susceptible to strain. Returning to the precipitating activity before the muscle has healed leads to recurrence of injury. Once the pain has resolved, muscle strength is still not normal. the structure involved,finding the precipitating cause (activity), and embarking on a regimen of stretching and strengthening exercises designed to combat the particular weakness. Returning to the precipitating activity before the structure has regained normal strength andflexibility can lead to recurrence. Muscles may take two to three months to return to normal; tendons and ligaments take even longer. Part 1 of tliis article provided an overview of soft tissue rheumatism and described the specific features of enthesitis and bursitis. • Conclusion Recurrence of soft tissue injuries can be minimised by identifying CPD questions appear on page 35 QUESTIONS FOR CPD ARTICLE NUMBER TWO CPD: 1 point Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) Soft tissue rheumatism Part 2: tendinitis, tenosynovitis, ligament sprains and muscle strains Part 3. T h e following statements are true of tenosynovitis: a. Tenosynovitis may be associated with psoriatic arthritis. b. In chronic tenosynovitis, crepitus may be felt over the tendon. Instructions c. Tenosynovitis may be treated by injection of local anaes1. Before you fill out the computer answer form, thetic mark and corticosteroid into the tendon, rather than the your answers in the box on this page. This providestendon sheath. you with your own record. d. De Quervain's tenosynovitis involves abductor poilicis 2. The answer form is perforated and bound Into longus this and extensor poilicis longus tendons at the wrist. e. De Quervain's tenosynovitis should be managed by journal. Tear it out carefully. early exercise. 3. Read the instructions on the answer form and folPart 4. T h e following statements are true of muscle and low them carefully. ligament strains: 4. Your answers for the September issue must reach a. Muscle strains usually occur at the musculotendinous MOOEEN MEDICINE, PO BOX 2271. Clareinch 7740, by junction. Decembers!. 20QQ, b. An imbalance between the strength of the quadriceps and hamstring muscles can cause a hamstring strain. 5. You must score at least 60% in order to be awarded the a s s i g n e d CPD points. c. Exercises should be commenced as early as possible in managing a lateral ligament strain of the ankle. d. Lateral ligament Answer true or false to parts (a) to (e) of the following ques- strain of the ankle should be treated with adhesive tape to restrict inversion and eversion of tions. the hindfoot. Part 1. T h e following statements are true of tendinitis: e. In the treatment of lateral ligament strain of the ankle, a. Tendinitis may manifest as pain on isometric contraction exercises may be discontinued as soon as symptoms of the muscle. have resolved. b. In the treatment of tendinitis prolonged rest is necessary to allow the inflammation to resolve. c. Nonsteroidal anti-inflammatory drugs (NSAIDs) usually provide dramatic benefit. C P D Article 2 d. Tendinitis may be managed by applying cold packs to the affected tendon. e. Rehabilitation should include eccentric muscle exercises for the involved musculotendinous unit. Part 2. T h e following statements are true of specific forms of tendinitis: a. A heel raise, usually a sponge insert, may be helpful in the treatment of Achilles tendinitis. b. Achilles tendinitis may be managed by corticosteroid injection into the Achilles tendon. c. Shoulder rotator cuff tendinitis is common in swimmers. d. Rotator cuff tendinitis in the elderly usually has an obvious precipitating cause. e. Thoracic kyphosis may predipose to rotator cuff tendinitis. See tear-out sheet for details. S E P T E M B E R 2002 / M O D E R N M E D I C I N E O F S O U T H A F R I C A 35 COUNSELLING - A KEY TO USER SATISFACTION Dr Mary O'Flynn MICGP, Mallow, Ireland The concept means freedom for both patients and doctors — freedom from Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) • the worry of sub-optimal contraception • the side-effects of contraception (whether real or perceived) • the tyrannies of menstrual cycle problems. Never before has there been such need for optimal contraception, when our planet's increase in population - estimated at approximately 85 million per annum - is threatening to exceed its nutritional resources. A WHO report estimates that 64% of pregnancies throughout the world are either unplanned or unwanted and as a consequence, a significantly high number of the 580 000 maternal deaths that occur each year could and should be avoided by the use of suitable contraception', In addition, in the western world, the feminist movement has fought for developments to free women from the bondage of their fertility. 36 Mirena fulfils most of the criteria for the ideal contraceptive. It is safe, effective, available, independent of intercourse, forgettable, reversible and has beneficial side-effects. Its more untoward side-effects become more acceptable with good counselling, thus imparting knowledge to the patient, prior tofitting. This is the price of achieving freedom and pre-supposes that the patient has already been fully informed to exercise her own and possibly her partner's choice of method. Remember, 'we are the advisers, we are the suppliers, but we are not the deciders.' Thefirst published research on user satisfaction and compliance for the LNGIUS cites changes in bleeding patterns as the commonest cause of discontinuation. Again in newer research published in 2000, excessive bleeding or spotting was by far the commonest reason for premature removal3. When used as a therapy for menturhagia, satisfaction and continuation rates appear higher - nuisance bleeding becomes more tolerable when the alternative is perhaps hysterectomy. The most recent work of Backman and colleagues would indicate that women were up to five times more satisfied when forewarned oi the occurrence of bleeding changes (personal communication)'. If the patient is given background knowledge on a normal menstrual cycle, then explanation of the mode of action and possibility of the side-effects occurring become apparent. She is then prepared to accept and deal with them, in the full knowledge that they are not dangerous and usually transient. Achieving this level of awareness in patients, together with mastering thefitting technique, is the great challenge for the practitioner. It does take time, but the time invested in good counselling is well rewarded by the freedom achieved by the patient - and patient satisfaction, in turn, will confer freedom on the doctor. We, in Ireland, are very proud of our continuation rates for use of the LNG IUS. Perhaps it relates to the Irish characteristic of enjoying conversation - an essential element of good counselling, but not always recognised as the most basic skill in the art of medicine. References: ' World Health Organisation: Division of (Reproductive Health) Safer Motherhood Progress Report 1993-1995. Geneva: WHO; 1996 2 Luukkainen T, Allonen H, Haukkamaa M et al. Five years experience with levonorgestrel-releasing IUDs. Contraception 1986; 33,139-78. 5 Backman T, Huhtala S, Tuominen J, Luoto R, Erkkola R, Blom T, Rauramo I, Koskenvuo M. Length of use and symptoms associated with premature removal of levonorgestrele-releasing intrauterine system: a nationwide study of 17 360 users. Brit J Obstet Gynaecol 2000; 107: 335-9. 4 Dr Tiina Backn i n, Turku, Finland. To be published. M O D E R N M E D I C I N E O F S O U T H A F R I C A / S E P T E M B E R 2002 I Ai : . freedom^ wish Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012) Contraceptive begins with a For you, Mirena offers a long-term contraceptive solution with built in flexibility... ...for her, a wish come true. • Contraception that offers peace of mind for 5 years • Reliability comparable t o sterilisation Mirena* • Completely reversible' I rfniitii^r^fTfl • Ideal for w o m e n w h o have had children I^WWM Contraception titled and forgotten Available from Gynaecologists and Well-Woman Doctors wwfcv femaleltle xoaa No, i*:WQ3JJ try? rfttv-xfliMifti:*! 1 .i.-Ja* JiwrtJ^rkfnH GpmtatoQyforvm Mult* *-r>.i> irVMitwrw: 1W&: itfXt mfivn ,'-5.3. jOu&Jl iU/'iiftjr tours, F, fjift tU*Htt Otiftfetoud i, /> MfvBufWlW trttem ftfaMlMMt Aiitnvrt&u ™ift»»r» vf 5Jmff tofaprxn me ,<tvomirgBtreUvM*>{/>g inrrimwtM l fiadejy (tua»x I Anawwi fatertt £irna*,jfrtjri0?6: * fcTwfog of (V>ryJ trtf fttg rtf