Women Health

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aphongsy
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Women Health
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TWU exam 1
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  1. What is the ACOG recomendation for first PAP
    First Pap test: Women should have their first Pap test approximately 3 years after first sexual intercourse or by age 21, whichever comes first
  2. PAP is used for what
    A screening test for abnormal/atypical cells suggesting actual or possible preinvasive cervical neoplastic changes
  3. How often will a 20's yrs  women need a PAP
    should have a Pap smear every two years.
  4. When should women 30 and older have PAP?
    every three years only after 3 consective normal smear
  5. PAP for women 65 and older is ?
    PAP can be stopped if had 3 consective PAP smear.
  6. PAP schedule for hysterectomy is?
    If hysterectomy was for non-cancer or no hx. abnormal smear it can be stopped.  If hysterectomy with intact cervic continue PAP every 3 yrs.
  7. Does HPV vaccine mean stopping PAP smear?
    NO.  Continue the ACOG guideline
  8. Type of PAP cytology
    • Atypical squamous cells of undetermined significance (ASCUS)
    • Low Grade Squamous Intraepithelial Lesion (LSIL)
    • High Grade Squamous Intraepithelial Lesion (HISIL)
    • Atypical glandular cells of undetermined significance (uterine cell)
  9. Unsatisfactory smear type.
    • –Inadequate for diagnosis or no endocervical cells
    • -Repeat pap smear
  10. Type of Atypical Squamous Cells of Undetermined Significance (ASCUS)
    • –Unqualified or favors reactive process
    • •Repeat PAP Q 4-6 months for 2 years until _2___ consecutive negative smears–

    • Unqualified with inflammation
    • •-treat specific cause-usually an infection
    • •Repeat PAP in 2-3 months-after treatment (i.e. antibiotics or antifungals)

    • Post menopausal, not on HRT
    • -intravaginal estrogen for 3-6 weeks
    • •Repeat PAP one week after trial of estrogen is complete and again in 4-6 months
    • •If ASCUS again, consider colposcopy
  11. smear type of Low-Grade Squamous Intraepithelial Lesions (LSIL)
    • Follow-up
    •  PAP every 4-6 months for 2 years until 3 consecutive negative smears
    • Repeat smear persistent abnormalities:
    • •-colposcopy and directed biopsy
    • •Must be reliable, carefully selected patient
  12. Smear type of High Grade Squamous Intraepithelial Lesion (HSIL)
    –Colposcopic examination with directed biopsy

    Treatment:
    excisional biopsy or ablative cryotherapy
  13. Smear type of Atypical Glandular Cells of Undetermined Significance (AGUCS)
    • Unqualified or reactive
    • •-management hasn’t been established
    • •Look at patient history, physical findings
    • •-cone biopsy if necessary
    • •Refer**

    CA 80% of postmenopause (cell  type from utreus)
  14. Smear type Carcinoma
    refer immediately!
  15. U.S. Preventive Services Task Force (USPSTF)  2009 on  BREAST SCREENING
    •The USPSTF recommends biennial (every other year) screening mammography for women aged 50 to 74 years.
  16. U.S. Preventive Services Task Force (USPSTF)  2009 on  BREAST SCREENING
    •The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  17. U.S. Preventive Services Task Force (USPSTF)  2009 on  BREAST SCREENING
    •Current evidence is insufficient to assess the  no additional benefits and harms of screening mammography in women 75 years or older.
  18. U.S. Preventive Services Task Force (USPSTF)  2009 on  BREAST SCREENING
    • •Against teaching breast self-examination (BSE).
    • •Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  19. What is PrimaryAmenorrhea
    • Failure to reach menarche by
    • –16 years of age in a fully developed female–14 years of age in a female with no pubertal development
    • -3 years after onset of pubertal development

    • Causes:  if breast and uterus present:
    • –hypothalamic suppression from eating disorders, excessive exercise, chronic illness
    • -CNS, hypothalmic, or pituitary disorders
    • –uterine outflow obstructions
  20. Treatment PrimaryAmenorrhea is?
    •Usually evaluation of primary amenorrhea involves consult or referral with expert
  21. What is Secondary Amenorrhea
    • –3 months with no period with history of regular menses previously
    • –6-12 months with history of irregular menses previously
    • –The absence of menses for a shorter period of time is referred to as “delayed menses”.
  22. Test for amenorrhea are
    • •URINE PREGNANCY (HCG)
    • •Vaginal/bimanual exam
    • •FSH, LH, TSH
  23. Managment of amenorrhea
    • •Depends on test results–
    • + HCG >refer to OB
    • –^ TSH > treat for Hypothyroidism
    • –LH/FSH ratio > 2 >>DHEA-S, Testosterone  (PCOS )
    • –Medications
    • •OCP
    • •Metoclopramide
    • •Antipsychotics
    • -Carcinoma
    •  immediate Referal
  24. What is Dysmenorrhea
    •Crampy pain that occurs in the lower abdomen/pelvis around the time of menses.

    • –Primary:usually begin in women <20 y/o; no other pelvic disease present
    • –Secondary:  Usually occurs after age 20.  pelvic pathology present (causing symptoms)
  25. What Pathogenesis of Primary dysmenorrhea
    • –Result of excessive uterine prostaglandin production
    • –Leads to alterations in uterine basal tone, increase in uterine contraction strength and frequency
    • –pain occurs from hypoxia or ischemia
    • –Affects approximately 25-50% of all menstruating females
  26. Pathogenesis of Secondary dysmenorrhea
    • –External to uterus
    • –Wall of uterus
    • –cavity of uterus
  27. S/S of primary dysmenorrhea
    • –Pain located in suprapubic area and radiates to back, upper thighs
    • –may have N/V/D
    • –Usually begins at onset of menstruation and lasts 48-72 hours
  28. S/S of secondary dysmenorrhea
    • –Pain occurs at any point in cycle
    • –Dyspareunia and pelvic pain unrelated to menses suggest causes such as endometriosis, PID
  29. Obatin HX for dysmenorrhea
    • •Complete menstrual and contraceptive history
    • •Location of pain, when it begins, radiation, associated symptoms
    • •-does the pain occur independently of menses?
    • •Urinary tract symptoms
    • •Treatment
  30. Dysmenorrhea physical exam
    • –Look for infection
    • –Bimanual
    •   •-tenderness
    •   •-cervical motion tenderness (CMT) – PID*
  31. Differential Diagnosis of dysmenorrhea
    • •Differentiate between primary and secondary
    • •-Rule out secondary pathological conditions!
  32. Testing for Dysmenorrhea
    • Primary= none
    • Secondary=
    •   H&P should guide
    •   •Ultrasound
    •   •CT
    •   •Pap smear
    •   CMT= start antibiotic
  33. Management/Treatment of Dysmenorrhea
    • Primary
    • Oral contraceptives
    • •Prevent fluctuations of androgenous progesterone levels
    • –Drugs that suppress production of prostaglandins
    •    •NSAID’s : naproxen, ibuprofen
    • –Teach to start OTC meds day before cycle

    • Secondary
    •  Always treat underlying cause!
  34. What is vulvovaginitis
    infection or inflammation of vulva and/or vagina 
  35. Etiology of vulvovaginitis
    • Commonly caused by
    • –Trichomonas vaginalis
    •   •-sexually transmited
    •   •Also infects the lower urinary tract
    • –Bacterial vaginosis
    •   •Most frequently diagnosed symptomatic   vaginitis
    •    Not necessarily always an STD
  36. Candida albicans
    • –Occurs in close to 30% of women
    • Not considered a STD
    • –Predisposed by
    •    •-pregnancy
    •    •Broad-spectrum antibiotics or corticosteroids
    •     •-DM
  37. Trichomoniasis
    • Malodorous yellow-green discharge with pruritus (red flag!) usually severe
    • –-dyspareunia
    • Dysuria
  38. Bacterial vaginosis
    • Malodorous, white (fishy) discharge
    • –-spotting
    • Clue Cells on microscopic exam
  39. Candida Vaginitis
    • •Thick discharge with pruritis
    • •Erythema of vagina and vulva
    • PH < 4.5 acidic/                                             normal value is 4.6-8.0 alkaine
  40. History to ask for Candida Vaginitis
    • •Antibiotics
    • •Sexual activity
    • •Predisposing factors
    • •-symptoms
    • •Douching and use of feminine hygiene products (changes PH-susceptible to infection)
  41. Physical exam of vagina
    • –Discharge
    •     •-note color, odor, amount
    • –Redness, edema, excoriation of vulva
    •       •Trichomoniasis:                                       diffuse vaginal redness with strawberry patches on cervix
  42. DifferentialDiagnosis for STD
    • •Chlamydia
    • •-gonorrhea
    • •Herpes genitalis

    Gon and chlam must be treated together.  If have one likely have other
  43. DiagnosticTests for STD
    • •Consider STD
    •   –-HIV
    •   –Syphilis
    •    –Gonorrhea
    •    –Chlamydia
    • •Order test accordingly
  44. Management/Treatment Trichomoniasis
    • –Metronidazole 2 g PO one time OR
    •     –Metronidazole 500 mg bid for 7 days
    • –-Treat sexual partner!!
    • –Flagyl 2g PO x 1
    •    –Or 500 mg BID x 7 days

    Use single if concern about complaince
  45. Treatment for Bacterial vaginitis
    • –Clindamycin Cream 2%, one applicator      (5 g) intravaginally at HS for 7 days
    • –Metronidazole gel, 0.75%, one applicator intravaginally bid for 5 days

    –Know Flagyl or Clindamycin (not specific doses!)
  46. Treatment for •Candida
    • –Miconazole 2% (5 g) intravaginally at HS for 7 days
    • –Terconazole 80 mg suppository, 1   suppository intravaginally at HS for 3 days
    • –Fluconazole 150 mg Po once (1st choice)
  47. client educatuion for STD.
    • •Avoid sexual intercourse until patient and partner cured
    • •Education regarding prevention, transmission, treatment
    • •-caution against douching
  48. Intial assessmnet for contraception use.
    • •Medical History
    • •Gyn/OB history–-menstrual–Contraceptive–STD’s–-sexual history
    • •Family History-reproductive cancers, strokes, clots
    • •Social History–HPV–-drugs and alcohol use–Cigarettes–-work–Income–Desire for children in future?
    • •Review of Systems
    • •Targeted physical exam–Thyroid–-breast–Abdomen– -pelvis-if first time with OCPs–Pertinent labs
    • •TSH, CBC, PAP, STD testing
  49. Subsequent Evaluation
    • •Women using method requiring prescription:
    •      annual exam
    •     •-weight, BP, BMI
    • •Review interval history for
    •    –-any side effects
    •    –Satisfaction
    •     –Contraindications
    •     –-concerns
  50. What are absolute contraindication of use of OC?
    • –Deep vein thrombosis or pulmonary embolism
    • –CAD or CVA
    • –Structural heart disease-congenital
    • –Diabetes with vascular disease of > 20 yrs – chest pain, or documented vascular
    •     disease
    • –Breast cancer
    • –Pregnancy
    • –Liver problems
    • –Older than 35 and heavy smoker
  51. What are relative concerns for OC prescription

    Think Risk over Benefits.
    • –Undiagnosed abnormal vaginal/uterine bleeding
    • –Diabetes mellitus
    • –Lactation
    • –Active gallbladder disease
    • –BP > 140/90 on 3 separate visits
    • –Migraine headaches
    • –Family history of death of a parent or sibling prior to age 50 due to an MI
  52. What are advantages of OC?
    • –easy to use
    • –Convenient
    • –Rapidly reversible
    • –-other benefits: 
    •      helps with acne,
    •      dysmennorhea (cramps),
    •      fibrocystic breast disease (tenderness)
    • -50% reduction of cervical/endometrial CA
    • -prevent osteoporosis
  53. What are disadvantage of OC?
    • –Dependent on user for adherence
    • –Provides no protection against STD’s
    • –-expensive
    • –-prescription needed
    • –Possible side effects
  54. Methodsof Action of OC
    • •Inhibits ovulation
    • •Act directly on cervical mucus, making it thicker which inhibits sperm penetration
    • •Act directly on the endometrium, inhibiting its development into a state favorable for implantation

    • Progestrion inhibits LH which stops ovulation.
    • Estrogen inhibits FSH which disrupts uterine staging for implantation
  55. What are prescribing Guidline?
    • •Most women are started on OC containing <35 mcg estrogen
    • Efficacy of low dose may be lowered with
    •      :–Medications that affect liver metabolism
    •       –-anticonvulsants 
    •        -herbal
    •       –Antibiotics
    •           –-rifampin
    •            –Griseofulvin

    If nesscessary to prescribe ABX at that time instruction on additional preventional methods.
  56. OCP’smay potentiate the effects of which drugs?
    • –Antidepressants
    • –Benzodiazepines
    • –-Beta blockers
    • –Theophylline

    May considering decreasing dosage of drug.
  57. What is the baseline limit of weight for most common oral 30-35ug OC
    Women weighing 70.5  KG  will need higher dosing
  58. What are some Experts differ on first choice of OC
    • –Some believe no single OC in the sub-50 mcg is superior to another
    • –Others recommend third-generation progestins in combination preparations NOT be first choice.
  59. Clint education on OC should be what?
    • •No protection against STD’s
    • •-explain risks and side effects
    • •Smoking cessation
    • •-do NOT skip doses!
    • •Take at same time every day
    • •-still need annual pap smear
    • •Have back-up method
  60. Implanon is a ?
    • •One rod implanted under the skin
    • •Office procedure
    • •-progestin only
    • •Good for 3 years
    • -low failure rate<1%
    • -Rapid return to fertility than DMPA

    • Disadvantages are:
    •  Irregular bleeding
    •  Requires MD for insertion
    •  weight gain (3lb in 1yr)
  61. What are Type of combo OC
    • Combo Progestrin+Estrogen
    •  -most common 30-35ug (lowdose)
    •  -Ultra low (loestrin)20-25ug ideal s/e
    •  -Seasonale 91 days (4mens per year) ideal symptomatic 
    •  -Progestrin-drospirenon (sprionolactrone) ideal fluid retenion (hyperkalemia/reneal/adrenal)
    • -Transdermal Patch (weekly)
    • -Nuvaring (3week,few s/e)
    • -Lunella injection (monthly) (weight gain, delay return fertility,irregular bleeding)
  62. type of Progestrin only
    • -Depo Provera
    • -Noretgindron (mini-pill) rapid reversal
    • -Mirena (IUD)
      -Implanon (implant) 3yrs, <1% failure rate, teens clinic- Weight gain, irregular bleeding
  63. Depo-Provera (DMPA) is what?
    • –Injectable progestin
    • –-administer every 12 weeks-3months
    •  - inexpensive
    •  -High effective


    • Disadvantages:
    •  –Weight gain (4 1yr, 5 2yrs, 14 3yr)
    • –- decrease bone mass! Risk of osteoporosis
    •  - Irregular bleeding
    •  - depression
    •  - Up 2 yrs to return to fertilization

    • Use calcium and VIT D supplementation  
    •   - recommend exercise
    •   - Bone density testing 
    •   
  64. best type of contraceptive for STI
    Condom

    • OTC
    • best protection STI
    • best  with spermicide

    • Disadvantage:
    • 10-20% failure rate m/f
  65. Diaphragm
    • Advantage:
    • -spontanous use
    • -reusable
    • -
  66. What is a IUD
    • Contraceptive device inserted into the uterus
    •     –-potential for bleeding
    •     -Incovience requires MD office procedure.

    • Advantages:
    •   -Long duration of efficacy.
    •   -Highly effective
    •   -Rapid reversal

    • Contraindications:
    •  -STI
    •  -HIV
    •  -infection
    •  -pregnnacy
    •  -nulliparity (never childbering)

    • two types
    •  Progestrin (mirean) 5 yrs
    •  copper 10 yrs
  67. Sponges are what?
    • Contraceptive devices.
    • Advantage
    • -•Blocks cervical opening
    • •-spermicidal
    • •Can remain in place for 24 hours
    •   •Effective for numerous sexual encounters/ideal one time use
    • -Spontaneous use
    • -OTC

    • Disadvantage:
    • -High failure rate.
    • -Can result in Toxic shock syndrome if not removed. 
    • -less effective in parous women.
  68. EmergencyContraception
    • •Should be initiated within 72 hours after unprotected intercourse
    • •Primary action of EC pill is to inhibit or delay ovulation
    • •It may also interfere with fertilization and/or implantation
    • •-it does NOT cause abortion!
  69. What is Plan B (EC)
    • •(2 tablets of 750 mcg levonorgesterl)
    • •Take 2 tablets together within 72 hours after unprotected intercourse
    • Most effective when initiated in the first 12 hours after unprotected coitus
  70. Menopause
    Life change  Not a disease process

    • •Ovarian failure marked by cessation of menses for 12 consecutive months
    • .•Serum FSH level over 40 mIU per mL on two occasions one week apart.


    Nornal FSH lvl is 15-30
  71. Etiology/Incidence of menopause
    • •Average age of onset is 51 years
    • Women who smoke experience menopause 1-2 years earlier than nonsmokers
    • •The main clinical consequence of menopause is the cessation of secretion of ovarian hormones that accompany folliculogenesis
    • Estrogen deficiency increases woman’s risk for cardiovascular disease and osteoporosis.
  72. What are S/S of Menstural changes
    • –varies widely between women
    • –Begin about 5 years prior to menopause
    • –May experience a combination of long, short, normal, and anovulatory cycles.
  73. What are hormonal changes seen in prior toi and during menopause?
    • Hormonal Changes
    • –Immediately preceding menopause
    •      •Lower estradiol levels
    •      •Increased FSH levels
    •      •LH levels somewhat increased
    •  –Following menopause
    •     •Primary estrogen is estrone
    •     •FSH elevated 10 to 20 fold
    •      •LH elevated three fold
  74. Hot Flashes/Flashes
    • –The first physical manifestation of ovarian failure
    • –Caused by declining estradiol 17 B secretion by the ovarian follicles
    • –May occur during the day or present as night sweats
  75. What are Psychological Changes in menopause
    • –-depression
    • –Anxiety
    • –Irritability
    • –-changes in libido
    • –Insomnia
  76. PhysicalChanges From Estrogen Loss
    • •Genitourinary–Pubic hair becomes sparse
    • –Vulva atrophy
    • –Vagina
    •     •-decreased lubrication
    •     •Vaginitis
    •     •-dryness
    •     •Loss of rugae
    •  •Can use OTC creams to help with symptoms
  77. Physiological changes menopause
    • •Pelvic Floor
    •     –Muscular tissue loss causing uterine prolapse, cystocele, and rectocele
    • •Bladder/Urethra
    •    –-atrophy–Frequency and urgency
    •    –-stress incontinence
  78. Physiological changes menopause
    • •Uterus
    •      –-decrease in size and weight
    • •Breasts
    •    –Decrease with gradual atrophy of glandular tissue
    •    –-nipples become smaller and flatter
  79. Physiological changes menopause
    • •Cardiovascular
    •     –-changes in lipids – HDL levels drop
    • •Musculoskeletal
    •      –-oseteoporosis (decreases in estrogen levels)
  80. Histroical insight of menopause
    • •Determine severity, onset, and duration of symptoms
    • •Complete gynecologic history
    •     –-menstrual history
    •     –Number of pregnancies, births, abortions, miscarriages
    •     –-contraceptive methods
    •     –Surgical procedures
    • •Medication history
    • •Assess risk status for CAD, osteoporosis, breast cancer, and endometrial cancer
    • •-age mother went through menopause
  81. What is physical exam for menopause
    • •Complete physical exam if new patient
    • •-Breast exam
    • •Pelvic and speculum examination
  82. Differential Diagnosis ofg menopause are?
  83. –Thyroid disorders-amennorhea
    • –Clinical depression
    • –Pregnancy
  84. Diagnostic test of to confirm menopause are?
    • –-TSH
    • –Serum FSH
    • –PAP smear
    • –Pregnancy test
    • –-mammogram
    • –Bone density screening
    • –Other tests based on risk factors
  85. Management of menopause is based on what?
    • •Hormone Replacement Therapy is no longer  automatic!
    •     –Relief of hot flashes, urinary symptoms, vaginal dryness
    •      –Prevention against cardiovascular disease
    •      –Prevention of osteoporosis
  86. Types of HRT for menopause.
    • •If HRT is prescribed, consider
    • Estradiol skin patch (hot flashes)
    •     -changed every week
    • –Premarin 0.3 mg QD (lowest dose)
    • –Prempro
    •     -if uterus is intact:Estrogen and Progestin combination!
    • –May need sequential dosing.  ( more reflective of hormonal pattern and gradual tritration
  87. Managment of menopause
    • •Psychological Symptoms
    •    –-consider antidepressants
    • •Cardiovascular protection
    •   –-diet
    •    –Exercise
    •    –-smoking cessation
    •    –Consider lipid lowering medication
  88. Vaginal management for menopause
    • –Vaginal creams and lubricants
    • –Consider estrogen cream
    •    •Premarin vaginal cream, 0.625 mg/g–½ to 1 g intravaginally QD cyclically
    •       –Discontinue or taper after 3 months
    •       -not for long term use
  89. Treatment/managment of menopause
    • •Hot Flashes
    •     –-soy
    • •Osteoporosis
    •    –-calcium
    •    –Vitamin D 400 IU per day
    •    –Fosamax
    •         •Inhibits osteoclast activity
    •         •Decreases bone turnover
    •         •5 mg Q day or 35 mg Q week
    •  –Exercise
  90. What are AlternativeMedicine for menopause
    • •Black Cohosh (Remifemin)
    •      –-reduces hot flashes
    •       –20 mg bid
    • •Red Clover
    •       –May improve cognitive function
    •       –-may increase bone density
    •       –Not for women with breast cancer or family history of breast cancer
  91. What are AlternativeMedicine for menopause
    • Dong quai
    •    –-contains coumarins
    •    –Not for women taking anti-coagulants or who have heavy menstrual flow
    • •Evening Primrose Oil
    •     –May reduce night time hot flashes but no more effective than placebo for day time hot flashes
  92. St john wort for treatment of menopause
    • –Used for treatment of psychological symptoms
    • –Not enough evidence to support use for mood swings associated with menopause
    • –Decreases serum level of digoxin, warfarin, oral birth control pills, theophylline
    • –Dose of 300-1200 mg/day causes mental confusion, nausea

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