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245 Cards in this Set

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Describe the procedure for performing a breast exam.
1. introduce self
2. explain purpose of exam
3. wash hands
4. ask patient to lower gown
5. inspect breasts, nipples, and areolae
-arms hanging loosely at sides
-hands behind head
-hands on hips
6. palpate supraclavicular, infraclavicular, and axillary lymph nodes bilaterally
7. have patient regown on one side
8. have patient lie down and place arm above head on side that is ungowned
9. palpate breast with light, medium, and deep pressure in strips, moving fingers in circles without lifting them
10. repeat with other breast
11. review results
12. ask about self-breast exams
During inspection of the breasts, what are you examining?
size
shape/contour
symmetry
texture
color
venous patterns
lesions
During inspection of the nipples and areolae, what are you examining?
size
shape
symmetry
texture
eversion/inversion/retraction
color
discharge
Mosbys p514
List the breast quadrants.
1. UIQ (upper inner quadrant)
2. LIQ (lower inner quadrant)
3. LOQ (lower outer quadrant)
4. UOQ (upper outer quadrant)
5. Tail of Spence
What should you include when documenting a breast mass?
1. location – breast, quadrant, o'clock location from nipple, distance from nipple, document with illustration
2. size – length, width, thickness, document in cm
3. shape – round, oval, lobular, irregular
4. margins – circumscribed, microlobulated, spiculated, ill-defined, obscured
5. consistency – soft, firm, hard
6. mobility – fixed, mobile, direction of mobility
7. retractions – altered contour, dimpling
8. tenderness
Mosbys p508
supernumerary nipple
What does this breast most likely indicate?
peau d'orange → inflammatory or advanced breast cancer
What is peau d'orange and what does it indicate?
edema of the breast due to blocked lymphatic drainage → indicative of inflammatory or advanced breast cancer
Mosbys p502
Describe the location of the breasts.
1. between sternal border and midaxillary line
2. superior to pectoralis major m. and serratus anterior m.
3. between 2-3rd rib to 6-7th rib
Mosbys p492
Describe the anatomy of glandular tissue of the breast.
each breast consists of 15-20 lobes
each lobe consists of 20-40 lobules
each lobule contains acini cells
acini cells produce milk that drains into laciferous ducts that drain to nipple
Mosbys p492
What are Cooper ligaments?
suspensory ligaments that support the breasts
Mosbys p492
What arteries supply the breasts?
1. superificial tissue → intercostal aa.
2. deep tissue and nipples → branches of internal mammary a. and lateral thoracic a.
Mosbys p492
What are Montgomery tubercles?
sebaceous glands in areola which secrete oil for lubrication and protection of nipples and areolae
List the lymph nodes that drain the breasts.
supraclavicular
infraclavicular
axillary
internal mammary
interpectoral (rotter)
subscapular
Define thelarche.
breast development
What HPI questions should you ask for breast discomfort/pain?
-onset - sudden or gradual
-duration - start, constant, intermittent
-severity
-character - aching, throbbing, stinging, burning, stabbing, pulling
-location - localization, unilateral, bilateral, radiation
-associated symptoms - nipple discharge, mass
-other - irritation from skin-to-skin contact or bra, strenous activity, recent trauma
-relationship to menses
Mosbys p496
What HPI questions should you ask for nipple discharge?
-onset - sudden, gradual
-duration - start, constant, intermittent, spontaneous, provoked
-character - amount, color, constistency, odor
-location - unilateral, bilateral
-associated symptoms - breast pain, nipple retraction, mass
-other - recent trauma
-relationship to menses
Mosbys p496
What HPI questions should you ask for breast mass?
-onset - when first noticed
-duration - constant, intermittent
-character changes - size, consistency, mobility
-location - localization
-associated symptoms - breast pain, nipple discharge, nipple retraction, breast dimpling, tender lymph nodes
-relationship to menses
Mosbys p496
What PMH questions should you ask for breast complaints?
-history of breast disease - fibrocystic changes, fibroadenomas, cancer
-history of cancer - endometrial, ovarian, colorectal
-surgeries - breast aspirations, biopsies, implants, reductions, plasties; oophorectomy
-mammography history - last mammogram, frequency, results
-menstrual history; breast changes during menstruation
-pregnancy history
-lactation history
-menopause
-hormonal meds
-other meds
Mosbys p496
Define oophorectomy.
surgical removal of ovary/ovaries
Stedmans
List risk factors for breast cancer.
1. non-modifiable
age - increases with age
gender - increases if female
genetics - increases if BRCA1 or BRCA2 gene mutations present
history of breast cancer
family history of breast cancer
2. modifiable
childbirth - increased if nulliparity or late age at birth of first child
hormone therapy - increased if estrogen and progesterone homrone therapy after menopause
obesity
alcohol
Mosbys p497
What is the ddx for unilateral bloody nipple discharge?
intraductal papilloma (most common)
mammary duct ectasia
breast cancer
What is the ddx for nipple discharge?
pregnancy
lactation
nipple stimulation
nipple/areola/breast infection/abscess
intraductal papilloma (most common)
mammary duct ectasia
fibrocystic changes
breast cancer
paget's disease
hyperprolactinemia
When is the best time to perform a self-breast examination?
2-3 days following menstruation when breasts are least likely to be tender or swollen
Mosbys p498
Define hyperprolactinemia.
↑ prolactin in blood
normal during pregnancy and lactation
How often should self-breast exams be performed?
once a month
Mosbys p498
Describe a self-breast examination.
1. stand in front of mirror and look for anything unusual (size, shape, symmetry, nipple discharge, puckering, dimpling)
-arms at sides
-hands behind head
-hands on hips
2. move fingers in circle, feeling for any lumps
-check entire breast
-check armpit
Mosbys p499
What are the recommendations for breast cancer screening?
1. clinical breast exam
-if <40y/o, every 1-3 years
if >40y/o, every year
2. mammogram
-if average risk, start at 40y/o, every year
-if increased risk, consider more frequent CBE, earlier mammogram, additional tests
3. self breast examination
-optional
-if >20, monthly
Mosbys p500
Describe peau d'orange.
skin of breast resembles orange peel due to thickened skin, enlarged pores, and accentuated skin markings
Mosbys p502
What is the ddx for visible venous patterns in breasts?
normal, bilateral
-obesity
-pregnancy

abnormal, unilateral
-dilated veins due to ↑ blood flow to malignancy
Mosbys p502
Which part of the breast is peau d'orange often first visible?
areola
Mosbys p502
What is the ddx for nipple inversion?
-if lifetime inversion → normal
-if recent inversion → cancer
Mosbys p502
When should nipple compression be performed?
only if complaint of spontaneous nipple discharge
Mosbys p509
Define galactorrhea.
milk production in non-pregnant or non-lactating woman
Define gynecomastia.
abnormally large mammary glands in males
Define amastia.
absence of breast, aveola, and nipple
may be congenital or iatrogenic
Define polymastia.
extra breast(s)
Define mastalgia.
breast pain
amastia
Define supernumerary nipple.
congenital accessory nipple(s) located in milk line
polymastia
Left: asymmetric gynecomastia
Right: normal
List possible signs/symptoms of breast cancer.
nipple discharge
nipple retraction
breast dimpling
breast mass
peau d'orange
List lifestyle changes that can reduce risk of breast cancer.
1. reduce alcohol intake to ≤ 1 drink per day
2. exercise regularly to maintain healthy weight
3. avoid postmenopausal combination hormone therapy
Mosbys p510
How do you differentiate between nipple inversion and nipple retraction?
nipple retraction due to breast cancer
paget's disease of the breast
dimpling due to breast cancer
What are the indications for performing a breast exam?
routine health maintenance
mastalgia
nipple discharge
changes in breast appearance
breast mass
Define mastitis.
inflammation of breast tissue
Who is most commonly affected by mastitis?
lactating women where blocked lactiferous ducts (due to inadequate emptying or tight bra) cause engorgement and subsequent mastitis
mastitis
*notes on breast exam
1. don't peer, stand up straight
2. have patient press down on hips
3. do 3 complete circles
4. include notation of tattoos if in area
What is the ddx for gynecomastia?
puberty
hormonal imbalance
pituitary or testicular tumor
steroid or estrogen-containing medications
Ovaries can be found at the level of what surface landmark?
ASIS
Mosbys p582
What is the function of the bartholin glands?
secrete mucus for vaginal lubrication during sexual excitation
Mosbys p579
Why might a pelvic exam be performed?
1. general health check-up - important to detect infections, STIs, cancer in early stages, other reproductive problems
2. suspected vaginal infections (candidiasis, bacterial vaginosis)
3. suspected STIs (trichomonasis, gonorrhea, chlamydia, herpes, HPV)
4. screen for cervical abnormalities (PAP)
5. evaluate abdominal/pelvic pain
6. evaluate abnormal uterine bleeding
7. evaluate pelvic organ abnormalities (uterine fibroids, ovarian cysts, uterine prolapse)
7. required before prescribing certain contraception (IUD, diaphragm)
7. collect evidence for sexual assault
What is the ddx for cervical motion tenderness?
PID
ovarian cyst
ectopic pregnancy
What is anteversion?
uterus tipped anteriorly (normal)
What is retroversion?
uterus tipped posteriorly
What is anteflexion?
fundus of uterus anterior to cervix; anterior of uterus is concave
What is retroflexion?
fundus of uterus posterior to cervix; anterior of uterus is convex
What is the position of the uterus found in most women?
anteverted and anteflexed
What are the 3 layers of the uterus?
endometrium
myometrium
perimetrium
List the parts of the uterus.
1. corpus
-fundus
-body
-isthmus
2. cervix
-internal os
-cervical canal
-external os
What is the etiology of a bartholin cyst?
blockage of bartholin gland due to trauma, inflammation, or infection, resulting in fluid-filled cyst
What are the complications of a bartholin cyst?
may progress to bartholin abscess (i.e. infected bartholin cyst)
*abscess likely if pain present
bartholin cyst/abscess
bartholin cyst/abscess
What is the function of the skene glands?
associated with female ejaculation (homologous to male prostate)
What is dispareunia?
painful sexual intercourse
What is the etiology of a skene duct cyst?
blockage of skene gland usually due to infection
What are the complications of a skene duct cyst?
skene duct abscess
urethral obstruction
recurrent UTIs
Describe vaginal discharge due to candida.
white curd-like discharge
What is the ddx for vaginal discharge?
normal discharge
bacterial vaginosis (BV)
vulvovaginal candidiasis (candidal vaginitis)
trichomoniasis (trichomonal vaginitis)
gonorrhea
chlamydia
atrophic vaginitis
allergic vaginitis
pelvic inflammatory disease (PID)
cervicitis
foreign body
infected IUD
What organism causes bacterial vaginosis most commonly?
gardnerella vaginalis
cystocele
cystocele
uterine prolapse
rectocele
What is vaginitis?
non-infectious or infectious inflammation of the vaginal mucosa (and sometimes inflammation of the vulva)
What is pelvic inflammatory disease (PID)?
infection of the upper female genital tract (i.e. cervix, uterus, fallopian tubes, or ovaries)
Define cystocele.
prolapse/herniation of urinary bladder into vagina
Define rectocele.
prolapse/herniation of rectum into vagina
What are the adnexa of the uterus?
appendages of the uterus (i.e. fallopian tubes, ovaries, and associated ligaments)
During pregnancy, when should you order hct and 1 hour glucose?
28 weeks
During pregnancy, when should you order GBSDNA probe?
36 weeks
Define urethrocele.
prolapse/herniation of urethra into vagina
List 7 broad pelvic complaints.
1. pain
2. urinary symptoms
3. premenstrual symptoms
4. menopausal symptoms
5. vaginal dischage
6. abnormal uterine bleeding
7. infertility
Describe the normal appearance of the cervix in a nulliparous patient.
pink uniform squamous epithelium; os appears small and round
Mosbys p601
Describe the normal appearance of the cervix in a parous patient.
pink uniform squamous epithelium; os appears as horizontal slit
Mosbys p601
Candida albicans is part of normal flora, true or false?
true
found in oropharynx, large intestine, and vagina
List red flags for sexual abuse.
1. medical
-general neglect or physical abuse
-trauma or scarring of genital or anal areas
-ususual skin color in genital or anal areas
-STI
-genitourinary symptoms (pruritus, pain, rash, lesions, odor, bleeding, discharge, dysuria, hematuria, UTI, enuresis)
-anorectal symptoms (pruritus, pain, bleeding, fecal incontinence, poor anal sphincter tone, bowel habit dysfunction)
2. behavior
-school problems
-dramatic weight change/eating habits
-depression
-sleep problems
-sudden personality/behavior changes
-sudden avoidance of certain people/places
3. sexual behavior
-excessive masturbation or sexual behavior
-repeated object insertion
-sexually provacative mannerisums
-age-inappropriate sexual knowledge
-sex play between children with >4 years age difference
-sex play involving force, threats, bribes
-child asking to be touched/kissed in genital area
Mosbys p611
What are clue cells?
epithelial cells coated by Gardnerella vaginalis
indicative of bacterial vaginosis
What does this vaginal discharge indicate?
thin milky white discharge → bacterial vaginosis
VULVOVAGINAL CANDIDIASIS
ETIOLOGY:
caused by candida albicans (90%)
may be associated with pregnancy, obesity, systemic disorder (DM, HIV), medication (antibiotics, corticosteroids, oral contraceptives), chronic debilitation
occurs in 75% of women

CLINICAL PRESENTATION:
severe vulvar pruritis
vulvar erythema
white cottage-cheesy vaginal discharge
+/- burning following urination
+/- labia minora erythema, excoriation, edema
if affecting skin adjacent to labia, think DM or other systemic illness

DIAGNOSTIC WORKUP
pH normal (≤4.5)
wet mount (KOH) → pseudohyphae
fungal culture

MANAGEMENT:
1. treat only if symptomatic
2. d/c antibiotics if possible
3. control underlying disease
4. avoid nonabsorbent undergarments
5. avoid douching
Describe vaginal discharge due to bacterial vaginosis.
thin milky white discharge
BACTERIAL VAGINOSIS
ETIOLOGY:
altered vaginal flora (decreased lactobacilli + overgrowth of Gardnerella vaginalis, Mobiluncus, Prevotella, Porphyromonas, Bacteroides, Peptostreptococcus)

CLINICAL PRESENTATION:
grayish-white vaginal discharge
fishy odor (more noticeable following unprotected intercourse)
non-irritating

DIAGNOSTIC WORKUP:
pH 5.0-5.5
whiff test positive (fishy odor following application of KOH)
wet mount → clue cells, ↓ lactobacilli, few WBCs
gram stain → lots of small gram-negative bacteria, few lactobacilli
*gram stain more sensitive (93%) and specific (70%) than wet mount

MANAGEMENT:
treat symptomatic patients and consider treating asymptomatic patients
IF NON-PREGNANT:
Options include:
1. metonidazole 2g PO single dose
2. metronidazole 500 mg PO twice daily x 5 days
3. clindamycin 300 mg PO 2x daily x 7 days
4. metronidazole gel 0.75% (1 full applicator, 5g) intravaginally once or twice daily x 5 days
5. clindamycin cream 2% (1 full applicator, 5g) intravaginally at bedtime x 7 days
6. clindamycin ovules 100g intravaginally at bedtime x 3 days
7. inform patients that condoms or diaphragms may be weakened during treatment with clindamycin cream since it is oil-based
IF PREGNANT:
Options include:
1. metronidazole 250mg PO 3x daily x 7 days
2. clindamycin 300 mg PO 2x daily x 7 days
3. do not use topical agents

COMPLICATIONS:
PID, post-abortion infection, post-hysterectomy vaginal cuff cellulitus

PREVENTION:
condoms
hydrogen peroxide douches
oral or vaginal application of yogurt containing lactobacillus acidophilus
intravaginal planting of exogenous lactobacilli
prophylaxis
longer treatment periods
*treatment of male does not help prevent recurrence in female

MATERNAL-FETAL TRANSMISSION:
BV may increase risk of preterm delivery, though treatment of asymptomatic pregnant women does not necessarily reduce risk of preterm delivery or adverse outcomes
GONORRHEA
ETIOLOGY:
sexually transmitted infection caused by Neisseria Gonorrhoeae
infects glandular structures of vulva, perineum, anus, urethra, and cervix

CLINICAL PRESENTATION:
symptoms range from asymptomatic (85%) to severe
copious mucopurulent discharge

DIAGNOSTIC WORKUP:
gram stain → gram-negative diplococcic within WBCs
NAAT or GCCHDNA

MANAGEMENT:
IF UNCOMPLICATED, options include:
1. ceftriaxone 125 mg IM single dose (3rd gen cephalosporin)
2. cefixime 400 mg PO single dose (3rd gen cephalosporin)
3. ciprofloxacin 500 mg PO single dose (2nd gen quinolone)
4. ofloxacin 400 mg PO single dose (2nd gen quinolone)
5. levofloxacin 250 mg PO single dose (3rd gen quinolone)
6. If infection acquired while in California, Asia, or the Pacific (including Hawaii) → spectinomycin 2g IM single dose (d/t cephalosporin or quinolone resistance)
7. treat for chlamydia

COMPLICATIONS:
salpingitis, tubo-ovarian abscess, peritonitis
ectopic pregnancy, infertility

PREVENTION:
safe sex practices including condoms

MATERNAL-FETAL TRANSMISSION:
if active infection present during delivery, newborn may develop conjunctivitis
What organism is considered normal flora of the vagina?
lactobacilli
CHLAMYDIA
ETIOLOGY:
sexually transmitted infection caused by Chlamydia Trachomatis

CLINICAL PRESENTATION:
may be asymptomatic
dysuria
post-coital bleeding
mucopurulent cervicitis
may present as lymphogranuloma venereum (LGV) → initially a painless, vesicular, transient lesion or shallow ulcer of vulva; retroperitoneal lymphadenopathy; may progress to genital or anal fistulas, strictures, or rectal stenosis; uncommon in U.S. but common in SE Asia and Africa

DIAGNOSTIC WORKUP:
NAAT or GCCHDNA

MANAGEMENT:
1. treat patient and partner
2. azithromycin 1 g PO single dose
3. other options include doxycycline, erythromycin, ofloxacin, levofloxacin
4. avoid sex for 7 days
5. repeat screening 3-4 months following treatment
6. if persistent symptoms, recurrence, or pregnancy → test for cure
7. if LGV → doxycycline 100mg 2x daily x 21 days
8. treat gonorrhea

COMPLICATIONS:
salpingitis, tubual occlusion, ectopic pregnancy, infertility

PREVENTION:
screen all sexually active women
safe sex practices including use of condoms

MATERNAL-FETAL TRANSMISSION:
neonatal conjunctivitis
What equipment is needed for the pelvic exam?
gown
drape
stirups
light
gloves
speculum
pap broom/vial
gc/chlam dna probe
cotton swab and saline solution
lubrication
fecal occult card
TRICHOMONIASIS
ETIOLOGY:
sexually transmitted infection caused by Trichomonas vaginalis (unicellular flagellate protozoan)
infects lower urinary tract of women and men
most prevalent non-viral STI in U.S.

CLINICAL PRESENTATION:
copious greenish-white frothy vaginal discharge
vaginal wall erythema
strawberry cervix
+/- malodor, urinary symptoms, vulvar pruritis, labia minora edema and tenderness

DIAGNOSTIC WORKUP:
pH > 5.0
wet mount → motile trichomonads, ↑ PMNs
*Trichomonas vaginalis are larger than PMNs but smaller than epithelial cells

MANAGEMENT:
1. treat patient and partner
2. metronidazole 2g PO single dose
3. metronidazole 500mg PO 2x daily x 7 days
4. avoid alcohol to prevent severe nausea and vomiting
5. avoid sex or use condoms until treatment completed
6. if persistent symptoms → repeat metronidazole after 4-6 weeks if presence of trichomonads confirmed and WBC normal
7. if resistance → 2-4g daily x 10-14 days, consult CDC
8. evaluate for gonorrhea, chlamydia, syphilis, and HIV


COMPLICATIONS:

PREVENTION:
safe sex practices including use of condoms
use of spermicidal agents (Nonoxynol 9)

MATERNAL-FETAL TRANSMISSION:
increased transmission of HIV
The cervix feels similar to cartilage of the nose, true or false?
true
*pelvic exam notes
1. angle speculum downward
2. do wet mount before pap/gc/chlam
3. cervix should feel like cartilage
Define vestibule.
area enclosed by labia minora
What is the function of the ovaries?
secrete estrogen and progesterone which control menstrual cycle and support pregnancy
What are the 3 parts of the broad ligament of the uterus?
mesosalpinx
mesoovarium
mesometrium
List 5 ligaments that support the uterus.
ovarian ligament
broad ligament
round ligament
cardinal ligament
uterosacral ligament
What is a urethrocele?
prolapse of female urethra into vagina
Describe breast anatomy.
Describe breast lymph nodes.
How do you differentiate nipple retraction vs. inversion?
Define mastalgia.
breast pain
Define polymastia.
extra breast(s)
Define galactorrhea.
milk production in absence of lactation or pregnancy
Define supernumerary nipple.
extra nipple(s)
Define amastia.
absence of breast, areola, and nipple; congenital or iatrogenic
Describe the documentation for a breast mass.
1. location – breast, quadrant, o’clock position from nipple, distance from nipple (document with illustration)
2. size – length, width, thickness (document in cm)
3. shape – round, oval, lobular, irregular
4. margins – circumscribed, microlobulated, spiculated, ill-defined, obscured
5. consistency – soft, firm, hard
6. mobility – fixed, mobile, direction of mobility
7. retractions – altered contour, dimpling
8. tenderness
Describe how to collect and perform a wet mount.
1. swab vagina
2. place swab in saline (NaCl)
3. add drop of discharge/saline to one side of slide
a. place cover slip over it
b. examine slide using microscope at 40X
c. look for RBCs, WBCs, clue cells, trichomonas
4. add drop of discharge/saline to other side of slide
d. add drop of KOH
e. place cover slip over it
f. examine slide
g. look for yeast
What are the indications for a wet mount?
vaginal discharge
What is a wet mount?
suspension of vaginal discharge in saline
What are the components of a back office wet mount?
a. RBCs
b. WBCs
c. KOH → yeast – budding yeast or pseudohyphae
d. trichomonas
e. clue cells
f. whiff test → odor after adding KOH?
Define amenorrhea.
absence of menses
Define menorrhagia (AKA hypermenorrhea).
abnormally heavy or prolonged menses
Define thelarche.
onset of breast development
Define menarche.
onset of menstruation
Define pubarche.
first appearance of pubic hair
Define polymenorrhea.
abnormally frequent menses
Define oligomenorrhea.
abnormally light or infrequent menses
Define metrorrhagia.
menstrual bleeding at irregular intervals, particularly in between expected menstrual periods
Define menometrorrhagia.
abnormally heavy and prolonged menses that occurs at irregular intervals
Define post-coital bleeding.
vaginal bleeding following intercourse
Define hypomenorrhea.
abnormally light and shortened menses
Define cryptomenorrhea.
condition characterized by the occurence of menstruation without visible blood due to obstruction of the outflow tract
Define prenatal.
before birth
Define perinatal.
interval from 28 weeks gestations to 7 days of life
Define postnatal.
after birth
Define mittelschmerz.
pain due to ovulation
mittelschemerz means "middle pain"
presents as unilateral lower abdominal pain
Define puberty.
process of physical changes by which a child's body becomes an adult body capable of reproduction
Define infertility.
the state of being unable to produce offspring
Define gravida/gravity.
women who is or has been pregnant; number of pregnancies regardless of outcome

*include current pregnancy
Define nulligravida, primigravida, and multigravida.
nulligravida = women who has never been pregnant
primigravida = women who is pregnant for the first time or has been pregnant once
multigravida - women who has been pregnant 2 or more times
Define para/parity.
women who has given birth; number of viable births (>20 weeks) regardless of outcome

*count multiple births as 1
Define nulliparous, parous, and multiparous.
nulliparous = women who has never given birth or completed a pregnancy beyond 20 weeks
parous = women who has given birth once
multiparous = women who has given birth 2 or more times
What do these wet mount slides indicate?
Top: clue cells → bacterial vaginosis

Bottom: epithelial cells → normal wet mount
How is gravity/parity documented?
GP, GPA, or G/TPAL, where:
G = number of pregnancies
P = number of viable births (>24 weeks)
T = number of term births (≥37 weeks)
P = number of preterm births (>24 weeks or <37 weeks)
A = number of abortions (<24 weeks) (spontaneous or induced)
L = number of living children

*count multiple births as 1

1. 2 pregnancies resulting in 2 live births = G₂P₂
2. 2 pregnancies resulting in 1 live birth and 1 miscarriage = G₂P₁A₁
3. 4 pregnancies resulting in 2 term births, 1 preterm birth, 1 miscarriage, and 3 living children = G4T2P1A1L3
How is the last menstrual period (LMP) documented?
first day of last menstrual period
What happens to the maternal blood volume during pregnancy?
↑ 40-50%
mainly due to ↑ plasma volume
begins during 1st trimester and peaks after 30th week
returns to normal 3-4 weeks post-delivery
Mosby's p422
Define colostrum.
first milk secreted at termination of pregnancy
contains more protein and minerals than mature milk
also contains antibodies and host resistance factors
Stedmans
What changes occur in the breast as a result of pregnancy?
1. nipples darken, become more prominent and erect
2. areolae darken and enlarge
3. montgomery tubercles appear due to sebaceous gland hypertrophy
4. breasts enlarge (sometimes 2-3 times normal size) due to increased glandular tissue
5. veins become visible due to increased vascularization
Mosbys p495
Breasts rarely return to pre-lactation size, true or false?
true
Mosbys p495
Following colostrum production, when does milk production occur?
2-4 days following delivery
Mosbys p495
What causes lactation to occur?
↑ prolactin
↓ estrogen
sucking stimulation
Mosbys p495
Discuss the initial presentation of sexual assault.
often present to emergency department complaining of being mugged or concerned about STIs/HIV and do not admit to being raped

may present with psychiatric symptoms (depression, anxiety, suicide attempt)
Discuss the long-term sequelae of sexual assault.
PTSD characterized by intense pyschological distress, psychic numbing, re-experiencing of trauma, and avoidance of stimuli associated with trauma

difficulty in reestablishing sexual and emotional relationships (50%)
suicidal ideation (33-50%)
suicide attempts (20%)
What is sexual assault?
any sexual act performed by one person on another without the person's consent

includes genital, oral, or anal penetration by the assaulter or by an object

may result from force, the threat of force either on the victim or another person, or the victim's inability to give appropriate consent
List sexual assault statistics.
700,000 to 1,000,000 American women are sexually assaulted every year
only 30% reported to the police
50% of rape victims tell no one
20% of adult women, 15% of college-age women, and 12% of adolescent girls have experienced sexual abuse and assault during their lifetime
incidence may be higher for African American women and for adolescent females
adolescents, elderly, and physically/developmentally disabled are particularly vulnerable
List date rape drugs.
flunitrazepam (Rohypnol)
gamma-hydroxybutyrate (GHB)
Discuss initial assessment of sexual assault.
obtain informed consent prior to examining sexual assault victim
obtain history and physical exam in presence of chaperone
ask patient to describe attacker and course of events
history → LMP, contraceptive, pre-existing pregnancy, pre-existing infection, last consensual sex before assault, activities between assault and examination (eating, drinking, urination, defecation, bathing, douching)
physical exam → inspect skin, oropharynx, and breasts for trauma (take photos), perform pelvic/rectal exam (moisten speculum only with saline, inspect for trauma or foreign objects)
rape kit
saliva
TRIC
GCCHDNA probe
PAP smear
HEPB
RPR
HIV
collect samples of attacker (pubic hair, fingernail scrapings, blood, semen)
inform victim she will likely experience rape-trauma syndrome and advise to seek help if and when these symptoms occur
FUV in 2 weeks for repeat physical exam,TRIC, and GCCHDNA
refer for counseling
monitor for alcohol and drug abuse
monitor for pysch symptoms (depression, suicidal ideation)
repeat HEPB and RPR in 12 weeks
repeat HIV in 6 months
"Rape" and "physical assault" are legal terms that should not be used in the medical record, true or false?
true
instead report findings as "consistent with use of force"
Describe the rape-trauma syndrome.
ACUTE PHASE:
may last for hours or days
characterized by a distortion or paralysis of the individual's coping mechanisms
responses vary from complete loss of emotional control (crying, uncontrolled anger) to an unnatural calm and detachment

DELAYED PHASE:
may occur months or years after the sexual assault
characterized by chronic anxiety, feelings of vulnerability, loss of control, self-blame, anxiety, nightmares, flashbacks, catastrophic fantasies, feelings of alienation and isolation, sexual dysfunction, psychological distress, mistrust of others, phobias, depression, hostility, and somatic symptoms (fatigue, HAs, nausea, myaglias, eating disturbances, sleep disturbances, intense startle reactions)
When does ovulation occur?
day 14 of menstrual cycle (i.e. 14 days after 1st day of period)
What are the phases of the menstrual cycle and the major hormone associated with each?
PROLIFERATIVE PHASE (AKA follicular phase):
day 1-14
menstruation d/t no fertilization
follicular development
major hormone = estrogen

OVULATION:
day 14
ovum released from follicle
major hormones = surge in LH and FSH, slight surge in estrogen

SECRETORY PHASE (AKA luteal phase):
day 14-28
corpus luteum development
corpus luteum degeneration if no fertilization occurs
major hormone = progesterone
List questions for a sexual history.
Now I am going to take a few minutes to ask you some direct questions about your
sexual health. These questions are very personal, but it is important for me to know so I
can help you be healthy. I ask these questions to all of my patients regardless of age or
marital status and they are just as important as other questions about your physical and
mental health. Like the rest of this visit, this information is strictly confidential.

Are you currently sexually active?
Do you have sex with men, women, or both?
How many partners do you currently have?
How many partners have you had in the last 2 months? The last year?
Do you use any substances or devices to enhance your sexual experience?
Are you trying to get pregnant?
Are you concerned about getting pregnant or getting a partner pregnant?
What are you doing to prevent pregnancy? Oral contraceptives? Patch? Injection? IUD?
Have you ever been tested for HIV? Do you want to be?
Have you ever had any STIs? How about your partners? If so, what was it and when did it occur?
Have you or any of your partners used injected drugs?
Have you or any of your partners had sex with a prostitute?
Have you gotten your hepB vaccines?
What are you doing to protect yourself against sexually transmitted infections and HIV? Condoms?
What type of sex do you have? Vaginal, oral, or anal? Do you use condoms? If not, why not? In what situations do you use condoms?
Are there any changes with your or your partner's sexual desire? In frequency of sex?
Do you have difficulty getting or maintaining an erection?
Do you have difficulty getting an orgasm?
Do you have any pain with sex?
What are the breast cancer screening recommendations from American Cancer Society, American College of Gynecologists, and USPSTF?
American Cancer Society:
1. yearly mammogram starting at age 40
2. CBE every 3 years if 20-39 and yearly starting at age 40
3. optional SBE starting at age 20
4. MRI if risk factors (FH)

American College of Gynecologists:
1. mammogram every 1-2 years if 40-49
2. mammogram yearly if ≥50
3. optional SBE

USPSTF:
1. mammography every 2 years if 50-74 (grade B)
2. mammography before age 50 depends on risk factors and patient values (grade C)
3. insufficient evidence to recommend mammography after age 74 (grade I)
4. SBE is not recommended (grade D)
5. insufficient evidence to recommend CBE (grade I)
6. insufficient evidence to recommend digital mammography or MRI (grade I)
Describe the role of vaginal estrogen pre-menopause.
premenopausal → estrogen thickens vaginal epithelium and results in presence of intraepithelial glycogen → glycogen results in production of lactic acid → lactic acid promotes growth of normal vaginal flora (lactobacilli and acidogenic corynebacteria)
Current OB/Gyn
Describe the role of vaginal estrogen post-menopause.
postmenopausal → endogenous estrogen production declines → vaginal epithelium loses glycogen → vaginal acidity declines → lactobacilli replaced by mixed flora (pathogenic cocci) → vagina becomes atrophic and more prone to trauma and infection
Current OB/Gyn
What does normal physiologic vaginal discharge look like?
white and milky
Define leukorrhea.
vaginal discharge
What questions should be asked about vaginal discharge?
amount
color
odor
consistency
associated pruritus
associated dyspareunia
What is the w/u for vaginal discharge?
1. history → vulvar or vaginal pain, pruritis, discharge, sexual activity, feminine hygiene products (douching, soaps, perfumes), overlying garments, medications (OCP, abx), previous infections, underlying medical conditions (diabetes)
2. physical examination → vulva, vaginal walls, and cervix
3. labs → pH, whiff test, wet mount
A mixed vaginal bacterial flora is expected when?
premenarche
postmenopause
Lactobacilli (vaginal flora) produce?
hydrogen peroxide
NABOTHIAN CYSTS:
tunnel or cleft of tall columnar endocervical epithelium becomes covered by squamous metaplasia

few mm to 3 cm
translucent or yellow
LEIOMYOMA OF UTERUS:
AKA uterine fibroid
benign smooth muscle neoplasm
originate in myometrium of uterus
associated with abnormal uterine bleeding
POLYCYSTIC OVARIAN SYNDROME (POS):
characterized by persistent anovulation
related to hypothalamic pituitary dysfunction and insulin resistance.
enlarged polycystic ovaries, secondary amenorrhea or oligomenorrhea, infertility, obesity, hirsutism
diagnosed if 2 of the following are present:
1. oligomenorrhea or amenorrhea
2. hyperandrogenism
3. polycystic ovaries on ultrasound – “oyster ovaries,” enlarged, sclerocystic with smooth pearl-white surfaces without indentations
diagnostic w/u:
elevated androgens, high LH, low FSH (increased LH/FSH ratio), low day-21 progesterone (anovulation), lipid abnormalities, insulin resistance
ENDOMETRIOSIS:
endometrial-like cells grow in areas other than endometrium
reproductive age
constant pelvic pain
premenstrual low sacral backache which subsides following onset of menses
dyspareunia especially with deep penetration
dysmenorrhea, infertility
tender nodules in the posterior vaginal fornix
uterine motion tenderness
ADENOMYOSIS:
growth of endometrium into myometrium
may be distinct nodules (adenomyomas) or diffuse
etiology unknown
classic presentation – parous, middle-aged, menorrhagia, dysmenorrheal, symmetrically enlarged uterus
menorrhagia
premenstrual or comentrual dysmenorrheal
menorrhagia
uterus uniformly enlarged, globular, boggy
hysterectomy curative
TERATOMA:
AKA dermoid cyst
benign ovarian neoplasm derived from any of the 3 germ cell layers
reproductive-age
asymptomatic unless torsion or rupture
transvaginal ultrasound
laparoscopic removal
CERVICAL POLYPS:
benign cervical neoplasm
common in multigravidas >20y/o
rare before menarche
often asymptomatic
intermenstrual or post-coital bleeding
menorrhagia
leukorrhea
if endocervical → red, smooth, narrow pedicle, soft, protrusion from cervical canal at external os
if ectocervical → pale, flesh-colored, smooth, rounded or elongated, broad pedicle
hysterosalpingogram or hysteroscopy if polyp high in endocervical canal
remove and biopsy b/c malignant change may occur
List ddx for cervicitis.
INFECTIOUS:
chlamydia
gonorrhea
trichomoniasis
genital herpes
HPV
BV

irritation from diaphragm, cervical cap
allergy to latex of condoms, spermicides
What is menopause?
cessation of menses due to aging or bilateral oophorectomy

no menstruation for 1 year
What is the etiology of menopause?
aging
bilateral oophorectomy

premature menopause:
ovarian failure and menstrual cessaton <40y/o
often d/t genetic or autoimmune
What is the clinical presentation of menopause?
~51y/o if d/t aging
hot flashes
night sweats
vaginal dryness
dyspareunia
mood changes → anxiety, depression etc.

thinned vaginal mucosa → pale smooth vaginal mucosa
small cervix and uterus
ovaries non-palpable
What is the diagnostic workup of menopause?
elevated FSH and LH
What is the management of menopause?
1. for hot flashes → consider estrogen/progestin therapy or SSRIs
2. for vaginal atrophy → lubrications, vaginal creams, estradiol vaginal ring
3. calcium and vitamin D supplements
4. monitor for osteoporosis and treat accordingly
5. if vaginal bleeding occurs following menopause → R/O endometrial cancer
5. provide education and support and referral to midlife discussion groups
6. if surgical menopause → immediate estrogen therapy that is then tapered
How long does menopause last?
menstruation diminishes until absent usually over 1-3 year period
What are hot flashes?
feeling of intense heat over face and trunk
flushing
sweating

worse following oophorectomy
may occur at night and cause insomnia and fatigue
What is the controversy behind menopause-associated hormone replacement therapy?
estrogen-progestin therapy increased risk of cardiovascular disease, cerebrovascular disease and breast cancer

can consider prescribing if early menopause + severe hot flashes but d/c after 3-4 years
How long do hot flashes typically last?
2-3 years
List most common types of gestational trophoblastic disease.
hydatidiform mole
choriocarcinoma
HYDATIFORM MOLE:
over-production of tissue supposed to develop into placenta
2 types:
1. Partial – abnormal placenta + some fetal development
2. Complete – abnormal placenta + no fetal development
Etiology unknown but may be associated with diet low in protein, animal fat, and vitamin A
Usually benign but may develop into cancer (
hyperemesis
vaginal bleeding in 1st trimester
preeclampsia before 24 weeks
abnormally large uterus gestational age
absent fetal heart tones
serial HCG higher than expected
ultrasound with absent fetus
D & C or hysterectomy
may develop into choriocarcinoma
CHORIOCARCINOMA:
type of gestational trophoblastic disease
may result from hydatidiform mole, abortion, ectopic pregnancy
usually late vaginal bleed in postpartum
enlarged uterus, ovaries
vaginal lesions
serial HCG
chemotherapy
What is the normal pH of the vagina?
3.5-4.0
Current OB/Gyn
List the 4 criteria for diagnosis of bacterial vaginosis.
1. thin white/yellow homogenous discharge
2. pH > 4.5
3. clue cells
4. fishy odor (after adding KOH)

*3 of 4 must be present for diagnosis
What does this wet mount slide indicate?
lactobacilli (1) and epithelial cells (2) → normal wet mount
What does this wet mount slide indicate?
clue cell (3) → bacterial vaginosis
What does this wet mount slide indicate?
trichomonas and WBCs → trichomoniasis
For suspected ovarian cancer, which tumor marker would you order?
CA 125
Do yeast form hyphae or pseudohyphae?
pseudohyphae

*yeast are unicellular and therefore cannot form hyphae, but yeast can form pseudohyphae if incomplete budding occurs and cells remain intact after division
A wet mount with a fishy odor (positive whiff test) is indicative of?
bacterial vaginosis or trichomoniasis
What are clue cells and what are they indicative of?
epithelial cells coated in bacteria that are indicative of bacterial vaginosis
What is the normal range for vaginal pH?
3.8-4.2
How long are pap specimens kept in pathology?
21 days
The presence of intermediate or basal cells on wet mount indicates?
inflammation of vaginal epithelium
What are the FDA pregnancy categories and their significance?
What are the recommendations for calcium for women?
age 14-18 1300mg/day
age 19-49 1000mg/day
age >50 1200mg/day
pregnant or lactating 1300mg/day
List methods of non-hormonal contraception.
TRADITIONAL METHODS:
1. abstinence
2. natural family planning
3. coitus interruptus (withdrawal method)
BARRIER METHODS:
1. male condom
2. female condom
3. vaginal diaphragm
4. cervical cap
5. spermicides
6. copper IUD
STERILIZATION:
1. vasectomy
2. tubal ligation
COITUS INTERRUPTUS (AKA withdrawal method):
withdrawal of penis before ejaculation
disadvantages → requires sufficient male self-control, failure may occur if semen escapes before orgasm or semen deposited on external genitalia near vagina
no contraindications
no reliable theoretical or actual user effectiveness rates
no adverse effects or risks except pregnancy
MALE CONDOM:
contraceptive sheath which covers penis during coitus and prevents deposition of semen in vagina
made from latex, polyurethane or lamb ceca (latex and polyurethane are impervious to organisms causing STIs while lamb ceca is not)
advantages → highly effective against pregnancy and STIs, inexpensive
indications → prevents pregnancy and STIs, recommend for all non-monogamous couples
theoretical user effectiveness rate → 99.7% (failure in 3/1000)
failure d/t sheath defect
actual user effectiveness rates → 70-90% in 1st year of use (10-30% failure in 1st year of use)
failure d/t applying condom late or not withdrawing penis before detumescence
FEMALE CONDOM:
contraceptive sheath which is inserted into vagina with 1 ring near cervix and the other ring outside vagina near introitus and prevents ejaculation of sperm in vagina
made of polyurethane
advantages → under control of female partner, some STI protection, perfect use reduces annual risk of HIV by >90%
disadvantages → bulky, expensive
theoretical user effectiveness rate → 2.6% failure during 1st 6 months, effectiveness comparable to diaphragm and cervical cap
VAGINAL DIAPHRAGM:
contraceptive barrier which is inserted into the vaginal cul-de-sac and covers the cervix
circular ring ranging from 50-105mm in diameter (must be fitted)
apply jelly or cream on cervical side before insertion (otherwise ineffective), then apply more jelly on and around diaphragm after insertion
may insert 6 hours prior to intercourse
leave in place for 6-24 hours following intercourse
advantages → some STI protection
disadvantages → requires fiiting (and yearly refitting), must anticipate need for contraception, vaginal diameter altered by weight fluctuations or deliveries
contraindications → significant pelvic relaxation, shortened vagina, sharply retroverted or anteverted uterus
theoretical user effectiveness rate → 94% (6 pregnancies per 100 women per year of exposure)
actual user effectiveness rate → 80-85% (15-20 pregnancies per 100 women per year of exposure)
failure d/t improper placement or dislodgement, early removal
side effects → vaginal wall irritation, increased risk of UTIs
CERVICAL CAP:
small cuplike diaphragm which is placed over cervix and held in place by suction
must be fitted (though tailoring to fit each individual cervix is difficult)
little advantage over diaphragm
confirm proper placement following intercourse
do not remove for 8-48 hours following intercourse
disadvantages → fitting difficult, must be able to feel cervix
side effects → foul discharge after 1 day of use
theoretical user effectiveness → similar to diaphragm
failure d/t dislodgement
List most to least effective forms of non-hormonal contraception.
abstinence
vasectomy
tubal ligation
male condom
vaginal diaphragm
coitus interruptus
family planning method
female condom
spermicides
cervical cap
SPERMICIDES:
kill sperm and act as mechanical barrier which prevents sperm from entering cervical canal
types include jellies, creams, gels, foam tablets, suppositories, or vaginal sponge (contain nonoxynol 9)
disadvantages → foam tablets or suppositories may require few minutes for adequate dispersion, not effective against chlamydia, gonorrhea, or HIV
theoretical user effectiveness rate → 15% failure rate if used alone
actual user effectiveness rate → 30% failure rate if used alone
side effects → external genitalia and vaginal mucosa irritation, frequent use associated with genital lesions (which increases risk of HIV transmission)
Categorize hormonal contraceptives based on the hormones present.
ESTROGEN & PROGESTIN combo:
oral contraceptives
injection (Lunelle)
patch (Ortho Evra)
vaginal ring (Nuvaring)

PROGESTIN only:
progestin only pill
injection (Devo Provera)
contraceptive implant (Implanon)
IUD (Mirena)
Define monophasic, biphasic, triphasic, and extended cycle oral contraceptives.
MONOPHASIC:
constant dose of estrogen and progestin

BIPHASIC:
ORAL CONTRACEPTIVE PILLS:
combination of estrogen (ethinyl estradiol) and progestin (norethindrone, norethindrone acetate, levonorgestrel, desogestrel, norgestimate, or drospirenone)
INDICATIONS:
MOA:
RELATIVE EFFECTIVENESS:
ABSOLUTE CONTRAINDICATIONS:
>35y/o smoker
pregnant
breastfeeding <6 weeks postpartum
BP >160/100
thrombogenic mutation (factor V leiden)
current or hx of VTE, MI, CVA
↑ risk for CVD (HTN, uncontrolled DM, active SLE)
valvular heart disease
liver disease
migraines with aura
breast cancer
major surgery with prolonged immobilization
RELATIVE CONTRAINDICATIONS:
<35y/o + smoker
Undiagnosed vaginal bleeding
DRUG INTERACTIONS:
ADVERSE EFFECTS:
breakthrough bleeding, spotting, nausea, HA, weight gain
RISKS:
VTE (increased if stasis, factor V leiden, leg trauma, pelvic surgery)
MI (increased if smoker, dyslipidemia, uncontrolled HTN, or longstanding DM)
CVA (increased if age, smoking, HTN, migraine HA with neurologic symptoms)
no protection against STIs
BENEFITS:
↓ acne
↓ menstrual blood flow (preventing anemia) and dysmenorrhea
↓ risk of benign fibrocystic breast disease (30-50%), menstrual disorders, PID, salpingitis, endometrial (50%), ovarian (40-80%), and colorectal cancer, ectopic pregnancy (90%), RA progression, bone mineral density loss
PATIENT EDUCATION:
taken for 21 days followed by 7 days of placebo (in which menstruation occurs)
COST:
PROGESTIN-ONLY ORAL CONTRACEPTIVE:
progestin only (usually norethindrone or levonorgestrel)
INDICATIONS: unable to take OCP d/t contraindications (>35y/o smoker, breastfeeding, sickle cell anemia, HTN, SLE, migraine HA, mental retardation), estrogen contraindicated
MOA:
unknown
cervical mucus thickens → cervix less permeable to sperm
endometrial activity is out-of-phase → prevents implantation even if fertilization occurs
does not suppress ovulation
RELATIVE EFFECTIVENESS:
BENEFITS:
ABSOLUTE CONTRAINDICATIONS:
RELATIVE CONTRAINDICATIONS:
ADVERSE EFFECTS:
irregular bleeding
DRUG INTERACTIONS:
RISKS:
PATIENT EDUCATION:
take at same time every day (2-3 hours late can reduce effectiveness for 48 hours)
COST:
What are the types of emergency contraception?
contraception to prevent unwanted pregnancy if:
1. unprotected intercourse
2. error in contraceptive use
3. sexual assault
types include:
1. Preven – estrogen and progesterone combination, delays or inhibits ovulation or disrupts corpus luteum, 100g ethinyl estradiol and 500-600g levonorgestrel, take 1st dose within 3 days, take 2nd dose 12 hours later, side effects include nausea (50%) and vomiting (20%), take meclizine (antiemetic) 1 hour before 1st dose
2. Plan B – progestin only, thickens cervical mucus which inhibits sperm survival and passage through uterus, inhibits GnRH which inhibits FSH/LH secretion which inhibitions ovulation, inhibits implantation, 750g levonorgestrel, take 1st dose within 3-5 days, take 2nd dose 12 hours later (may also take single dose of 1500g), nausea and vomiting less severe than in Preven
3. Copper IUD – no hormone, interferes with sperm function or inhibits implantation, insert within 7 days, effective for 10 years
Describe ACHES in regards to oral contraceptive use?
A → abdominal pain → blood clot in liver or pelvis, gallbladder or benign liver tumor
C → chest pain → angina, MI, PE
H → headache → migraine with focal neurologic symptoms, HTN, CVA
E → eye problems → vision changes, CVA
S → severe leg pain → DVT

Contact provider immediately if experience any of these symptoms!
What is the appropriate history and physical exam for prescribing oral contraceptive pills?
MENSTRUAL HISTORY:
age of menarche
LMP
duration of menses
length and regularity of menstrual cycle
occurence of spotting and breakthrough bleeding

CONTRACEPTIVE HISTORY:
type
response
adverse effects
compliance

RISK FACTORS:
smoking
clotting disorder
HTN
DM
migraine HAs
MI
CVA
VTE
liver disease
cholestasis
breast cancer
surgery with immobilization within 1 month

PHYSICAL EXAM:
BP
breast exam
pelvic exam - abnormal vaginal bleeding
PAP smear
What is the MOA of progestins?
thickens cervical mucus → preventing migration of sperm

inhibits GnRH secretion → inhibiting FSH/LH secretion → preventing ovulation

thins endometrium → preventing implantation
DEPO PREVERA:
DEPO PREVERA: injection, depot medroxyprogesterone acetate (DMPA) 150mg IM (deltoid or gluteus maximus) every 3 months (effective for 4 months)
BENEFITS: ↓ risk of ectopic pregnancy, endometrial cancer; ↓ sickle cell crisis, seizures; improved symptoms associated with endometriosis; no ↑ risk for arterial or venous disease
RISKS: ↓ bone mineral density (encourage adequate calcium intake), irregular bleeding or prolonged menstrual flow during 1st 6 months, amenorrhea after 1st year, +/- weight gain, return to baseline fertility requires 10 months after stopping injections
WHEN TO PRESCRIBE: want intermediate or long-term contraception, need to avoid estrogen, not intending to become pregnant in near future, breast feeding >6 weeks postpartum, menstrual bleeding is problem or nuisance, sickle cell disease or seizures, prefers injections, prefers contraceptive use to be unknown to partner
If patient has secondary amenorrhea + negative pregnancy test, what is the treatment to stimulate withdrawal bleeding?
trial of progesterone
medroxyprogesterone acetate10 mg PO daily x 10–13 days per month (or every other month)
What are risks of UTI in women?
young or >65 y/o
sexually active
use of diaphragm or spermicide cream
List sulfonamides used to treat UTIs.
sulfamethoxazole
trimethoprim
Sulfamethoxazole + Trimethoprim (Bactrim): MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:
inhibits folate synthesis

INDICATIONS:
UTIs
acute otitis media in children
acute exacerbations of chronic bronchitis in adults due to H. flu or S. pneumo
prophylaxis and treatment of pneumocystic jiroveci pneumonitis (PCP)
traveler's diarrhea due to entertoxigenic E. coli
enteritis due to Shigella flexneri or Shigella sonnei

CONTRAINDICATIONS:
hypersensitivitiy to any sulfa drug
infants <2 m/o
pregnancy
breast feeding
megaloblastic anemia due to folate deficiency
severe hepatic or renal disease

ADVERSE EFFECTS:
rash, urticaria
nausea, vomiting, anorexia

DOSING PARAMETERS FOR UTI:
1 double-strength tablet PO q12 hours
x 3-5 days if uncomplicated
x 7-10 days if complicated
x 14 days if pyelonephritis
x 2 weeks if acute prostatitis
x 2-3 months if chronic prostatitis

PATIENT EDUCATION:
take with 8oz of water
wear sunscreen and avoid prolonged sun exposure to prevent photosensitivity
Lexi-Comp p1407
List quinolones used to treat UTIs.
ciprofloxacin
norfloxacin
List cephalosporins used to treat UTIs.
cephalexin
List penicillins used to treat UTIs.
procaine penicillin G
ampicillin
amoxicillin + clavulanic acid (Augmentin)
Ciprofloxacin: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:
inhibits bacterial DNA synthesis and reproduction

INDICATIONS:
systemic infections

CONTRAINDICATIONS:

ADVERSE EFFECTS:

DOSING PARAMETERS:

PATIENT EDUCATION:
Norfloxacin: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:
inhibits bacterial DNA synthesis and reproduction

INDICATIONS:
effective against gram-neg and gram pos in treating:
uncomplicated UTIs
complicated UTIs
prostatitis

CONTRAINDICATIONS:

ADVERSE EFFECTS:

DOSING PARAMETERS:

PATIENT EDUCATION:
Leuprolide: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:
agonist of luteinizing hormone-releasing hormone → inhibiting gonadotropin secretion → decreasing testosterone

INDICATIONS:
palliative treatment of advanced prostate cancer
endometriosis
anemia caused by uterine fibroids
central precocious puberty

CONTRAINDICATIONS:
hypersensitivity
abonormal vaginal bleeding
pregnancy
breast feeding

ADVERSE EFFECTS:
altered mood, depression, memory
HA, weakness, pain, depression, insomnia, fatigue, dizziness, vertigo
skin reaction
edema
nausea, vomiting, weight change
hot flashes, testicular atrophy, hyperlipidemia, decreased libido
vaginitis, urinary disorder
flu-like syndrome

DOSING PARAMETERS:

PATIENT EDUCATION:
if treating for prostate cancer, initial rise in serum testosterone may cause worsening of symptoms
When should a 3 day regimen vs a 7 day regimen be used for acute uncomplicated UTI?
3 day regimen if:
uncomplicated cystitis

7 day regimen if cystits +
diphragm use
>65 y/o
DM
symptoms >7 days
recurrent infection
What is the clinical use of pyridium in acute UTI?
symptomatic relief of urinary itching, burning, urgency, or frequency
Nitrofurantoin: MOA, indications, contraindications,
adverse effects, dosing, patient education
MOA:
inhibits several bacterial enzymes → interfering with metabolism and cell wall synthesis

INDICATIONS:
prevention and treatment of UTI caused by E. coli, klebsiella, enterobacter, S. aureus, enterococcus

CONTRAINDICATIONS:
hypersensitivity
pregnancy at term
breastfeeding
renal impairment

DOSING:
7 day regimen

PATIENT EDUCATION:
take with food
requires monitoring of LFTs
if for prophylaxis, take at bedtime
Discuss the use of nitrofurantoin in the use of UTIs.
rarely used due to narrow-spectrum and toxicity
useful against E. coli and gram-pos cocci
other organisms may be resistant
causes GI upset, acute pneumonitis, neurologic problems
What are the adverse effects of nitrofurantoin?
GI disturbances
acute pneumonitis
neurologic problems
What does HCG stand for?
human chorionic gonadotropin
What are the indications for ordering an HCG?
HCGP → pregnancy confirmation, suspected ectopic pregnancy, suspected miscarriage

BHCG → suspected trophoblastic disease or germ cell tumors of ovaries or testes
What is an HCG test?
tumor marker
measures human chorionic gonadotropin in blood
normally undetectable
produced by placenta to maintain function of corpeus luteum
also produced by some germ cell tumors
Compare and contrast types of vaginal discharge.