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307 Cards in this Set
- Front
- Back
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Stages of Adolescence
Early? Middle? Late? |
Early: age 11-14 elementary and middle school
Middle: age 15-17 high school Late: age 17-21 college or employed |
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what percentage of teens and what percentage of women are sexually active, fertile and do not want to be pregnant?
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4 of 10 teens
2 out of 3 women |
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HEADSS Is Very Good
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Home
Education Activities Drugs Sexuality Suicide Internet Violence Gangs |
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what additional medical history must you take for a woman health's h&p?
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menstrual history
obstetric history gynecologic history contraceptive history sexual history |
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what are indications for a pelvic exam?
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pelvic pain/mass
severe dysmenorrhea amenorrhea pregnancy unexplained vaginal bleeding reported sexual activity assault trauma STI |
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what percentage of women do not use contraception?
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7.5% of women do not use contraception
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FNP counseling for adolescents
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-info on normal sexual development
-abstinence -safe sex -S&S of STIs -contraception options -high risk situations (alcohol, drugs, sex) |
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Healthy People 2010 Leading Health Indicators
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-physical activity
-overweight -tobacco use -substance abuse -responsible sexual behavior -mental health -injury and violence -environmental health -immunizations -access to care |
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what percentage of couple were using some form of contraception during the month they conceived?
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53% of couples were using some form of contraception during the month they conceived
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what is dysmenorrhea?
primary? secondary? |
Dysmenorrhea: pain with mensturation; cramping centered in lower abdomen
primary: menstrual pain without pathology secondary: menstrual pain with pathology |
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what are some common chief complaints in women's health?
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Routine visit (well woman exam for reproductive and post menopausal women)
OB visit Postpartum 1st exam GYN complaint |
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Dysmenorrhea affects ___% of menstruating women.
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50%
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2 hormones used in combined oral contraception
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estrogen (ethinyl estradiol)
Progestrin |
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when does pain begin and end with primary and secondary dysmenorrhea?
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Primary: begins a few hours prior to or just after the onset of menses and lasts 48-72 hrs
Secondary: begins 1-2 weeks prior to menses and persists until after menses stops |
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what are common GYN disorders?
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Vaginitis
STIs/PID Infertility Endometriosis Ovarian cysts Bladder problems Uterine structural abnormalities Abnormal Pap smears |
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what are symptoms of Primary dysmenorrhea?
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-pain (usually colicky)
-suprapubic cramping (labor like) -mild suprapubic tenderness -N/V/D -headache -syncopal episodes (rare) -normal VS and Normal pelvix exam -systemic symptoms from prostaglandin to release -mild uterine tenderness on exam during menses |
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what is the mechanism of action of combined oral contraception?
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--Suppress FSH (no LH surge)
--Thicken cervical mucus (inhibit sperm transport) --Atrophic endometrium (zygote unable to implant on endometrium) |
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How do you confirm diagnosis of primary dysmenorrhea?
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Rule out pathology!
-normal pelvic exam and normal VS -not pregnant -no acute/chronic abdominal pain -no chronic pelvic disorders (non-cyclic, adhesions, salpingo-oophoritis, cancer) -no GI, GU, neuro problems |
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what is "catamania"?
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13 x 28-30 x4
age onset menarche (13) menstrual interval (28-30) duration of flow (4) |
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Treatment for primary dysmenorrhea?
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Prostaglandin inhibitors
-ponstel (mefennamic acid) 500mg stat, 250mg q6 -ibuprofen 400mg q4-6, start 4 days prior to menses -Naproxen sodium 550mg stat, 275mg q 8 (take prior to or onset of pain)- 80% effective -NSAIDs for 4-6 mo. Change after 2-4 cycles if no relief. -OCPs- 90% have some relief -if nothing helps, refer! |
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what is estradiol?
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a highly potent estrogen
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Patient education for pts with primary dysmenorrhea.
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-medication compliance
-exercise- esp when pain is worst -heading pads/warm baths -relaxation -good diet -follow-up |
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Questions when obtaining a menstrual history
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LMP
Catamania Menstrual calender Flow Menopause |
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What is secondary dysmenorrhea?
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menstrual pain with pathology
-imperforate hymen -transverse vaginal septum -cervical stenosis -uterine anomalies -endometrial polyps -adenomyosis -uterine leiomyomas (fibroids) -endometriosis -IUD -chronic ectopic, chronic functional cyst -GI, GU, Neuro, GYN- adhesions, infection |
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what is ethinyl?
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allows estrogen to survive GI environment
(stimulates renin-angiotensin system contributing to high BP in some women) |
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what is endometriosis?
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presence of endometrial tissue outside of uterus
-often includes glands and stroma -most frequent sites are pelvic viscera and peritoneum -extra pelvic sites are intestines (colon and rectum), ureteral, lungs, umbilicus |
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Definition of Perimenopause
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PERIMENOPAUSE: the phase prior to the onset of menopause, during which the woman with regular menses changes, perhaps abruptly, to a pattern of irregular cycles and increased period of amenorrhea.
*cycle length changes/missed cycles *flow changes *vasomotor symptoms (hot flashes) *decreased vaginal lubrication |
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what is the etiology of endometriosis?
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-estrogen
-ectopic transplantation of endometrial tissue (retrograde menses) -immune system factors -genetic (7x greater risk if mother/sister effected; 75% incidence in homozygotic twins) |
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what is mestranol?
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converts to estrogen in the liver
used in Europe |
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associated symptoms of endometriosis
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dysmenorrhea
pelvic pain infertility dyspareunia abdominal back pain GI and Gu problems |
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GYN term: Menorrhagia
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heavy bleeding lasting longer than normal
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how do you diagnose endometriosis?
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laparoscopy
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There is a variety of progestin options. what is the advantage of several different options?
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There are 2 families of progestin-- Estrane and Gonane.
If a patient has a problem with a pill in 1 family, you can switch to another family. |
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Management of endometriosis
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-surgery (laser ablation, hysterectomy with oophrectomy)
-continuous OCPs -depo provera for pain management -GNRh agonists (lupron) -danazol |
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questions for postmenopausal women
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age at menopause
HRT use alternative therapies |
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STD history
5 P's |
partners
prevention of pregnancy protection from STDs sexual practices past history of STDs |
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what is the novel progestin?
who is the target market? |
A new progestin.
Drospirenone= Spironalactone derivatitve (diuretic)-- YAZ --lowers androgen levels Target market: - PCOS - Androgen excess (hirsutism, acne) -Improves premenstrual symptoms |
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Cardinal rule: a woman of reproductive age with a complaint of abdominal/pelvic pain has an ____ _____ until proven otherwise
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ectopic pregnancy
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GYN term: Metrorrhagia
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bleeding at irregular intervals; between expected menstrual periods
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STD workup
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DNA probe
cultures rpr hiv hbsag wet mount |
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what is the advantage of having a shortened placebo? such as Yaz which has a 4 day placebo
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--less premenstrual symptoms
--decreased likelihood of ovulation |
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clinical manifestations of chlamydia
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-cervicitis
-pharyngitis -bartholinitis -proctitis -endometritis -urethritis |
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GYN term: Menometrorrhagia
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excessive bleeding; at usual time and in between periods as well
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serious sequelae of chlamydia
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PID
ectopic pregnancy infertility |
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What is seasonale?
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-new COC
-84 active pills/ 7 day placebo -a period once a quarter (good choice for pts with anemia and menstrual migraines) |
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risk factors of chlamydia
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young age (15 – 21 highest prevalence)
multiple sex partners non-white race low Socioeconomic status cervical eversion OCP’s New partner Unprotected sex |
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GYN term: Oligomenorrhea
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reduced bleeding frequency interval > 40 days but < 6 months
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signs and symptoms of chlamydia
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-asymptomatic
-abnormal vag discharge -postcoital or intermenstrual spotting/bleeding -dysuria, frequency -dyspareunia -pelvic/abdominal pain -usually normal, elevated temp -abdomen usually normal, RUQ pain -cervix may be friable w/ mucopurulent discharge -fundus may be tender if endometritis present -adnexae may be tender; mass may be present |
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what is lybrel?
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-new COC
-No placebos-- no periods |
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diagnosis of chlamydia
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DNA probe gold standard
NAATs- nucleic acid amplified test |
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OB/GYN term: Nulligravida
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never pregnant or never pregnant past 14 weeks (gestational age of abortion)
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treatment of chlamydia
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azithromycin 1gm po x1 dose or
doxycycline 100mg po bid x7d alternatives: erythromycin, ofloxacin, or levofloxacin x7 days |
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what is the advantage of the new quadriphasic OCP?
and disadvantage? |
-questionably less break-through bleeding
-good for pts with prolonged or heavy menstrual bleeding -very complicated instructions of what to do if a pill is missed |
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Test of cure of chlamydia is not indicated except for ____.
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pregnancy, test of cure in 3-4 weeks after completing therapy
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OB/GYN term: Gravida
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Is/has been pregnant
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how do you manage partners of a patient with chlamydia?
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-partners must be evaluated, tested, and treated
-all partners with sexual contact 60 days prior to onset of symptoms -most recent partner should be evaluated even if >60 days |
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Describe the "Conventional Start" and "quick start" methods of starting a birth control pill?
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Conventional Start
--start on the 1st day of menses --or 1st sunday of start of menses --ensures pt is not pregnant --aligns the pills with correct days of the week --**no back up contraception needed Quick Start --start right away (hormones is not harmful to fetus if woman is pregnant) **both methods have similar rates of effectiveness and side effects-- provider and patient can choose |
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what is the recommended treatment of chlamydia in pregnant patients?
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azithromycin 1gm po x1 dose or
amoxicillin 500mg po tid x 7d alternates: erythromycin |
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OB/GYN term: Primigravida
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Is/has experienced first pregnancy
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sites of gonorrhea infection
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-endocervix-primary site for women
-urethra-primary site for men; usual site in women with hysterectomy -skene's and bartholin's -rectum -pharynx |
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What are other Combined NON-ORAL contraceptives?
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patch
ring |
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gonorrhea sequelae
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PID-15 to 20%
infertility ectopic pregnancy disseminated gonococcal infection |
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OB/GYN term: Multigravida
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has been pregnant more than once
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symptoms of gonorrhea
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-asymptomatic- women may not have symptoms until PID
-vulvar pruritus, irritation, labial edema -abnormal vag discharge -abnormal vag bleeding -dysuria, urgency/frequency, dyspareunia, dysmenorrhea -males have drippy discharge- purulent creamy -painful to urinate |
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How often do you change the patch?
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new patch every 7 days for 3 weeks
1 week is patch free |
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signs of gonorrhea
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-temp may be elevated
-pharyngeal injection, cerivcal node -volar aspects of arms, hands, fingers -joint tenderness, swelling, erythema, effusion -abdomen wnl; tender if PID -external genitalia-erythema, edema, excoriation -vagina abnl discharge, blood, pus -cervix-purulent, mucopurulent discharge; friable -uterus tender if PID -adnexa- tender, mass if PID |
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OB/GYN term: Primipara
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delivered one pregnancy > 14 weeks
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how do you diagnose gonorrhea?
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nucleic acid amplifed tests- dna
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Where can you place the patch?
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upper/outer arm, torso, abdomen, buttocks
(not breast) |
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treatment of uncomplicated gonorrhea of cervix, urethra, rectum
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cephalosporins only!
ceftriaxone 125mg IM x1 dose or Cefixime 400mg PO x1 dose PLUS txt for chlamydia if not ruled out altenatives: spentinomycin 2gm IM x1 dose (only UK) or cephalosporin single dose |
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OB/GYN term: Multipara
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delivered > 1 pregnancy > 14 weeks
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how do you manage sexual partners of your pt with gonorrhea?
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treat sex partners with sexual contact 60 days prior to onset of symptoms (treat both chlamydia and gonorrhea)
-most recent sexual partner should be treated even if sexual contact is >60 days |
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What is advantage of the patch compared to COCs?
disadvantage? |
-less break through bleeding
--higher failure rates documented for women weighing more than 198 lbs |
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how do you treat gonorrhea in pregnant women?
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NO quinolones or tetracyclines!
use recommended or alt. ceftriaxone 125mg IM x1 dose or Cefixime 400mg PO x1 dose PLUS txt for chlamydia if not ruled out |
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OB/GYN term: Grand multipara
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delivered > 6 pregnancies
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what are STDs characterized by lesions?
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ULCERS
-genital herpes (most prevalent) -syphilis -chancroid all 3 are associated with increased risk for HIV Warts -HPV (condyloma) |
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How do you use the vaginal ring?
when do you use back up contraception? |
-Insert ring
-Leave in place of 3 weeks, then remove for 1 week. -Back up contraception is required 1st 7 days or if ring is expelled/removed for > 3 hours |
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diagnosis of STD lesions
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diagnosis based only on HPI, PMH, and PE is often inaccurate
serology testing should be done on all pts with lesions |
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OB/GYN term: Parturient
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currently in labor
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what are specific tests for evaluation of genital ulcers?
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-darkfield examination or direct immunofluorescence test for treponema pallidum
-culture or antigen test for HSV -culture for haemophilus ducreyi (where chancroid is prevalent) |
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what are ABSOLUTE contraindications of COCs?
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-pregnancy
-undiagnosed Vag Bleeding -Coagulation disorder (get fm hx) -CVA/CAD -Breast cancer -Liver-- tumor or impaired function -Renal or Adrenal insufficiency (drospirenone- diuretic) |
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1st episode of HSV
incubation period? timeline of healing of lesions? viral shedding? |
incubation 2-10 days
healing of lesions after 1-2 wks completely healed 2-4 wks viral shedding 11-14 days severe systemic symptoms |
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OB/GYN term: Puerpera
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recently given birth- within 6 weeks
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Ulcer stages of genital herpes
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-vesicles or pustules
-crusting -healing -adjacent pustules often coalesce to form areas of ulceration -deep necrotic ulcers |
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What are RELATIVE contraindications of COCs?
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-hx of severe headaches
-HTN (even controlled) -Immobility (surgery, long-leg cast, prolonged flight) - >40 years old with CVD risks ->35 years old smoker - Drospirenone (ACEI's, ARB's, NSAIDs, potassium overload- diuretics or supplementation) |
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symptoms of genital herpes
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-multiple genital lesions
-itching, burning, tingling -dysuria, retention -inguinal adenopathy with tenderness |
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OB/GYN term: embryo
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through 8th week completed gestational week
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Signs of genital herpes
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-fever, extragenital lesion
-pharnyx erythematous, white exudate, cervical lymph nodes enlarged -abdomen tender, enlarged inguinal lymph nodes -females: vaginal outlet tender, lesions in various stages, friable cervix -males: may have ulcers around glans, on shaft, pubic area, scrotum, or perianal |
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what are CONSIDERATIONS when prescribing COCs?
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-lactating, seizure disorder, active gallbladder disease
-BMI >30 -Personal history of (wt gain > 10 lbs on COCs, depression, sickle cell disease, congenital hyperbilirubinemia-- Gilbert's disease) -Family history of DM or MI < 50 years old (esp mother or sister) |
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diagnosis of genital herpes
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clinical presentation
culture tzanck smear serology- glycoprotein g assays (may have false +) -cytology: pap giant, multinucleated cells; not diagnostic |
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OB/GYN term: fetus
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8th completed week until delivery
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Treatment of genital herpes
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-acyclovir 400mg PO TID x7-10 days
-or acyclovir 200mg PO 5x/d x7-10 days -or famciclovir 250mg PO TID x7-10 days -or valcyclovir 1gm PO BID x7-10 days treatment may be extended if healing is not complete |
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what are non-contraceptive advantages of COCs?
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-easy to use, safe, reliable, reversible
-predictable menstrual cycles -decreased cramps and pain -decreased bleeding (good for anemic pts) |
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patient educations to pts with genital herpes
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-nature of disease, potential for recurrence, asymptomatic viral shedding
-abstain from sexual activity when lesions are present or prodromal symptoms present -encourage to inform partners -use condoms with all new sexual contacts -transmission can occur during asmptomatic periods- viral shedding -neonatal infection risk -antiviral therapy can shorten duration of episodes or ameliorate/prevent outbreaks |
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GPTPAL
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G= gravidity= lifetime pregnancies
P= parity= pregnancy completed at/after viability T=term > 37 weeks P=premature < 37 weeks A= abortion < 20 weeks L= living children |
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symptoms of recurrent episodes of HSV
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-prodrome 1-2 days
-painful, localized genital sore(s)- single or cluster -external dysuria -systemic symptoms absent -resolve in 7-10 days |
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what are health benefits of COCs?
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-decreased risk of ovarian and endometrial cancer
-decreased PID and PMS -decreased ectopic pregnancy -decreased fibrocystic changes -improvement in acne |
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treatment for recurrent HSV
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acyclovir 400mg TID x 5 days
or famciclovir or valcyclovir |
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definition of viability
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pregnancy >20 weeks with > 500g fetus
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daily suppressive regimens for HSV
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-Acyclovir 400 mg po bid, or
-Famciclovir 250 mg po bid, or -Valacyclovir 500 mg po qd, or (less effective inpatients with >10 episodes yr) -Valacyclovir 1000 mg po qd *if pt has 10 outbreaks/yr- start thinking about why this pt is immunocompromised |
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what are disadvantages of COCs?
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-cost
-dosing (qd, weekly) -no protection against STDs -drug interactions (decreased efficacy of birth control if taking rifampin) - rare complications (thromboembolism, risk for gall bladder disease, mood changes--esp progestin only) |
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chancroid is often a cofactor for ____ transmission
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HIV
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what are essential delivery information
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Gestational age
place/type of delivery weight, sex, and condition of baby complications during any phase treatments, eg. cerclage |
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20-40% of pts with chancroid have _____
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inguinal lymphadenitis-often unilateral
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When individualizing birth control, what are some considerations?
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-medical history
-personal history -family history -physical exam -personal preference |
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diagnosis of chancroid
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-no commercial tests available
-painful genital ulcer and tender suppurative -negative darkfield exam or RPR, HSV testing of ulcer negative |
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Name the 4 Female Sexual Dysfunction disorder classes according to Masters & Johnson model
what improvements can be made to the M&J model? |
1. Desire disorder
2. Arousal disorder 3. Orgasmic disorder 4. Pain disorder *improvements -integration of biology and psychosocial factors -classified based on where disruption occurs -includes "personal distress" criterion |
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symptoms of chancroid
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-multiple, painful, punched out ulcers with undetermined borders on vulva
-painful ulcer with marked surrounding erythema and edema |
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Patient Education on ACHES
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A-abdominal pain
C-chest pain, SOB H-headache (severe) E- Eye problems (blurry vision, loss of vision) S-Severe leg pain |
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Treatment of chancroid
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-Azithromycin 1 gm po x1 dose or
-Ceftriaxone 250 mg IM in a single dose, or -Ciprofloxacin*500 mg po bid x 3 days, or -Erythromycin base 500 mg po tid x 7d *Ciprofloxacin is contraindicated for pregnant and lactating women and for persons aged < 18 yo |
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Describe the Desire disorder
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-most common disorder 27-32% of FSD
-lack of desire (no thoughts/fantasies) -sexual aversion disorder -symptoms must be persistent and cause distress, if there is no distress then it is not a sexual dysfunction |
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followup for chancroid
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-reexamine pt 3-7 days after treatment
-healing >2 weeks -fluctuant lymphadenopathy may required I&D -treat partner regardless of symptoms if contact within 10 days prior to symptoms |
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what are nuisance side effects of birth control?
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-breast tenderness
-headaches -nausea -break through bleeding -weight gain -amenorrhea |
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how is syphilis transmitted?
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Treponema palladium
-primary: sexually -nonsexual intimate contact -blood transmission |
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Describe the Arousal disorder
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-Problem attaining/maintaining excitement
-must cause personal distress -wide diversity in presentation, e.g. lack of excitement, lack of genital response (no lubrication, no engorgement), other somatic complaints -potential causes: fatigue, time limitations, partner issues, meds |
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what are the stages of syphilis?
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primary
secondary early latent<1 yr late latent >1 yr late/tertiary 1-20 yr after infection, usually CNS involvement |
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what is the mechanism of action of Progestin only contraceptives?
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(same as combined)
-thickens cervical mucosa (inhibits sperm transport) -Atrophic endometrium (inhibit implantation) |
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risk factors for syphilis
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-heterosexual
-young age 15-24 -black race -low socio-economic status -drugs, sex, multiple partners -increasing incidence in homosexuals -unprotected sex |
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Describe the Orgasm disorder
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22-28% of FSD
-delay in or absence of orgasm, despite adequate stimulation/arousal -must cause personal distress -associated factors: physiological- urological neuropathy; psychological- safety concerns |
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signs of primary syphilis
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genital lesion 10-90 days, usually 3 wks
-lesion indurated, painless -inguinal or cervical lymphadenopathy 7-10 days after chancre, nontender, bilateral with genital chancre -no systemic symptoms |
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what are contraindications of Progestin only contraceptives?
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-acute liver disease
-jaundice -unexplained vaginal bleeding -history of functional ovarian cysts -ectopic pregnancy on POPs |
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secondary syphilis
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-onset 3-6wks to 6 mo after primary
-may overlap with primary -may be asymptomatic -flu-like symptoms in 50% -maculopapular rash 80%- trunk, extremities, palms, soles, pruritic -condyloma lata- large, raise, broad papules, resemble warts, vulva perineum anus -split papule- eroded, fissured papules-nasolabila folds, angles of mouth, behind ears -mucosal lesions -alopecia- patchy on scalp, eyebrows, lashes -lymphadenopathy- rubbery, nontender, mod enlarged -systemic symptoms, CNS involvement |
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Describe Sexual Pain disorder
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8-21% of FSD
-Dsypareunia -Vaginismus -Vulvodynia |
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Latent syphilis
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late benign syphilis
-cardiovascular syphilis -CAD |
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what are the benefits of taking Progestin only contraceptives?
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-good for women who cannot take estrogen
-fewer side effects than COCs (less risk for ACHES) -expanded population-- lactating mothers, DM, HTN, or older women |
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Late syphilis
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-neurosyphilis
occurs 2-35 yrs after infection -rare -reactive VDRL from CSF -3 types -meningiovascular 2-10 yrs -tabes dorsalis 5-30 yrs -general paresis 15-30 yrs |
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Define Dyspareunia
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recurrent/persistent pain before, during or after intercourse not caused exclusively by lack of lubrication or vagnisumus
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Diagnosis of syphilis
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-Presumptive Diagnosis: VDRL or RPR, Fluorescent Treponema Antibody-Absorbed (FTA-ABS), Microhemaglutination-T. pallidum (MHA-TP)
-Definitive Diagnosis: Early syphilis - Darkfield exam; direct fluorescent antibody test -Rule out HIV and other STD’s |
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What are disadvantages of taking Progestin only contraceptives?
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-QD at the same time
-irregular menses -more break through bleeding -increase in functional ovarian cysts -reduce HDL -possible increase in fibrocystic changes - |
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What are causes of a false positive RPR or VDRL?
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-mononucleosis
-leprosy, malaria -lupus, other autoimmune diseases -viral pneumonia, viral infections -immunizations |
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Define Vaginismus
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Involuntary spasm of outer 1/3 of vagina interfering with or preventing penetration
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What is the treatment for primary and secondary Syphilis?
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-Benzathine pencillin G
allergy to PCN? doxycyline 100mg PO BID x2 weeks or tetracycline 500mg PO QID x 2weeks |
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Depo Provera
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Progestin
Intramuscular injection q 12 weeks 150mg IM Subcutaneous injection q 12 weeks 104mg Sq |
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what are complications of syphilis in pregnancy?
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fetal hepatomegaly, stillborn
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Define Vulvodynia
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vulvar pain, burning or discomfort interfering with quality of life (not associated with intercourse)
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what is the follow-up plan for pts with syphilis?
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in pregnancy, monthly quantitative titers
for all others, quantitative nontreponemal tests at 6 and 12 months, titers should drop 4 fold within 6 months If HIV+, follow-up is every 3 months |
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What are benefits of dep provera?
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-eventual amenorrhea --80% (good for anemia)
-effective -Q 12 weeks dosing -invisible -drug choice for seizure d.o pts -good for lactating mothers -good for women who cannot remember to take a pill QD |
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How do you manage partners of pts with syphilis?
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-If exposed within 90 days before diagnosis of primary, secondary, or early latent--> treat presumptively even if seronegative
-If exposed >90 days before diagnosis of primary, secondary, or early latent--> treat presumptively if serology not available or poor f/u -long term partners of patients who have late syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of findings. |
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Etiology for FSD
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-marital discord
-comorbid medical & psychiatric conditions (diabetes, hypertension, anxiety, depression) |
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Granuloma Inguinale
Donovanosis |
-Organism: Klebsiella granulomatis (formerly: Calymmatobacterium granulomatis) -
-Intracellular Gram-negative bacterium. -Incubation: 1-4 weeks (up to 6 months) -Rare in the USA: Approx 100 cases per year -Endemic in tropical and sub-tropical areas, central and northern Australia, southern India, Viet-Nam, Guyana, & New Guinea |
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What are disadvantages of depo provera?
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-irregular bleeding prior to amenorrhea
-prolonged return to fertility (avg return is 10 months) -weight gain (16 lbs, less with 104mg dose Sq) -depression -low bone density (osteopenia)- less with 104mg Sq) - education-- supplement with calcium 1200mg, VIT D 400 IU, weight bearing exercise q 30 min qd |
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how does a patient with Donovanosis present?
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-Painless, progressive, ulcerative lesion
-Lesions are highly vascular -Beefy red appearance> bleed easily on contact |
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Compartment IV Amenorrhea
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Disorders of the CNS (hypothalamus)
-hypothalamic amenorrhea -weight loss, anorexia, bulimia -exercise -post pill amenorrhea -kallman's syndrome (genetic d.o-failure of olfactory axons and GnRH neruons to migrate from the nose to the hypothalamus) |
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how do you diagnose donovanosis?
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Darkfield examination for donovan bodies (intracytoplasmic rod shaped organisms)
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what is implanon?
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-a single rod implant that contains progesterone
-contraception for 3 yrs -1st 1-2 yrs (higher concentration): suppress ovulation; normal follicular activity- estrogen is stable -less concern of bone mass density -Year 2 &3 (lower concentration): thickens cervical mucus inhibiting sperm transport; few or no ovulatory cycles |
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what is the treatment for donovanosis?
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Doxycycline 100mg BID x 3 weeks
alternatives: azithromycin, ciproflocacin, erythromycin, or Trimethoprim-sulfamethoxaloe |
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Compartment III Amenorrhea
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Disorders of the pituitary
-Empty Sella Syndrome: subarachnoid tissue separates pituitary gland from hypothalamus -Sheehan Syndrome: acute necrosis of pituitary gland due to PP hemorrhage; s/s failure of lactation and loss of pubic and axillary hair-can be life threatening -Pituitary Adenomas |
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how do you manage partners of pts with donovanosis?
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Treat partners within 60 days before onset of patient symptoms
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how does emergency contraception work?
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-interrupts hormone feedback loop
-prevent ovulation -prevent fertilization -prevent implantation (not an abortifacient) |
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Lymphogranuloma Venerium
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-ORGANISM: Chlamydia trachomatis serovars L1, L2, or L3
-INCUBATION: 3 – 30 days for a primary lesion -Rare in the USA: prevalent in tropical and semi-tropical climates. -Endemic in parts of Asia and Africa. -Recent increased incidence in Men Who Have Sex With Men (MSM) |
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Compartment II Amenorrhea
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Disorders of the ovary
-Turners syndrome (45, X) -Mosaicism- watch for Y Chromosome -XY gonadal dysgenesis -Gonadal agenesis -Resistant ovary syndrome -premature ovarian failure -radiation and chemotherapy |
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How does a patient with lymphogranuloma Venerium (LGV) present?
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-Unilateral tender inguinal and/ or femoral lymphadenopathy.
-Self limiting genital ulcer or papule at site of innoculation -Rectal exposure may result in proctocolitis |
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what are the 2 methods of emergency contraception?
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- EC pills
- IUD (paraguard-copper) take within 72 hrs of unprotected sex |
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what is the treatment for LGV?
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-Doxycycline 100mg PO BID x21 days
-alternative: erythromycin for pregnancy |
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Compartment I Amenorrhea
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Disorders of the outflow tract or uterus
-Ashermans syndrome -Mullerian anomalies -Mullerian Agenesis -Androgen Insensitivty (testicular feminization) |
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what is the management of partners of pts with LGV?
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treat all partners within 60 days before onset of symptoms..
also test for urethral or cervical chlamydia infection-- if infected, treat with azithromycin or doxycycline |
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what are side effects of of ECPs?
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nausea (COC due to high estrogen levels)
headaches |
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Human Papillomavirus (HPV)
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-ORGANISM – Over 100 types idenitfied, more than 30 types of HPV can infect the genital tract
-Most common types causing genital lesions are 6 and 11 -High Risk Types: 16, 18, 31, 33, 35 associated with cervical dysplasia |
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Define: Primary and Secondary Amenorrhea
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Primary
-no period by age 14 in the absence of secondary characteristics -no period by age 16 Secondary -absence of periods to total of 3 of the previous cycle intervals, or 6 months (in a previously menstruating woman) |
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how do you diagnose HPV?
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-Clinical appearance, response to treatment
-Biopsy - rarely needed -DNA typing (not routine), but becoming more common (standard of care for cervical dysplasia) |
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what are the 2 available IUDs?
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Mirena- progestin
Paragard-copper IUD |
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which HPV strains are most common, causes genital lesions, and are associated with genital squamous intraepithelial cancer?
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HPV type 6 and 11
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Basic Principle:
Visible bleeding = ? |
Visible bleeding= intact outflow tract and mature endometrium
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what is the patient applied treatment for Genital Warts?
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-Podofilox 0.5% solution or gel (BID x 3 days then 4 days off. May repeat up to 4 cycles)
OR -Imiquimod 5% cream (Once daily at bedtime for up to 16 weeks. Wash area with soap and water 6 – 10 hours after application) -The safety of Podofilox and Imiquimod has not been established in pregnancy. |
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what is the mechanism of action of IUDs
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-spermicidal
-suppress endometrium -create inflammatory process |
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with is the provider applied treatment for Genital Warts?
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-Cryotherapy
-Podophyllin resin -Surgical removal -Laser or Electrocautery (surgical plume may contain viral particles) |
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what are therapeutic options for annovulation?
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cycle regularly with progesterone
OCP's |
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how do you educate pts who have genital warts?
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Use condoms- it will decrease risk of exposure but does not eliminate risk of transmission
Pt may remain infectious even though there are no visible warts. All women should have routine cervical screening. |
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what are benefits of the LNG- IUS (Mirena)?
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-cost effective
-long acting 5 yrs -not coitus dependent and does not required adjustments in daily activities such as remembering to take a pill QD -no weight gain -good for women with abnormal bleeding not desiring hysterectomy or endometrial ablation -20% experience amennorhea 1st yr -90% report decreased bleeding |
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Vaccine for HPV
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-Gardasil (protection against HPV type 6,11,16, 18)
-recommended for females age 9-26 -recommended prior to start of sexual activity -does not eliminate HPV infection once acquired |
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Work up to rule out anovulation
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Labs: TSH, Prolactin levels
Progesterone challenge- if a developed endometrium is present, progesterone x5-10 days should cause bleeding within 14 days of stopping hormone + withdrawal suggests anovulation with progesterone deficiency -withdrawal- perform estrogen progesterone challenge test |
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what are common causes of Vaginitis?
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-Vulvovaginal candidiasis
-Bacterial vaginosis -Trichomoniasis -Dual infections -Vaginal Atrophy |
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what are the benefits of Paragard IUD (copper)?
disadvantages? |
-long term use 10-12 yrs
-no hormones -cost effective -emergency contraception option *causes an increased bleeding |
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what are other less common infectious causes of vaginitis?
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-Streptococcoal infections
-Cytolytic vaginosis/vaginal lactobacillosis -Recurrent herpes simplex -Genital warts -Cervicitis |
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What is the estrogen progesterone challenge test?
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It is indicated if a patient fails to bleed after progesterone challenge test.
+withdrawal bleed outflow tract normal, endometrium responsive probably ovarian failure -withdrawal bleed end organ problem ectopic production of prolactin (rare) outflow obstruction |
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what are noninfectious causes of vaginitis?
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-Contact dermatitis
-Erosive lichen planus -Diabetic vulvodynia -Lichen sclerosis -Vulvar hyperplasia -Other dermatologic conditions -Carcinoma |
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what are CONTRAINDICATIONS of all IUDs?
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-active or recent PID, GC, or chlamydia
-multiple sex partners -prior ectopic pregnancy -known or suspected pregnancy |
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Factors that influence physiolgic discharge?
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-AGE (prepubertal, reproductive, post-menopausal)
-HORMONES (the pill, cyclical hormonal changes, pregnany) -LOCAL FACTORS (menstruation, post partum, malignancy, semen, personal habits and hygiene) |
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What labs do you draw to assess ovarian function?
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FSH, LH
high values suggest ovarian failure if under 30: chromosome evaluation if over 30: assume menopause If normal or low values: pituitary or CNS failure (by exclusion) |
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what are questions to ask women who complain of vaginal discharge?
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DISCHARGE (onset, duration, amount, color, blood staining, consistency, odor, previous episodes)
ASSOC. SYMPTOMS (itching, soreness, dysuria, intermenstrual or post-coital bleeding, lower abdominal pain, pelvic pain, dyspareunia--superficial or deep) |
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what are STRONG RELATIVE contraindications of all IUDs?
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-PID risk factors
-known or suspected uterine/cervical cancer -unresolved abnormal Pap - history of ectopic pregnancy -inability to check iud string -inability to monitor danger signs of PID |
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what does the physical exam of a patient c/o vaginal discharge include?
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Complete pelvic exam
-determine source of discharge -check for foreign bodies -evaluation of discharge -wet mount prep Saline: clue cells, WBC, and Trich KOH: yeast Amine (whiff) test: BV, Trich |
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What labs do you draw to r/o pituitary tumor?
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Serum prolacin
NL<20, abnormal >100 |
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what is vulvovaginal candidiasis (VVC)?
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-A fungal infection
-caused by Candida albicans, but can be caused by other yeast forms -75% of all women report at least 1 episode of VVC, and 40-45% will have 2 or more occurrences -About 10% of women will have recurrent/complicated VVC |
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what are RELATIVE contraindications of all IUDs?
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-nulliparous
-valvular heart disease -infertility and desire for future pregnancy -submucosal fibroids -Bicornate uterus - Anemia (with Paraguard-copper d/t increased bleeding) |
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what are precipitating factors of VVC?
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-Immunocompromised
-Diabetics or high sugar intake -Recent antibiotic use -Douching -Diaphragm/cervical cap users -Spermicide users -Chronic conditions or poor diet -Pregnancy |
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Management of a pituitary tumor
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Conservative management with annual f/u with prolactin levels and scans
Microadenomas- may not treat Large or rapidly growing tumors -surgery -dopamine agonists (Bromocriptine-Parlodel- inhibits prolactin secretion |
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how does a patient with VVC present clinically?
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-Pruritus and erythema in vulvovaginal area
-White discharge, may be “cheesy” or “curd like” in consistency |
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Name types of barrier contraceptions?
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condoms
diaphragms cervical caps vaginal sponges |
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How do you diagnose VVC?
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-ph is <4.5 (normal)
-10% KOH prep will show peudohyphae, yeast spores -Can culture for a yeast species, if recurrent |
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What is Kallman's Syndrome (Amenorrhea and Anosmia)?
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Compartment IV: CNS
Failure of olfactory axons and GnRH neurons to migrate from the nose to the hypothalamus- genetic d.o. |
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what are Intra-vaginal treatments for VVC?
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-Miconazole
-Butaconazole -Clotrimazole -Terconazole |
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How do you use a diaphragm?
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-fit over cervical opening (prevent sperm from entering uterus)
-must be fitted -used with spermicidal cream/jelly -leave in place for at least 6 hrs after intercourse (not more than 24 hrs) |
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what is the oral treatment for VVC?
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Fluconazole (Diflucan) 150mg PO x1 dose
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what is the treatment of Kallman's Syndrome?
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Hormone Replacement therapy, indicated for bone (osteoporosis) and CV disease prevention
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what are other helpful treatments for VVC?
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-2% hydrocortisone cream for pruritus
-Acijel or "boric acid" suppositories |
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what are benefits of the Barrier contraceptions?
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-possible STD protection
- low cost - non-systemic (unless latex allergy) - diaphragm and spermicide protective against STIs -male condoms decrease ejaculation -readily available (diaphragm and caps need prescription) |
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what is Bacterial Vaginosis?
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-Caused by replacement of normal vaginal flora with anaerobic micoorganisms
-Characterized by vaginal discharge, vulvar itching and irritation, and vaginal odor -Most frequent causes: Gardnerella vaginalis and Mycoplasma |
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what is the treatment of Pituitary adenomas?
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Surgery
Radiation Dopamine agonist (Bromcriptine-Parlodel), directly mimic's Dopamine's inhibition of Prolactin secretion |
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How do you diagnose BV?
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Requires 3 out of 4:
-Homogenous, white, noninflammatory D/C coating the walls of the vagina -Vaginal pH of >4.5 -Fishy odor (+Whiff/Amine test) -Clue cells on microscopic exam other adjuncts -DNA probe for Gardnerella Vaginalis -Fem Exam card: detect high PH and trimethylamine |
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what are side effects or risks to barrier contraception?
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-toxic shock syndrome (diaphragms and cervical caps)
-UTIs (sponge, cervical caps, diaphragm) -Vaginitis -Messy -decrease spontaneity |
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what is the treatment for BV?
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-Metronidazole (vag or PO)
-Clindamycin cream consider f/u eval in 1 month for high risk pregnancies |
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what is Asherman's syndrome?
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Compartment I: Uterus
an acquired uterine condition, after a rough D&C, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus are fused together |
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Thrichomoniasis
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-Results from infection with Trichomonas vaginalis, a flagellated protozoan
-Incubation 5-10 days, range 1-28 days -3-5 million women infected annually -Comprises 15% of STI clinic visits -Non-sexual transmission rare, but possible |
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what are contraindications for natural family planning contraception?
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-unable to time periods of abstinence
-irregular menses -trouble learning method |
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Symptoms of Trichomoniasis
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-Malodorous yellow vaginal D/C
-Vaginal soreness -Vulvar itching -Dyspareunia, dysuria -10% may have abdominal symptoms -Asymptomatic infection is not uncommon |
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what are mullerian anomalies?
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Compartment I: Uterus
segmented disruptions (imperforate hymen, obliteration of vagina, segmented vagina) |
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Clinical signs of Trichomoniasis?
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-Copious, thin, homgenous pools of yellow or green D/C
-D/C may be frothy, since this is an anaerobe -May be confused with candidiasis or mucopurulent cervicitis -Wiping the cervix clean to see if D/C is oozing from the cervix may be helpful -strawberry cervix -abdominal and bimanual exams show mild lower quadrant discomfort |
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Vasectomy
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-20 min procedure
-small scrotal incision -tubes tied, cauterized or blocked with clips -sperm reabsorbed by the body -50-80% of men develop anti-sperm antibodies (issue if reversal desired) -takes 3 months to clear sperm from reproductive tract -advise pt to have a sperm analysis before stopping other contraceptions |
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Diagnosis of Trichomoniasis
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-pH>4.5
-Positive amine test -Wet prep demonstrates protozoa in only 60% of women -Pear-shaped with undulating flagella -Increased WBCs -recommend cultures if: high risk, negative wet prep but very suspicious, or persistent infection despite treatment -ELISA sensitive but expensive |
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what is Androgen Insensitivity (testicular feminization)?
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Compartment I: Uterus
absent uterus male pseudohemaphrodite XY failure of virilization consider in women with inguinal hernia High gonadal cancer rate-remove gonads after puberty and start hormone replacement therapy |
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what is the treatment for Trichomoniasis?
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Metronidazole 2gm PO x1 dose
treat partner! |
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What is the essure procedure?
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-catheter inserted through cervix into fallopian tube
-spring like coil in tube -over the next 90-120 days, tissue grows in and around spring, causing permanent irreversible blockage of tubes -evaluated with HSG at 3 months |
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what are complications of Trichomoniasis in pregnancy?
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-premature rupture of membranes
-preterm delivery -low birth weight |
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What are the 3 categories of Dysfunctional Uterine Bleeding?
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Estrogen breakthrough
estrogen withdrawal progestin breakthrough |
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what are some causes of recurrent and peristent vaginitis?
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-partner not treated- reinfection/reappearance of trich
-STD of the cervix (GC, chlamydia, syphilis) -atrophic vaginitis -irritant or allergic contact dermatitis |
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at what age does thelarche occur?
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8-13 years old, average 10
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Cardinal rule about abdominal pain
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Any woman of reproductive age who presents with abominal pain has an ectopic pregnancy until proven otherwise
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Of the 3 categories of Dysfunctional Uterine Bleeding, what is the most significant and why?
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Estrogen breakthrough- chronically elevated estrogen levels, no progesterone support, increased endometrial thickness causing irregular shedding.
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what are the statistics of PID?
how many outpatients visits annually? how many hospitalizations annually? |
-Accounts for approximately 2.5 million outpatient visits annually
-Accounts for approximately 200,000 hospitalizations per year. |
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if there is a delayed or absent development of breast by age 13, what should be assessed?
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HPO axis
thyroid function androgen levels |
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Clinical signs of PID
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-lower abdominal pain (can be subtle)
-abnormal uterine bleeding (1/3 of pts) -associated signs: new vaginal discharge, urethritis, proctitis, fever, and chills |
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How do you manage Von Willebrand disease?
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Hormones (OCP's and HRT) for mild
Hysterectomy and endometrial ablation for severe cases |
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Risk factors for PID
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-Age less than 35 years
-Non barrier contraception -New, multiple, or symptomatic partners -Previous episode of PID -Oral contraceptives -African – American ethnicity (higher reported incidence) |
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Normal Variants of Breasts
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-Breast tissue in the "milk line" (associated with cardiac & renal anomaly)
-nipple variations (inverted, bifid, intra-areolar, polythelia, dysplastic divided nipples) -macromastia (consider tumor, pregnancy, excess exogenous hormones), juvenile hypertrophy common |
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Physical examinations findings of a pt with PID
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-Purulent endocervical discharge and / or acute cervical motion tenderness and adnexal tenderness by bimanual examination is highly suggestive of PID
-Rectovaginal examination should reveal the uterine adnexal tenderness |
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Physiological causes of FSD
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neurological disorder
cardiovascular disorder cancer urogenital disorder medications fatigue hormone loss or abnormal |
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what is the CDC minimum criteria for empirical treatment for PID?
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-lower abdominal tenderness
-adnexal tenderness -cervical motion tenderness minor determinants: fever>101, vag d/c, documented STD, elevated ESR, C reactive protein, systemic symptoms, dyspareunia |
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what are treatments for cyclic breast pain?
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-Dietary (decrease caffeine, chocolate, red wine & increased fruits/vegetables)
-supportive bra -relaxation techniques -NSAIDS -Herbals- primrose oil (takes 2-4 mo for effect) -OCP- decrease dose, change brand -Hormonal therapy- tamoxifen, danazol, bromocriptine |
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what is the laboratory tests for PID workup
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-Pregnancy test !!!!!
-Microscopic exam of vaginal discharge (wet mount) -Complete Blood Count (CBC) -Test for Gonorrhea and Chlamydia -Urinalysis -Fecal Occult Blood- r/o diagnoses that cause abd pain -C-reactive protein (optional) |
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Interpersonal causes of FSD
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partner performance or technique
lack of partner relationship quality or conflict lack of privacy |
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Ultrasounds should be reserved for which pts?
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for the acutely ill patient with PID in whom you suspect a pelvic abscess
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what are treatments (non-pharm and pharm) for mastitis?
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non-pharm
-warm compress, increase BF/pumping, start on affected side, adequately drain breast, proper bf positioning, rest, nutrition, fluids Pharm -antibiotics- dicloxacillin or clindamycin -NSAIDS, acetaminophen |
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what are differential diagnoses for PID?
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-Ectopic Pregnancy
-Appendicitis -Hemorrhagic ovarian cyst -Ovarian torsion -Endometriosis -Urinary tract infection -Irritable Bowel Syndrome -Gastroenteritis -Cholecystitis -Nephrolithiasis -Somatization (abuse) |
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Psychological causes of FSD
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depression/anxiety
history of sexual abuse history of physical abuse stress alcohol/substance abuse |
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Treatment for PID (outpatient)
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-Ceftriaxone 250 mg IM in a single dose PLUS
-Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT -Metronidazole 500 mg orally twice a day for 14 days |
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what percentage of women develop Benign breast disease (BDD) typically fibrocystic breast changes?
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+/- 50%
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what other serology testing should be done for women with PID?
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-HIV
-Hep B and C -Syphilis |
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Sociocultural causes of FSD
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inadequate education
religious, personal or family values conflict societal taboos |
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Define rate
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number of events per number of individuals per timer interval
example: 44 events in 10,000 people per year |
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Depending on histology, BBD can increase risk for breast cancer by how much?
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5 fold increase in risk
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Define Relative Risk (ratio)
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-rate of disease in exposed group divided by rate of disease in unexposed group
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what are androgen cautions?
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-the impact on breast cancer and lipids are not clear
-difficult to determine what normal vs low is an individual woman -dosing not well established |
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Define Absolute risk
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-difference between incidence rates in exposed and unexposed groups (risk difference)
-more clinically useful -addresses number of new cases |
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Fibroadenoma
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-hyperplastic or proliferative process in a single terminal ductal unit
-common in teens and 20s -benign -firm, smooth, well-defined, mobile, non-tender mass -1-3cm in size -may resolve, often removed |
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what are the 1998 CIOMS risk levels for RARE and VERY RARE?
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RARE: < or = 10/10,000 per year
VERY RARE: < or = 1/10,000 per year |
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what drugs can cause FSD?
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antidepressants
corticosteroids oral estrogens beta blockers anxiolytics illicit substances |
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Results of HERS I
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-2763 postmenopausal women with CAD (average 67 years), were randomized to receive either 0.625 mg/day of CEE plus 2.5 mg/day of MPA or placebo.
-After 4.1 years of follow-up, there were no significant differences between groups in the primary outcome of CHD events, including nonfatal MI or CHD death. -But there was a significant difference in that the treatment group had more CHD events the 1st year, and fewer in the 3-5 year. |
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Phyllodes Tumor
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-40-50 years old, rare
-develops in stroma -usually benign BUT can be Cancer -may arise from untreated fibroadenoma |
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Results of HERS II
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-a continuation of HERS I to confirm trend to improvements in Cardiovascular profile in treatment group
-2.7 year unblinded, private physician prescribed -results of study: no continuing improvement |
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Primary care role for FSD?
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-screen all women for FSD
-provide reassurance, information and an opportunity to talk -more serious problems may require behavioral psychotherapy -know your local referral resources |
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Results of WHI
CEE/MPA ? |
-study was stopped 2 years early due to excess risk
- high risk for VTE: hazard ratio 111%, 18 more cases |
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Sclerosing adenosis
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-30+ years old
-excessive benign breast tissue in lobules (found on routine mammograms) -Symptoms- cyclic breast pain, small firm mass -diagnosed with mammogram and excisional biopsy - no treatment |
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Results of WHI
CEE only findings? |
-12 more cases of stroke compared to placebo
-6 fewer cases of hip fractures -7 fewer cases of breast cancer -bottom line: CEE should not be used to prevent chronic disease overall and heart disease in particular |
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why is desire disorder the most difficult disorder to treat?
What FSD class responds readily to treatment? |
pt is not motivated to seek treatment.
If relationship issues are a major problem, lack of desire rarely improves. - anorgasmia responds more readily to treatment |
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Results of WHI
Similarities and differences between CEE vs. CEE/MPA? |
Similarities: Increased stroke and decreased fractures
Differences: CEE did not increase breast cancer or decrease colorectal cancer. CEE/MPA did increase breast cancer and decrease colorectal cancer. |
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Intraductal papilloma
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-older women single ducts
-younger women multiple ducts -benign wart-like mass in sub-areolar ducts -common cause of nipple discharge from single duct -symptoms: mass under areolar, clear sticky or blood tinged discharge, may be bilateral -diagnosis (mammorgram, FNA, if under 35 years old- US, ductogram, ductal lavage) -treatment: observation, duct removal |
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Secondary Analysis of WHI
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- study of effect of age and years since menopause
-CHD risk decreased in ET vs HT -younger group 50-59 had a decreased mortality -If <10 yrs since menopause, there was no difference in total mortality -If >20 yrs since menopause, HT increased risk for CHD -stroke risk increased across all categories |
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Describe polycystic ovarian syndrome.
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-increased androgen levels, causing follicular atresia
-anovulation -endometrial hyperplasia and dysfunctional bleeding -irregular menstrual cycles |
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NAMS position statement 2010
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"The benefit-risk ratio for menopausal hormone therapy (HT) is favorable for women beginning HT close to menopause but decreases in older women and with time since menopause in previously untreated women."
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Periductal Mastitis
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-20-40 years old
-sub-aerolar ducts inflamed or infected -similar to symptoms of ductal ectasia -diagnosis: mammogram or US -treatment: observation or duct removal |
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alternatives for HRT
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-bioidentical hormones
-oral/IM progesterone -antidepressants -anticonvulsants -antihypertensives -soy & black cohosh |
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what is an antiverted uterus?
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uterus that is tipped FORWARD toward the bladder
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Ductal Ectasia
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-40-50 years old
-normal aging change-- sub-areolar ducts enlarge (ectasia) -abnormal: fluid collects, blocking and causing ulcerations -painful, bloody discharge, possible infection, nipple inversion from scarring -Diagnosis: mammogram -Treatment: observation or ductal removal |
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what is an retroverted uterus?
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uterus that is tilted BACKWARD instead of forward.
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Fat Necrosis
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-occurs in post surgical or post trauma
-mass that forms in fatty tissue -symptoms: painless, red skin, bruised, or dimpled -diagnosis: mammogram or US & FNA or core biopsy -Treatment: observation, usually resolves |
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when is a rectal exam indicated?
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-routine exam for women >40 years old
-evaluate retroverted uterus -confirm adnexal or uterine pathology (masses, uterine size, adenxal pathology) -fecal occult blood |
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Breast Calcifications
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-spots of calcium salts
-develops as breast ages and changes -reaction to inflammation and foreign bodies -can be sign of breast cancer -Diagnosis: white spots on mammogram |
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which stage is mediated by the parasympathetic nervous system?
1) desire 2) excitement 3) plateau 4) orgasm 5) resolution |
Excitement
|
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what are high risk "benign" lesions?
|
-atypical ductal hyperplasia
-atypical lobular hyperplasia -LCIS -DCIS |
|
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what % of women will admit to having experienced sexual problem at some point in their lives?
1) 1-5% 2) 5-10% 3) 15-20% 4) >20% |
>20 %
|
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what tests do you run if there is nipple discharge?
|
Cytology-- but only 50% sensitivity
hemoccult serum prolactin mammogram |
|
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In what stage does the orgasmic platform first appear?
1) desire 2) excitement 3) plateau 4) orgasm 5) resolution |
Plateau
|
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if breast cancer 5 year risk is > 1.7, what drug should be considered?
|
SERM- selective estrogen receptor modulator
-tamoxifen (Nolvadex) -raloxifene (Evista) Mixed estrogen antagonist/agonist -antagonist in breast -agonist in endometrium, bone and liver |
|
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what is the treatment for Dysfunctional Uterine Bleeding?
|
-determine cause
-education -surgery (myomectomy, hysterectomy) -NSAIDs -OCP's or cylic progesterone -hysteroscopy w/ or w/o D&C -Iron supplements |
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what are elements of risk for the Gail model?
|
-Current Age
-Age at Menarche -Age at first live birth -Number of previous biopsies Presence of ADH -Number of 1st degree relatives with breast cancer (maximum of 2) -Race |
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what are the functions of the pelvic floor muscles?
|
supportive
sphincteric sexual |
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what are limitations of the Gail model?
|
Does not consider:
-paternal lineage -2nd degree family members -male breast cancer -other hereditary cancers- Ovarian, pancreatic, colon -age of relatives with Breast Cancer *May overestimate risk particularly recent immigrants from Japan and China |
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what are the 2 main types of pelvic floor dysfunction?
|
1) supportive
2) hypertonus |
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when should you NOT use the Gail model?
|
-Personal history of breast cancer
-History of lobular or ductal carcinoma in situ -If “red flags” for hereditary breast cancer already present -History of thoracic irradiation especially at a young age -Underestimates Risk |
|
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what are common diagnoses of supportive dysfunctions?
|
urinary incontinence
fecal incontinence Urinary urgency/frequency cystocele/rectocle uterine prolapse |
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The Claus Model is used solely on ____ history?
|
family history
-if no family history, cannot be used |
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name some risk factors of incontinence
|
Vaginal infections
Dietary influences High impact physical activities pelvic/abdominal surgeries Diminished cognitive status (alzheimer's) pregnancy, vaginal delivery, episiotomy |
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what are the advantages of the Claus model?
|
-considers family history on maternal and paternal lineage
-considers early age onset of breast cancer |
|
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what are common diagnoses of hypertonus dysfunctions?
|
Pain in pelvic region/joint
Painful episiotomy vaginismus anal rectal pain dyspareunia vulvodynia |
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Elements of risk in the Claus model
|
Family History
-Maternal & Paternal lineage -Considers ‘early age-onset’ of breast cancer -Tables available for women with a first degree family history of ovarian cancer |
|
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what are some medications that contribute to incontinence?
|
-diuretics
-sedatives and hypnotics -pain relievers -antihistamine/anticholinergics -antipsychotics -antidepressants |
|
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what are limitations of the Claus model?
|
Excludes risk other than family history and early age of onset
|
|
|
what are common Physical therapy interventions for UI?
|
-behavioral therapy
-bladder exercises -therapeutic exercise -biofeedback training -electrical stimulation |
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When should you NOT use the Claus model?
|
-personal history of breast cancer
-history of lobular or ductal carcinoma insitu -history of thoracic irradiation -may underestimate risk |
|
|
when is an MRI recommended?
|
-BRCA Mutation
-1st degree relative of BRCA carrier (untested) -Lifetime risk >20% Using model considering family history -Chest radiation (10-20 yrs) -Li-Fraumini Syndrome -Cowden & Banayan-Riley-Ruvalcaba syndromes |
|
|
what are risk factors for breast cancer?
|
-Female Gender
-Age 50+ -Family History -Personal history of High Risk Lesion -Hormonal -Late Menopause (>55) -Early Menarche (<12) -Late pregnancy (>30) --No/little breastfeeding -Hormone replacement |
|
|
what is the difference in the 2 types of mammography?
screening? diagnostic? |
Screening:
No palpable lesion Appointment made with technician Batch read by radiologist Diagnostic: Abnormal breast finding Appointment made with radiologist Read by radiologist in “real time” |
|
|
when do you start annual mammography?
|
40 years old
|
|
|
what are the 3 types of breast cancer?
|
1) Non-invasive
DCIS, LCIS, Paget’s 2)Invasive Ductal (70%) Medullary, Papillary, Tubular, Mucinous Lobular 3)Inflammatory |
|
|
a breast cancer survivor should receive mammograms and clinical breast exams how often?
|
-annual mammogram
-clinical breast exam 6-12 mon -monthly breast self exam |
|
|
what are risk factors of anal cancer?
|
-anal receptive intercourse (MSM)
-HIV -transplant recipients -women with SIL (squamous intraepithelial lesions) |
|
|
Cytologic screening in HIV + men with CD4+ counts below ___
|
500
|
|
|
Genital warts are associated with which HPV strains?
|
HPV type 6, 11, 42, 43, 44
(low risk for cancer) |
|
|
The HPV vaccination can decrease a 12 year old female's lifetime cervical cancer risk by what percentage?
|
20-66%
|
|
|
which HPV vaccine can be used for males?
|
Quadrivalent
|
|
|
what is the target age of the HPV vaccine?
|
target 11-12
as early as 9/10 to 25/26 best given before sexual debut! |
|
|
how long does the HPV vaccine protect against HPV?
|
quadrivalent- 5 yrs
bivalent- 6.3 yrs no evidence of decrease in efficacy |
|
|
what is the timeline of HPV vaccine administration?
|
initial dose
2nd dose at 2 months 3rd dose at 6 months |
|
|
what are common reasons for unsatisfactory pap smears?
|
scant cellularity
obscuring inflammation blood |
|
|
If a pap smear needs to be repeated, how long must you wait before repeat test?
|
-wait at least 6 weeks
-repeat mid-cycle, no intercourse, no vaginal products x 24 hours |
|
|
With patients who are post-menopausal who have persistent vaginal atrophy, what can you prescribe prior to pap smear?
|
vaginal estrogen x 4-6 weeks
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