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97 Cards in this Set
- Front
- Back
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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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what percentage of women do not use contraception?
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7.5% of women do not use contraception
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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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2 hormones used in combined oral contraception
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estrogen (ethinyl estradiol)
Progestrin |
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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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what is estradiol?
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a highly potent estrogen
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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 mestranol?
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converts to estrogen in the liver
used in Europe |
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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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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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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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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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what is lybrel?
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-new COC
-No placebos-- no periods |
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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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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 are other Combined NON-ORAL contraceptives?
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patch
ring |
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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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Where can you place the patch?
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upper/outer arm, torso, abdomen, buttocks
(not breast) |
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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 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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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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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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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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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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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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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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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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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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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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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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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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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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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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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 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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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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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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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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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 are side effects of of ECPs?
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nausea (COC due to high estrogen levels)
headaches |
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what are the 2 available IUDs?
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Mirena- progestin
Paragard-copper IUD |
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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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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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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 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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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 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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Name types of barrier contraceptions?
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condoms
diaphragms cervical caps vaginal sponges |
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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 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 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 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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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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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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at what age does thelarche occur?
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8-13 years old, average 10
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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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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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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 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 percentage of women develop Benign breast disease (BDD) typically fibrocystic breast changes?
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+/- 50%
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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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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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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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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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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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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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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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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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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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what are high risk "benign" lesions?
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-atypical ductal hyperplasia
-atypical lobular hyperplasia -LCIS -DCIS |
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what tests do you run if there is nipple discharge?
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Cytology-- but only 50% sensitivity
hemoccult serum prolactin mammogram |
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if breast cancer 5 year risk is > 1.7, what drug should be considered?
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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 are elements of risk for the Gail model?
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-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 limitations of the Gail model?
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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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when should you NOT use the Gail model?
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-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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The Claus Model is used solely on ____ history?
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family history
-if no family history, cannot be used |
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what are the advantages of the Claus model?
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-considers family history on maternal and paternal lineage
-considers early age onset of breast cancer |
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Elements of risk in the Claus model
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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 limitations of the Claus model?
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Excludes risk other than family history and early age of onset
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When should you NOT use the Claus model?
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-personal history of breast cancer
-history of lobular or ductal carcinoma insitu -history of thoracic irradiation -may underestimate risk |
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when is an MRI recommended?
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-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 |
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what are risk factors for breast cancer?
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-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 |
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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” |
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when do you start annual mammography?
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40 years old
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what are the 3 types of breast cancer?
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1) Non-invasive
DCIS, LCIS, Paget’s 2)Invasive Ductal (70%) Medullary, Papillary, Tubular, Mucinous Lobular 3)Inflammatory |
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a breast cancer survivor should receive mammograms and clinical breast exams how often?
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-annual mammogram
-clinical breast exam 6-12 mon -monthly breast self exam |
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what are risk factors of anal cancer?
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-anal receptive intercourse (MSM)
-HIV -transplant recipients -women with SIL (squamous intraepithelial lesions) |
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Cytologic screening in HIV + men with CD4+ counts below ___
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500
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Genital warts are associated with which HPV strains?
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HPV type 6, 11, 42, 43, 44
(low risk for cancer) |
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The HPV vaccination can decrease a 12 year old female's lifetime cervical cancer risk by what percentage?
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20-66%
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which HPV vaccine can be used for males?
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Quadrivalent
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what is the target age of the HPV vaccine?
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target 11-12
as early as 9/10 to 25/26 best given before sexual debut! |
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how long does the HPV vaccine protect against HPV?
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quadrivalent- 5 yrs
bivalent- 6.3 yrs no evidence of decrease in efficacy |
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what is the timeline of HPV vaccine administration?
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initial dose
2nd dose at 2 months 3rd dose at 6 months |
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what are common reasons for unsatisfactory pap smears?
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scant cellularity
obscuring inflammation blood |
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If a pap smear needs to be repeated, how long must you wait before repeat test?
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-wait at least 6 weeks
-repeat mid-cycle, no intercourse, no vaginal products x 24 hours |
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With patients who are post-menopausal who have persistent vaginal atrophy, what can you prescribe prior to pap smear?
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vaginal estrogen x 4-6 weeks
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