Pc 615 Module 1 Overview Of Women's Health Fsmfn

Front 1

How would you define women’s health?

Back 1

"Women's health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology.” (from Let’s Talk)

Front 2

What do you think were the five most important women’s health events in the 20th century and why?

Back 2

1916- First birth control clinic opens in Brooklyn, NY; Margaret Sanger and sister Ethyl Byrne closed 10 days later after seeing 500 women under Comstock law which deemed it obscene.
1935- Title V of social security act; authorized grants-in-aids to states to fund maternal, infant and child health programs; sulfonamides introduced to treat puerperal fever.
1960- FDA approves birth control pill.
1970- Our Bodies, Ourselves published; Medical schools sued for gender discrimination; Title X family planning funding. Nationwide program to provide family planning services to low income
1973- Roe vs Wade.

Front 3

What are the recommendations made by Strobino, Grason, & Minkovitz (2002) in Charting a Course for Women's Health?

Back 3

1) to focus broadly on women’s health, not just during pregnancy; 2) for comprehensive, integrated programs and services addressing women’s unique needs; 3) for integrated programs and services across the lifespan; 4) for better provider training about women’s unique health needs, the differential effects of particular problems on them, and the consequences of chronic health problems heretofore considered primarily male problems; 5) to eliminate social policies that single out women, particularly pregnant women, for punitive actions; 6) to promote social policies that ensure economic security for women; and 7) for vigorous public health leadership to shape the women’s health agenda, recognizing the social and economic context of their lives.

Front 4

What are the recommendations made by Stewart, Shields, & Hwang (2006)re. 10 Priorities for women’s health?

Back 4

Address disparities in health in minority communities; Ensure economic justice; support programs to end violence against women; protect women’s rights in reproductive health decision-making; provide universal and accurate health education and information; improve access to affordable health care; stop gender discrimination in health care coverage; invest in prevention; close the research gap; keep politics out of science.

Front 5

What are some practical ways to incorporate a feminist perspective into clinical practice?

Back 5

A model based on partnership; heterogeneity; minimize and expose power imbalances; reject androcentric models of health and disease as normative; challenge the process of medicalization and pathologizing by identifying and exploring women’s uniques health experiences and normalizing them; acknowledge the broader context in which women live their lives and the subsequent challenges to their health s a result of living within a patriarchal society, arguing for social and political change.

Front 6

What is the source of the following hormones:
1. GnRH
2. FSH
3. LH
4. Estrogen
5. Progesterone

Back 6

1. Hypothalamus
2. Anterior pituitary
3. Anterior pituitary
4. Ovaries- ovarian follicles
5. Ovaries/corpus luteum. In the absence of pregnancy the corpus luteum degenerates.

Front 7

What is the role of GnRH?

Back 7

Stimulates pituitary gland
to produce FSH & LH

Front 8

What is the role of FSH?

Back 8

Targets ovaries stimulating growth and development of primary follicles l/t estrogen and progesterone production. Induces the development of increased receptors on the granulosa cell to produce estrogen.

Front 9

What is the role of LH?

Back 9

LH surge stimulates terminal growth of follicle and maturation of oocyte, l/t extrusion of ovum from follicle and l/t endocrine changes within the follicular cells l/t different hormone secretory profile in luteal phase (coad pg 83). Targets developing follicle; responsible for ovulation, corpus luteum formation, hormone production in the ovaries. l/t ruptured follicle becoming corpus luteum and secreting progesterone; sustains the corpus luteum. Stimulates theca cell production of androgen that is converted to estrogen by the granulose layers.

Front 10

What is the role of estrogen in the menstrual cycle?

Back 10

Modulates GnRH secretion; initially a negative feedback on hypothalamus and pituitary but creates a positive feedback on the anterior pituitary when levels high enough stimulating ovulation through LH and FSH surge.

Front 11

What is the role of progesterone in the menstrual cycle?

Back 11

Modulates GnRH secretion, reduces frequency of GnRH pulsation;
Marked increase in secretion several hrs after ovulation

Front 12

What is the feedback mechanism for GnRH?

Back 12

Modulated by the feedback effects of estrogen and progesterone.
Stimulates synthesis and secretion of LH and FSH

Front 13

What is the feedback mechanism for FSH?

Back 13

Stimulated by GnRH. Estrogen affects amount produced by negative feedback+.
Output changed by altering amplitude or frequency of GnRH pulses or by modulating the response to the pulses

Front 14

What is the feedback mechanism for LH?

Back 14

Stimulated by GnRH Estrogen affects amount produced by negative feedback
Output changed by altering amplitude or frequency of GnRH pulses or by modulating the response to the pulses

Front 15

What is the feedback mechanism for estrogen?

Back 15

Causes a **positive feedback loop when levels high enough, midcycle, on the pituitary resulting in LH and FSH surge causing ovulation

Front 16

What is the feedback mechanism for progesterone?

Back 16

Reduces frequency of hypothalamus pulses of GnRH

Front 17

What are the three phases of the menstrual cycle?

Back 17

1) follicular
2) ovulatory
3) luteal

Front 18

Describe the follicular phase.

Back 18

* development of the ovarian follicles and lasts from day 1-14.
* folliculogenesis begins during the last few days of the previous menstrual cycles, until the release of the mature follicle.
* The decrease in estrogen production by the corpus luteum and fall of inhibin levels allow FSH to rise during the last few days of the menstrual cycle.
* During days 1-4 primary follicles are recruited in response to FSH.
* Between days 5-7 one dominant follicle emerges. FSH levels decline d/t negative feedback of estrogen and negative effects of the peptide hormone inhibin (secreted by granulosa and theca cells of the developing follicle).
* Decreased FSH l/t more androgenic environment within adjacent follicles, by 8th day the graafian follicle is producing more estrogen than the total amount produced by the other follicles.
* LH receptors develop on the outermost granulose layers d/t estrogen and FSH.
* Oocyte maturation inhibitor (OMI) in follicular fluid suppresses final maturation of dominant follicle until ovulation.
* OMI suppression ends before LH surge.
* At the end of follicular phase estrogen reaches high level of 200 picograms/ml and is sustained for 50 hrs at this level.

Front 19

Describe the Ovulatory phase:

Back 19

* High levels of estrogen at beginning of ovulatory phase initiate a positive feedback of LH, generating preovulatory LH surge occurs 34-36 hrs prior to ovulation
* Ovulation occurs 34-36 hours after the LH surge (LH surge occurs over 3 day time period in a slow spike formation).
* Ovulation and subsequent conversion of follicle to the corpus luteum dependent on the increase of estrogen and the LH surge.
* The nuclear membrane around the oocyte breaks down, the chromosomes progress through the first meiotic division and the egg moves on to the secondary stage.
* Meiosis stops and will resume after fertilization.
* The LH surge stimulates luteinization of the granulosa cells and stimulates the synthesis of progesterone.
* Progesterone enhances positive feedback of estrogen on LH surge and is responsible for promoting enzyme activity that digests the follicular wall.
* High levels of LH and progesterone cause the synthesis of prostaglandins and proteolytic enzymes (collagenase and plasmin) which digest the collagen in the follicular wall l/t release of ovum with the zona pellucida and corona radiate surrounding it.
* The ovum is expelled and drawn into the fallopian tube by the beating ciliated fimbriae to begin migration to the oviduct.

Front 20

Describe the Luteal phase:

Back 20

Under the influences of LH the follicle’s granulosa cells left in the ruptured follicle enlarge, undergo luteinization and become the corpus luteum.
* Which continues to function for 8 days after ovulation. Secreting progesterone and some estrogen that start the negative feedback loop to the hypothalamus and pituitary gland preventing further ovulation within the cycle.
* In the absence of fertilization the luteal cells degenerate, with a decline in estrogen and progesterone levels;
* the corpus luteum regresses and becomes the corpus albicans.
* Estrogen and progesterone levels decrease removing the negative feedback effect.
* FSH and LH begin to increase again.

Front 21

What are the three phases of the endometrial cycle?

Back 21

1) proliferative
2) secretory
3) menstrual

Front 22

Describe the proliferative phase of the endometrial cycle.

Back 22

* Influenced by estrogen is the regrowth of the endometrium after menstrual bleed.
* Starting about the 4th or 5th day of the cycle and lasting ~10 days ending with the release of the ovum.
* Involves changes to the endometrium, myometrium and ovaries
* resulting from fluctuations in gonadotropin and estrogen levels.
* Characterized by progressive mitotic growth of the deciduas functionalis in response to increasing levels of estrogen released from the ovary.
* At the beginning of the proliferative phase the endometrium is thin and the glands are straight, narrow and short.
* The glands progressively become longer and more tortuous.
* The endometrium thickens as a result of glandular hyperplasia and stromal growth.
* The endometrium changes from 0.5 mm to 5.0 mm in height and increases 8 fold in thickness.

Front 23

Describe the secretory phase of the endometrial cycle.

Back 23

* begins with ovulation.
* Within a 28 day cycle from day 15-28.
* does not take place if ovulation has not occurred.
* The glands become more tortuous and dilated and fill with secretions primarily d/t progesterone.
* In the absence of implantation the corpus luteum declines and progesterone and estrogen levels decrease, the endometrium begins to regress and spiral arterioles in the thinning layer become more tortuous, coiled and constricted.
* Previously thought l/t ischemia of endometrium l/t menses.
* Now thought that enzymatic digestion of the functional layer of the endometrium triggered by estrogen-progesterone withdrawal.
* Enzymes are released into the cytoplasm of epithelial, stromal and endothelial cells and into the intercellular spaces.
* Ongoing digestion l/t endometrial degradation, capillary disruption with interstitial hemorrhage and dissolution of the surface membrane allowing blood to escape into the endometrial cavity.
* The degeneration continues, extending to the functional layer of the endometrium where rupture of the basal arterioles contributes to bleeding.

Front 24

Describe the menstrual phase of the endometrial cycle.

Back 24

* begins with the initiation of menses and lasts 4-6 days.
* Prostaglandins initiate contractions of the uterine smooth muscle and sloughing of the degraded endometrial tissue leading to menstruation.
* Menstrual fluid is composed of RBCs, inflammatory exudates, endometrial tissue and proteolytic enzymes.
* The blood does not clot d/t the proteolytic enzymes.
* Average amount is 20-80 ml.
* approx 2 days after the start of menstruation estrogen stimulates regeneration of the endometrial epithelium while concurrent endometrial shedding occurs.

Front 25

Describe cervical changes throughout the cycle.

Back 25

* mucus is scant and viscous after menstruation.
* During late follicular phase mucus becomes clear, copious and elastic.
* Increasing by 30 fold.
* Displays ferning.
* After ovulation with high progesterone mucus becomes thick, viscous, opaque and decreased.
* This mucus is hostile and impenetrable to sperm.
* Also reduces the risk of infection.
* Estrogen increases vascularization and edema, relaxes myometrial fibers.
* Collagenase causes collagen bundles to become looser so the cervix is softer a few days prior to and at ovulation.
* The external cervical os everts.
* Cervical muscles retract d/t progesterone the collagen matrix to tighten and the cervix to become firmer.

Front 26

Describe the breast and pubic hair development for Tanner stage 1:

Back 26

preadolescent (10-14), breasts have elevated nipples only. No pubic hair except vellus hair which is fine body hair.

Front 27

Describe the breast and pubic hair development for Tanner stage 2:

Back 27

elevation of the breast and nipple and the areola widens. Pubic hair is sparse, long and only slightly curly. Mainly on labia.

Front 28

Describe the breast and pubic hair development for Tanner stage 3:

Back 28

: (middle adolescence 12-14) breast and areola are enlarged further with increased elevation of the breast and nipple. But no separation of their contours. Pubic hair begins to occur over the mons pubis and is darker, coarser and curlier.

Front 29

Describe the breast and pubic hair development for Tanner stage 4:

Back 29

breasts with areola and nipple forming a secondary mound with projection of the nipple. Pubic hair is adult type but is seen over a smaller area with none on the thigh.

Front 30

Describe the breast and pubic hair development for Tanner stage 5:

Back 30

(14-16, middle adolescence) breasts are fully mature and only the nipple protrudes as the areola is flush with the breast contour. A secondary mound formed by the areola is a variation of normal. Pubic hair is thick, coarse and curly spreading onto the medial surfaces of the thigh, inverted triangle formation is distinct.

Front 31

Questions to ask during the General Health History:

Back 31

• Reason for visit, ie ‘what brought you here today’?
• Hx of present illness or complaint
• General medical hx (current illnesses, diseases, past hospitalizations, prior surgeries, immunization status, previous serious illnesses)
• Medications and allergies
• Substance use
• Family health hx
• Social and occupational hx
• Safety (DM, seat belts, etc)
• Personal habits (exercise, sleep, nutritional habits)

Front 32

Questions to ask during the Gynecological health hx:

Back 32

• Menstrual hx (age of menarche, length of cycle, average length of menses, flow characteristics, regularity of cycles, description of irregularities and/or accompanying symptoms.
• Pregnancy hx (total number of pregnancies, describe each in chronological order, GTPAL [gravida, term births, preterm births, abortions, living], type of delivery, etc.
• Hx of vaginal and pelvic infections (type, treatments, frequency of infection, complications, HIV risk screening, number of sexual partners, condom use)
• Douching (frequency, medication or solutions used, reason for douching)
• Gyn surgical procedures
• Urologic health (UTIs, incontinence, abn symptoms)
• Cervical cancer screening (approx dates of screenings, findings, follow-ups)
• Sexual health (active? With men or women or both, satisfied? Any concerns or problems)
• Contraceptive use (if using any what sort, satisfaction with method, past methods may be relevant)
• Abnormal symptoms (pelvic pain should be fully described, relation to menstrual cycle, sexual activity, tampon use. Vaginal bleeding not r/t menses should be fully described.
• Allow woman to express other concerns or relate info not covered.