NURS 6551 Midterm Study Guide
#1 Alcohol Abuse Among Women
- The USPSTF (2014a) assigns a “B” recommendation to screening all adults age 18 and older (including pregnant women) for alcohol misuse; screening adolescents younger than age 18 has been assigned an “I statement”.
- Most of all recent research regarding effects of alcohol has been conducted on males
- Smaller amounts of alcohol is associated with more severe damage to a women
- Alcohol consumption is considered hazardous for a women who has either more than seven drinks per week or more than three drinks per day. NURS 6551 Midterm Study Guide
- Women who consume more than seven drinks per day are considered at risk for developing AUD
- Alcohol misuse screening tools include the AUDIT or Abbreviated AUDIT-C instrument or asking single questions.
- Ask patient, how many times in the past year have you had four or more drinks in a day?
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#2 Feminist Perspective
- Feminist is a model of care that works with women as opposed to for women.
- Uses heterogeneity as an assumption, not homogeneity.
- Minimizes or exposes power imbalance.
- Rejects androcentric models as normative
- Challenges the medicalization and pathologizing of normal physiologic processes.
- Seeks social and political change to address women’s health issues.
- A feminist model supports egalitarian relationships and identifies the women as the expert on her own body.
- The women is the center of this healthcare model
- Acknowledges the broader context in which women live their lives and the subsequent challenges to their health as a result of living within a patriarchal society.
#3 Cultural Perspectives of Women
- Adolescents- Using a relational approach when providing care to adolescent females, which is how adolescent females often define themselves. By asking questions such as “Tell me about your friends or who you hang out with”.
- Early adulthood- Women at this age are facing childbirth and contraceptive issues, intimate partner violence, substance abuse and stress.
- Midlife- Clinicians providing care for women in midlife need to promote healthy sexual functioning and assess changes that may negatively impact desire.
- Older women- Some women become isolated. Elderly women contend with ageism and sexism.
- Problems faced by Mexican and Central American women include feeding their families, accessing formal health care.
- Undocumented migrant women also face problems with obtaining assistance with food and health care due to the inability to seek assistance
- Veterans have increased risk for having been sexually assaulted, have post-traumatic stress disorder and traumatic brain injury
- People who are assigned female sex at birth are natal females, those who are assigned as males are considered natal males.
- Transgender woman is a natal male who has a female gender identity.
- A transgender man is a natal female who has a male gender identity
- Cisgender refers to someone whose gender identity matches their natal sex
- LBQ women and TGNC (Transgender and gender non-confirming) experience interpersonal and institutional discrimination.
- LBQ and TGNC people face rejection of their families, their communities and spiritual levels.
- LBQ and TGNC face the risk of not being involved with their partners in times of health crises, or able to participate in medical decisions of their partners when incapacitated.
- LBQ and TGNC people are less likely to have insurance or be able to afford healthcare.
- TGNC persons are at higher risk for suicide and are 5 times at greater risk for depression
- Clinicians must create environments that are welcoming and nonthreatening to patients of all gender identities and sexual orientations
- EMR must be able to identify the patient with their physical sex as well as their identified sex
- Use open-ended and gender-neutral language
- Examinations must be based on anatomy and organs present, not the perceived gender of the patient
- For Transgender men taking testosterone- provide a short course of vaginal estradiol prior to vaginal examinations, as well as topical anesthetic to reduce pain.
- LBQ and TGNC youth are at an increased risk for violence, homelessness and substance abuse than others of their age.
- Older adults of the LBQ and TGNC population are particularly vulnerable to abuse, neglect and poverty.
- Some religions and restrictive family upbringings may alter a woman’s ideas about sexuality and their ability to enjoy their sexuality.
- Black women experience menopause earlier than other women, an average age of approximately 50 years.
- Caucasian and hispanic women have reported greatest number of psychosomatic symptoms of menopause (moodiness, headaches, palpitations),
- African American women reported highest severity of vasomotor symptoms of menopause
- Asian women reported problems with joint pain and stiffness, especially in the neck, shoulders and back.
- Women who are migrant workers may not report IPV for fear of deportation.
- Migrant workers commonly have the belief that the woman is subordinate to the man and not be aware of support services
- Domestic Violence is the leading cause of homicide in women globally
- Contraceptive considerations for couples that are part of cultural groups that prohibit contraceptives:
- Cervical mucus monitoring
- Basal body temperature monitoring
- Menstrual cycle charting
- Ovulation sensations
- Electronic hormonal fertility monitoring
- Native American women have the highest rates of rape and assault in the U.S. (Leik)
- Muslim women may refuse to undress and cannot be examined by a male practitioner without her husband or another male of her family present.
#4 Tanner Stages
- A commonly used scale for assessing sexual maturity and pubertal development is the Tanner scale, which for girls, relies on development of the breast and growth of pubic hair. It divides sexual physical maturity into five stages that extend from preadolescence to adulthood.
- Tanner Stage 1 (Prepubertal)
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- Papilla elevation only
- Pubic Hair
- Villus hair only
- No coarse, pigmented hair
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- Tanner Stage 2
- Tanner Stage 3
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- Breast
- Elevation of Breast contour; areolae enlarge
- Pubic Hair
- Dark, coarse, curly hair spreads over mons pubis
- Other changes
- Axillary hair develops
- Acne Vulgaris develops
- Breast
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- Tanner Stage 4:
- Tanner Stage 5:
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- Breast
- Adult breast contour
- Areola recesses to general contour of breast
- Pubic Hair
- Adult distribution of hair
- Pubic hair spreads to medial thigh
- Pubic hair does not extend up linea alba
- Breast
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#5 Primary prevention versus secondary prevention
- Primary Prevention: These services focus on preventing disease in susceptible populations. Examples of primary preventive efforts include health education and counseling, and targeted immunizations.
- Secondary Prevention: These services focus on early detection of disease states and subsequent prompt treatment that will reduce the severity and limit the short- and long-term sequelae of the disease. Routine laboratory screening is an example of secondary prevention.
- Tertiary Prevention: These services limit disability and promote rehabilitation form clinical disease states.
#6 The US Preventative Services Task Force (USPSTF) recommendations:
Mammography:
- Age: All women
- Recommendation: The USPSTF recommends against teaching breast self-examination (BSE).
- Age: 40 Years and Older
- Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
- Age: Women, Before the Age of 50 Years
- Recommendation: The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
- Age: Women, Age 50-74 Years
- Recommendation: The USPSTF recommends biennial screening mammography for women 50-74 years.
- Age: Women, 75 Years and Older
- Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older.
Cervical Cancer Screening:
- Age: Women younger than 21
- Recommendation: The USPSTF recommends against screening for cervical cancer in women younger than age 21 years.
- Age: Women 21 to 65 (Pap Smear) or 30-65 (in combo with HPV testing)
- Recommendation: The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years
- Age: Women younger than 30 years, HPV testing
- Recommendation: The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
- Age: Women Older than 65, who have had adequate prior screening
- Recommendation: The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
- Age: Women who have had a hysterectomy
- Recommendation: The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
Chlamydia and Gonorrhea: Screening
- Age: Sexually Active Women
- Recommendation: The USPSTF recommends screening for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
#7 Preventable causes of death
*Cardiovascular disease is the leading causes of death in females. (CDC, 2015).
Preventable causes of death for women are related to:
Modifiable, behavioral risk factors:
- Tobacco use with related illnesses (Lung Cancer)
- Leading preventable cause of death
- Risk of MI, CVA, lung cancer (and others)
- Overweight or Obesity
- Morbidity and mortality
Elevated Low-Density lipoprotein (LDL) cholesterol levels
Diabetes
- CAD, CVA, DM, Kidney Disease, Respiratory problems
- Risk of premature death
- Disability
- Poor diet
- Physical inactivity
USPSTF recommendations:
- Overweight or obese patients be referred for high-intensity behavioral counseling to promote a healthful diet and physical activity.
- Counseling on interventions on smoking cessation.
- Exercise
- Healthy diet (manage cholesterol)
Provide education and resources for smoking cessation, healthy food choices, exercising 30 minutes a day
- Common Health Issues
Dominant Breast Mass/Breast Cancer- Adult to older female with dominant mass on one breast that feels hard and irregular in shape and is immobile. Common locations upper outer quadrants. Skin changes may be evident- peau d’orange, dimpling and retraction. Mass is painless and may be accompanied by serous or bloody nipple discharge. Nipple may be displaced or fixed.
Ductal Carcinoma In Situ (Paget’s Disease)- Chronic scaly red-colored rash which bears similar appearance to eczema, starts on nipple and spreads to the areola on one breast. May c/o itching, pain or burning. Lesion slowly enlarges and evolves to include crusting, ulceration and/or bleeding of the nipple.
Inflammatory Breast Disease- Recent or acute onset of red, swollen and warm area in the breast of a younger woman, may mimic mastitis. No distinct lump and symptoms develop quickly. Skin may appear pitted (peau d’orange) or bruised. More common with African Americans. It is rare but very aggressive.
BRCA Associated Breast Cancer and Ovarian Cancer- High risk-family history of Breast ca before 50, male breast ca, triple negative breast ca before 60, or ovarian cancer and other types of gyn. Ca. Men with BRCA mutation are higher risk for breast ca and prostate ca. A patient reporting BRCA mutation should be followed by a breast specialist, and screened with both a mammogram and a breast MRI. Screening should occur 10 years before the age of the earliest member diagnosed with breast cancer. BRCA mutations are common among Ashkenazi Jews. Should also be referred for genetic counseling
Fibrocystic Breast-When the monthly hormonal cycle causes the breast tissue to become engorged and painful; symptoms occurs about 2 weeks before menstrual period and at the worst right before the cycle starts. Resolves after menses start, common to begin in women in their 30s.
Tx: Refrain from caffeine intake, Take Vitamin E and evening primrose capsules, wear bras with good support, monitor for skin changes
Polycystic Ovary Syndrome (PCOS)- Hormonal abnormality characterized by anovulation, infertility, excessive androgen production and insulin resistance. High risk for DM2, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity and OSA. Common symptoms are excessive facial and body hair, bad acne and amenorrhea or infrequent periods. Increased risk for CHD, DM2 and metabolic syndrome, breast and endometrial cancers, central obesity and infertility.
Assess: Transvaginal US to r/o enlarged ovaries, Bloodwork-serum testosterone, dehydroepiandrosterone (DHEA), androstenedione (these three are typically elevated), FSH normal or low), fasting glucose and 2 hr. oral GTT (glucoses are usually abnormal).
Tx: Low dose oral contraceptives, spironolactone, metformin, weight loss planning
Osteoporosis- Gradual loss of bone density secondary to estrogen deficiency and other metabolic disorders. Most common-older women of white or Asian background with thin or small body frame, especially with family history. Menopausal women with osteoporosis and those with hip or vertebral fracture history should be treated. Other risk groups include: chronic steroid use, anorexia nervosa or bulimia, long-term use of PPIs, gastric bypass, celiac disease, hyperthyroidism, ankylosing spondylitis, and RA
Assess: DXA to measure bone mineral density. Baseline, then every 1-2 years if on treatments, every 2-5 if not treated. Evaluate T-scores for osteoporosis and osteopenia
Tx: Weight bearing exercises on most days of the week and Calcium with Vitamin D (1200mg), Vitamin D2 (50,000IU once weekly) and Vitamin D3 (800mg to 1000 IU/d). Other medication options: Bisphosphonates (1st line- Ex: Fosamax 5-10mg/d or 70mg/wk, Actonel 5mg/d or 35mg/wk or 150mg/mon, Selective Estrogen Receptor Modulators (Ex: Evista, used for patients with contraindication of bisphosphonates), Tamoxifen (used in breast cancer patients), Parathyroid hormone analog (Ex: Teriparatide), Miacalcin and Calcitrol
Ovarian cancer- 5th most common cancer in US for women. Rare to diagnose in early stages, often women c/o vague symptoms: abdominal bloating and discomfort, low-back pain, pelvic pain, urinary frequency and constipation for certain women with BRCA1 or BRCA2 mutations. Some experts recommend bilateral salpingo-oopherectomy (BSO) between 35-40 for women with BRCA1 or BRCA2. USPSTF doesn’t recommend routine screening in general population. High risk women recommended for genetic screening. Transvaginal US and CA-125 should be done with screening. Begin screening at 30 or 5-10 years before earliest age of diagnosis in family member.
Bacterial Vaginosis – caused by an overgrowth of vaginal bacteria. Risk factors: sexual activity, new or multiple sexual partners, and douching. Fish-like odor, profuse milk-like discharge on the vaginal vault, not itchy and vulva not red
Assess: Clue cells and no or few WBCs on wet smear microscopy, whiff test (KOH application to discharge releases fishy odor) and vaginal pH (>4.5) are used to diagnose.
Tx: Metronidazole BID X 7D, abstain from sexual activity until completion of treatment
Candidal Vaginitis- Overgrowth of yeast (candida albicans) in the vulva/vagina. High-risk: HIV, antibiotic use, immunosuppression. Cheesy or curd-like white discharge
Assess: Pseudohyphae and spores with many WBCs of wet smear microscopy
Tx: Miconazole or clotrimazole for 7 D (OTC) or Diflucan 100mg x 1 dose or terconazole vaginal cream/suppository. If on antibiotics recommend daily yogurt or lactobacillus pill
Trichomonal Vaginitis- An infection involving a protozoan parasite. Causes inflammation (itching, burning and irritation) of the vagina/urethra. “Strawberry” cervix, bubbly discharge gray/green color.
Assess: Mobile unicellular organisms with flagella and large number of WBCs on wet smear microscopy
Tx: Metronidazole 2g PO x 1 dose or 500mg BID X 7D, avoid sexual contact, treat partner
Atrophic Vaginitis- chronic lack of estrogen in the urogenital tract. Atrophic changes in the vulva and vagina of menopausal women. C/O vaginal dryness, itching and pain with intercourse
Assess: atrophic labia with decrease rugae, vulva or vagina may have fissures, dry pale pink vagina, Pap smear
Tx: If Pap is mildly abnormal (atrophic changes) temporary topical estrogen vaginal cream for a few weeks and repeat Pap test. Topical estrogens may be cream, suppository or cervical ring (Premarin, Extrace, Vagifem).
Amenorrhea-
Primary- Failure to begin menses by 16 years old with normal tanner stages. Begin workup at 13 if no breast development of period. May be caused by genetic relation or functional abnormality in reproductive structures
Secondary- Cessation of normal menses for 3 months and irregular menses for 6 months. Common causes: PCOS, pregnancy, hypothalamic amenorrhea, primary ovulation insufficiency bulimia/anorexia and lifestyle.
#8 cont. Common Health Concerns for Women
– Endometriosis: The tissue that is normally found in the lining of the uterus grows in other places such as the ovaries, behind the uterus, on the bowel and the bladder.
– Uterine Fibroids: The most common noncancerous tumors found in women of childbearing age. Made of muscle cells and tissues that grow in and around the wall of the uterus. Exact cause is unknown. Affects African American and overweight women. Symptoms are heavy periods, frequent urination, painful sex, lower back pain, and infertility, miscarriages, or early labor.
– HIV/Aids: The virus can be spread through breast milk. Women contract the disease through unprotected sex with someone infected with the virus, or by sharing needles with an infected person. Minority women are affected the most.
– Interstitial Cystitis: A chronic bladder condition resulting in discomfort or pain in the bladder or surrounding pelvic region. The walls of the bladder are inflamed or irrated and can cause scarring and stiffening of the bladder. Can affect women more than men. Cause abdominal or pelvic pain, frequent urination, feeling of urgency to urinate, pelvic tenderness, or fullness, pain in bladder or pelvic area.
– Polycystic Ovary Syndrome (PCOS): Occurs when a woman ovaries or adrenal gland produce more male hormones than normal. Results in cysts developing on the ovaries. Obese woman is at a greater risk for developing. These women are also at a greater risk for developing diabetes and heart disease. Symptoms are infertility, pelvic pain, excess hair growth on face, chest, stomach, thumbs, and toes. Baldness, ache, oily skin, dandruff, or patches of thicken dark brown or black skin are also some of the symptoms of this disorder.
- ACOG Recommendations:
Cervical cancer:
-Cervical cytology alone every three years from 21-29
-Co-testing with Pap test and HPV every five years for women 30-65 years old w/o cervical cancer history, not immunocompromised, negative for HIV and no history of diethylstilbestrol exposure
-Screening every 3 years with Pap alone is acceptable without risk factors
-Women with risk factors may require unique screening needs
-HIV positive cytology every 6 months after diagnosis and then annually after two consecutive normal results
-No screenings for hysterectomy patients for reasons other than carcinoma, women with history of CIN 2 or 3 should have routine age-based screening for 20 years following post-treatment monitoring
-No screenings for over 65 with no history of cervical cancer and adequate negative results prior to 65.
Breast cancer:
-CBE every 1-3 years for 20-39 and annually for 40 and older
-Annual mammogram for 40 and older
-BSE for all women high risk for breast cancer, breast self-awareness for all women regardless of risk
Elevated cholesterol
-Lipid profile every 5 years beginning at 45, Screening for 19-44 based on risk factors
Osteoporosis
-Screening of women 65 and older or younger women with history of fracture or having one or more risk factors
Colorectal cancer:
-Begin screening at 50 for average risk patients, 45 for African-American women
-Screening of younger women is based on risk factors
-Screen every 10 years with colonoscopy
-Discontinue screening at 75
Ovarian cancer:
-No techniques demonstrate effectiveness for screening asymptomatic low-risk women
-Monitor for signs and symptoms of disease
-Transvaginal US or CA 125 for certain at high risk for epithelial ovarian cancer
Intimate Partner Violence:
-Periodic screening for all adolescents and women
-Screen all women at first prenatal visit, throughout pregnancy and postpartum
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#10 Rape and Definition of Rape
- Sexual abuse of children and adolescents is a serious and complicated issue that requires specialized training in interviews and physical examinations whenever abuse is suspected
- Collaboration with agencies that are specific to children and adolescents should be the goal for this population in effort to avoid lifelong complications related to abuse
- Older patients are also vulnerable because of age related illness and a decrease in physical strength
- Older adults often sustain more injuries and specifically more genital injuries they may feel embarrassed or ashamed therefore recording goes unnoticed, risk factors for being sexually assaulted include impaired hearing, diminished physical strength, reliance on others for help, memory issues, and limited mobility
- 18% of sexual assault victims are people over the age of 60
- The legal definition of rape according to the FBI is penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by sex organ of another person, without the consent of the victim
- Rape is a form of sexual assault, but not all sexual assault is rape.
- 60% of sexual assaults are not reported to the police the incidence of rape is about 10 times higher for women than for men
- If the patient does not desire to pursue an exam in the emergency department or if more than five days have passed since the assault medical care can be managed in an office setting
- If a patient does disclose a sexual assault, the provider should differ a physical examination and refer the patient to the emergency department if the assault occurred within the past 5 days, preferably within 72 hours a referral to the emergency department will ensure that the appropriate measures are taken to collect evidence into comply with standardized protocol
- There are no known absolute risk factors for becoming a victim of sexual assault
#11 Genital Trauma and Rape
- Can include external or internal genitalia
- Can result in pain, structural damage, impaired genitourinary function, sexual dysfunction and infertility
- After Rape or sexual assault, it’s important to complete a thorough physical exam, collect DNA, swabs and document the complete patient report and assessment
#12 Pneumonic EMPOWER
- Empathetic listening
- Making time to properly document
- Providing information about domestic violence (including later in life)
- Offering options and choices
- Working with a domestic abuse specialist (including elderly domestic abuse)
- Encouraging planning for safety and support
- Referring to local services
- Clinical interventions for IPV (intimate partner violence) patients should be based on four important principles: empowerment, childbearing cycle-stage specificity, abuse stage specificity, and cultural competence. Abusers take power and control away from victims by isolating them from the people and information that can help them make thoughtful choices. Therefore, it is crucial that clinicians use empowerment model of offering information, options and support. Clinicians must not judge an abused women’s choices, nor use any kind of tactics to get her to cooperate. An empowerment model should include the information given in the list above.
#13 World Health Organization
- Women’s health matters not only to women themselves. It is also crucial to the health of the children they will bear. This underlines an important point: paying due attention to the health of girls and women today is an investment not just for the present but also for future generations. This implies addressing the underlying social and economic determinants of women’s health – including education, which directly benefits women and is important for the survival, growth and development of their children.
- A life course approach emphases a temporal and social perspective, looking back across an individual’s or a cohort’s life experiences or across generations for clues to current patterns of health and disease, whilst recognizing that both past and present experiences are shaped by the wider social, economic and cultural context. In epidemiology, a life course approach is being used to study the physical and social hazards during gestation, childhood, adolescence, young adulthood and midlife that affect chronic disease risk and health outcomes in later life. It aims to identify the underlying biological, behavioral and psychosocial processes that operate across the lifespan. It fosters a deeper understanding of how interventions in childhood, through adolescence, during the reproductive years and beyond, affect health later in life and across the generations.
#14 CDC HIV Testing recommendations
- CDC recommends that everyone between the ages of 13 and 64 get tested for HIV at least once as part of routine health care. Knowing your HIV status gives you powerful information to help you take steps to keep you and your partner healthy. About 1 in 7 people in the United States who have HIV don’t know they have it.
- You should be tested at least once a year if you keep doing any of these things. Sexually active gay and bisexual men may benefit from more frequent testing (for example, every 3 to 6 months).
- If you’re pregnant, talk to your health care provider about getting tested for HIV and other ways to protect you and your child from getting HIV. If a woman is treated for HIV early in her pregnancy, the risk of transmitting HIV to her baby can be very low. Testing pregnant women for HIV infection and treating those women who have HIV have led to a big decline in the number of children infected with HIV from their mothers. The treatment is most effective for preventing HIV transmission to babies when started as early as possible during pregnancy. However, there are still great health benefits to beginning preventive treatment even during labor or shortly after the baby is born.
- Before having sex for the first time with a new partner, you and your partner should talk about your sexual and drug-use history, disclose your HIV status, and consider getting tested for HIV and learning the results.
- Even if you are in a monogamous relationship (both you and your partner are having sex only with each other), you should find out for sure whether you or your partner has HIV.
- The time between when a person may have been exposed to HIV and when a test can tell for sure whether they have HIV is called the window period. The window period varies from person to person and depends on the type of test used to detect HIV.
- A nucleic acid test (NAT) can usually tell you if you have HIV infection 10 to 33 days after an exposure.
- An antigen/antibody test performed by a laboratory on blood from a vein can usually detect HIV infection 18 to 45 days after an exposure. Antigen/ antibody tests done with blood from a finger prick can take longer to detect HIV (18 to 90 days after an exposure). When the goal is to tell for sure that a person does not have HIV, an antigen/antibody test performed by a laboratory on blood from a vein is preferred.
- Antibody tests can usually take 23 to 90 days to reliably detect HIV infection. Most rapid tests and home tests are antibody tests. In general, antibody tests that use blood from a vein can detect HIV sooner after infection than tests done with blood from a finger prick or with oral fluid.
- Ask your health care provider about the window period for the test you’re taking. If you’re using a home test, you can get that information from the materials included in the test’s package. If you get an HIV test after a potential HIV exposure and the result is negative, get tested again after the window period for the test you’re taking to be sure. If your health care provider uses an antigen/antibody test performed by a laboratory on blood from a vein you should get tested again 45 days after your most recent exposure. For other tests, you should test again at least 90 days after your most recent exposure to tell for sure if you have HIV.
- If you learned you were HIV-negative the last time you were tested, you can only be sure you’re still negative if you haven’t had a potential HIV exposure since your last test. If you’re sexually active, continue to take actions to prevent HIV, like using condoms the right way every time you have sex and taking medicines to prevent HIV if you’re at high risk.
- If you use any type of antibody test and have a positive result, you will need to take a follow-up test to confirm your results. If your first test is a rapid home test and it’s positive, you will be sent to a health care provider to get follow-up testing. If your first test is done in a testing lab and it’s positive, the lab will conduct the follow-up testing, usually on the same blood sample as the first test.
- After you get tested, it’s important for you to find out the result of your test so that you can talk to your health care provider about treatment options if you’re HIV-positive. If you’re HIV-negative, continue to take actions to prevent HIV, like using condoms the right way every time you have sex and taking medicines to prevent HIV if you’re at high risk.
#15 Gravida/Para/Abortus(GTPAL)
GTPAL system:
- Gravidity: number of pregnancies
- Term: Term deliveries (38 weeks or more)
- Preterm: Preterm deliveries (up to 37 weeks)
- Abortus/Miscarriages: Abortion (surgical or miscarriage)
- Living: Living Children
Other terms:
- P: para (number of births of viable offspring)
- nulligravida gravida 0: no pregnancies
- primigravida gravida 1, G1: 1 pregnancy
- secundigravida gravida 2, G2: 2 pregnancies
- nullipara para: 0 offspring
#16 Women’s health statistics
13.4% of women aged 18 and over are in fair or poor health
19.9% of women aged 18 and over have had four or more drinks in one day at least once in the past year
12.2% of women aged 18 and over currently smoke cigarettes
41.0% of women aged 20 and over are obese
33.6% of women aged 20 and over have hypertension (measured high BP and/or taking antihypertensives)
9.5% aged 65 and under are without health insurance coverage
Leading causes of death: heart disease, cancer (breast, lung, colorectal) (Ovarian Cancer is the leading cause of cancer deaths in women excluding breast cancer), stroke (cardiovascular disease)
#17 Pregnancy Statistics
A pregnancy is defined as the time between conception and birth and usually lasts 40 weeks. Nationwide pregnancy numbers and rates are difficult to survey because they also include abortions and miscarriages as pregnancy outcomes. In the United States, the latest figures report some 6.2 million pregnancies for 2010. Of this number, 4 million had a live birth outcome. On the other hand, approximately 1.1 million induced abortions and 1 million miscarriages at all gestational periods were reported. (https://www.statista.com/topics/1850/pregnancy/)
For some women and their partners this may be a pleasant surprise, but for others the pregnancy may be mistimed or simply unwanted. Of the estimated 211 million pregnancies that occur each year, about 46 million end in induced abortion. Approximately 50 percent of all pregnancies in the United States are unplanned, and of these, 43 percent will end in abortion.
#18 Body mass index (BMI) overweight
- A body mass index is the recommended method for identifying women at increased risk for morbidity and mortality from excessive weight. A body mass index (BMI) is calculated using a patient height and weight.
- BMI formula: weight (lbs) x 703 / height (in2)
- A BMI of 19 to 24 is considered normal.
- A BMI of 25 to 29 is considered overweight.
- A BMI of 30 to 39 is considered obese.
- A BMI above 40 is considered extreme obese.
#19 Common conditions of women
#20 Statistics in Unintended Pregnancy
- Nearly 6.6 million pregnancies occur in the US, with slightly more than half (51%) reported as unintended.
- In 2010 615,000 women between 15 and 19 years old became pregnant. 82% of teen pregnancies are unintended. About 60% end in birth and about 25% end in abortion.
- 31% of married women reported an unintended pregnancy, 20% of which end in abortion.
- Women experiencing unintended pregnancy as are increased risk for both interpersonal violence and reproductive coercion.
- Unintended pregnancy is most common among the 18-24-year-old group, women who are unmarried, have income less than 200% of the federal poverty level, minorities or have not finished high school.
- Women who did not graduate high school are three times more likely to have an unintended pregnancy than that of a college graduates but are far less likely to have abortion.
- 1% of infants born to never-married women under 45 were put up for adoption between 1996 and 2002.
- 40% of unintended pregnancies end in abortion.
- After the introduction of mifepristone in 200, medication abortion has increased, accounting for 18.3% of abortions in 2011
- 4% of abortions are performed prior to 13 weeks of gestation, 7.1% between 14 and 20 weeks and 1.4% after 20 weeks gestation
- The majority of abortions are performed via aspiration or medication administration.
- The average cost of a first-trimester abortion is about $500
- In the US labor induction is used in fewer than 2% of abortion
- Nearly half of all abortion in the world are unsafe and lead to significant health and economic consequences.
- Current mortality rate for legal, reported abortions in the US is 0.6 per 100,000 abortions. Risk of death increases with maternal age.
- The risk of death with live birth is 14 times higher than with abortion
- First trimester abortions when properly performed do not affect future risks for infertility, miscarriage, ectopic pregnancy, birth defect, preterm births or birth of and infant with low-birth-weight.
- Minor complications occur in 2.5% of abortions and serious complications 0.5% (complications include infection, missed or incomplete abortion, cervical tear, uterine perforation, hemorrhage and hematometra).
- In 38 states, minors must involve at least one parent or seek judicial bypass to obtain an abortion, except in cases of medical emergency or evidence of abuse/neglect.
- 61% of women who have abortions have had one or more previous births.
- 3/4 of women who have an abortion report a religious affiliation, 28% are Catholic, 15% are Born-Again, Evangelical or Fundamentalist Christians.
#21 Midwifery
Midwifery as practiced by certified nurse-midwives (CNMs®) and certified midwives (CMs®) encompasses a full range of primary health care services for women from adolescence beyond menopause. These services include primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods; admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. These services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers.
#22 Healthy People 2020 – Women’s Health Focus Objectives
ExternalArthritis, Osteoporosis, and Chronic Back Conditions
| Objective Number | Objective |
| 11 | Reduce hip fractures among older adults.
11.1 Females aged 65 years and older |
ExternalBlood Disorders and Blood Safety
| Objective Number | Objective |
| 14 | (DEVELOPMENTAL) Increase the proportion of providers who refer women with symptoms suggestive of inherited bleeding disorders for diagnosis and treatment. |
| 15 | Increase the proportion of women with von Willebrand disease (vWD) who are timely and accurately diagnosed. |
| Objective Number | Objective |
| 3 | Reduce the female breast cancer death rate. |
| 4 | Reduce the death rate from cancer of the uterine cervix. |
| 10 | Reduce invasive uterine cervical cancer. |
| 11 | Reduce late-stage female breast cancer. |
| 15 | Increase the proportion of women who receive a cervical cancer screening based on the most recent guidelines. |
| 17 | Increase the proportion of women who receive a breast cancer screening based on the most recent guidelines. |
| 18 | Increase the proportion of adults who were counseled about cancer screening consistent with current guidelines.
18.1 Increase the proportion of women who were counseled by their providers about mammograms |
ExternalEducational and Community-Based Programs
| Objective Number | Objective |
| 7 | Increase the proportion of college and university students who receive information from their institution on each of the priority health risk behavior areas (all priority areas; unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; and inadequate physical activity).
7.7 Unintended pregnancy |
| 10 | Increase the number of community-based organizations (including local health departments, tribal health services, nongovernmental organizations, and State agencies) providing population-based primary prevention services in the following areas:
10.6 Unintended pregnancy |
| Objective Number | Objective |
| 20 | Reduce exposure to selected environmental chemicals in the population, as measured by blood and urine concentrations of the substances or their metabolites.
20.5 Mercury, females aged 16 to 49 years |
| Objective Number | Objective |
| 1 | Increase the proportion of pregnancies that are intended. |
| 2 | Reduce the proportion of females experiencing pregnancy despite use of a reversible contraceptive method. |
| 5 | Reduce the proportion of pregnancies conceived within 18 months of a previous birth. |
| 6 | Increase the proportion of females or their partners at risk of unintended pregnancy who used contraception at most recent sexual intercourse. |
| 7 | Increase the proportion of sexually active persons who received reproductive health services.
7.1 Increase the proportion of sexually active females aged 15 to 44 years who received reproductive health services |
| 8 | Reduce pregnancy rates among adolescent females.
8.1 Reduce the pregnancy rate among adolescent females aged 15 to 17 years 8.2 Reduce the pregnancy rate among adolescent females aged 18 to 19 years |
| 9 | Increase the proportion of adolescents aged 17 years and under who have never had sexual intercourse.
9.1 Increase the proportion of female adolescents aged 15 to 17 years who have never had sexual intercourse 9.3 Increase the proportion of female adolescents aged 15 years and under who have never had sexual intercourse |
| 10 | Increase the proportion of sexually active persons aged 15 to 19 years who use condoms to both effectively prevent pregnancy and provide barrier protection against disease.
10.1 Increase the proportion of sexually active females aged 15 to 19 years who use a condom at first intercourse 10.3 Increase the proportion of sexually active females aged 15 to 19 years who use a condom at last intercourse |
| 11 | Increase the proportion of sexually active persons aged 15 to 19 years who use condoms and hormonal or intrauterine contraception to both effectively prevent pregnancy and provide barrier protection against disease.
11.1 Increase the proportion of sexually active females aged 15 to 19 years who use a condom and hormonal or intrauterine contraception at first intercourse 11.3 Increase the proportion of sexually active females aged 15 to 19 years who use a condom and hormonal or intrauterine contraception at last intercourse |
| 12 | Increase the proportion of adolescents who received formal instruction on reproductive health topics before they were 18 years old.
12.1 Abstinence-Females 12.3 Birth control methods-Females 12.5 HIV/AIDS prevention-Females 12.7 Sexually transmitted diseases-Females |
| 13 | Increase the proportion of adolescents who talked to a parent or guardian about reproductive health topics before they were 18 years old.
13.1 Abstinence-Females 13.3 Birth control methods-Females 13.5 HIV/AIDS prevention-Females 13.7 Sexually transmitted diseases-Females |
| 14 | Increase the number of States that set the income eligibility level for Medicaid-covered family planning services to at least the same level used to determine eligibility for Medicaid-covered, pregnancy-related care. |
| 15 | Increase the proportion of females in need of publicly supported contraceptive services and supplies who receive those services and supplies. |
| Objective Number | Objective |
| 1 | Increase the proportion of women with a family history of breast and/or ovarian cancer who receive genetic counseling. |
ExternalHeart Disease and Stroke
| Objective Number | Objective |
| 20 | (DEVELOPMENTAL) Increase aspirin use as recommended among adults with no history of cardiovascular disease.
15.1 Women aged 55 to 79 years |
| Objective Number | Objective |
| 8 | Reduce the number of perinatally acquired HIV and AIDS cases.
8.2 Number of new cases of perinatally acquired AIDS |
| 14 | Increase the proportion of adolescents and adults who have been tested for HIV in the past 12 months.
14.3 Pregnant women |
| 17 | Increase the proportion of sexually active persons who use condoms.
17.1 Unmarried females aged 15 to 44 years |
| 8 | (DEVELOPMENTAL) Reduce the number of perinatally acquired HIV and AIDS cases.
8.1 Number of newly diagnosed perinatally acquired HIV cases |
ExternalImmunization and Infectious Diseases
| Objective Number | Objective |
| 11 | Increase routine vaccination coverage levels for adolescents.
11.4 Three doses of Human papillomavirus vaccine (HPV) for females by age 13 to 15 years |
| 12 | Increase the proportion of children and adults who are vaccinated annually against seasonal influenza
12.10 Pregnant women |
ExternalInjury and Violence Prevention
| Objective Number | Objective |
| 39 | (DEVELOPMENTAL) Reduce violence by current or former intimate partners.
39.1 Reduce physical violence by current or former intimate partners 39.2 Reduce sexual violence by current or former intimate partners 39.3 Reduce psychological abuses by current or former intimate partners 39.4 Reduce stalking by current or former intimate partners |
| 40 | (DEVELOPMENTAL) Reduce sexual violence.
40.1 Reduce rape or attempted rape 40.2 Reduce abusive sexual contacts other than rape or attempted rape 40.3 Reduce non-contact sexual abuses |
ExternalMaternal, Infant, and Child Health
| Objective Number | Objective |
| 5 | Reduce the rate of maternal mortality. |
| 6 | Reduce maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery). |
| 7 | Reduce cesarean births among low-risk (full-term, singleton, vertex presentation) women.
7.1 Women giving birth for the first time 7.2 Prior cesarean birth |
| 10 | Increase the proportion of pregnant women who receive early and adequate prenatal care.
10.1 Prenatal care beginning in first trimester 10.2 Early and adequate prenatal care |
| 11 | Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women.
11.1 Alcohol 11.2 Binge drinking 11.3 Cigarette smoking 11.4 Illicit drugs |
| 12 | (DEVELOPMENTAL) Increase the proportion of pregnant women who attend a series of prepared childbirth classes. |
| 13 | (DEVELOPMENTAL) Increase the proportion of mothers who achieve a recommended weight gain during their pregnanciesExternal. |
| 14 | Increase the proportion of women of childbearing potential with intake of at least 400 µg of folic acidfrom fortified foods or dietary supplements. |
| 15 | Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations. |
| 16 | Increase the proportion of women delivering a live birth who received preconception care services and practiced key recommended preconception health behaviors.
16.1 (DEVELOPMENTAL) Discussed preconception health with a health care worker prior to pregnancy 16.2 Took multivitamins/folic acid prior to pregnancy 16.3 Did not smoke prior to pregnancy 16.4 Did not drink alcohol prior to pregnancy 16.5 Had a healthy weight prior to pregnancy 16.6 (DEVELOPMENTAL) Increase the proportion of women delivering a live birth who used contraception to plan pregnancy |
| 17 | Reduce the proportion of persons aged 18 to 44 years who have impaired fecundity (i.e., a physical barrier preventing pregnancy or carrying a pregnancy to term).
17.1 Reduce the proportion of women aged 18 to 44 years who have impaired fecundity |
| 18 | (DEVELOPMENTAL) Reduce postpartum relapse of smoking among women who quit smoking during pregnancy. |
| 19 | (DEVELOPMENTAL) Increase the proportion of women giving birth who attend a postpartum care visit with a health worker. |
ExternalNutrition and Weight Status
| Objective Number | Objective |
| 21 | Reduce iron deficiency among young children and females of childbearing age.
21.3 Females aged 12 to 49 years |
| 22 | Reduce iron deficiency among pregnant females. |
| Objective Number | Objective |
| 2 | Increase the proportion of older adults who are up to date on a core set of clinical preventive services.
2.2 Females aged 65 years and older who are up to date on a core set of clinical preventive services |
ExternalSexually Transmitted Diseases
| Objective Number | Objective |
| 1 | Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections.
1.1 Among females aged 15 to 24 years attending family planning clinics 1.2 Among females aged 24 years and under enrolled in a National Job Training Program |
| 2 | (DEVELOPMENTAL) Reduce Chlamydia rates among females aged 15 to 44 years. |
| 3 | Increase the proportion of sexually active females aged 24 years and under enrolled in Medicaid plans that are screened for genital Chlamydia infections during the measurement year.
3.1 Females aged 16 to 20 years ORDER AN EXAM OR A PLAGIARISM-FREE PAPER HERE 3.2 Females aged 21 to 24 years |
| 4 | Increase the proportion of sexually active females aged 24 years and under enrolled in commercial health insurance plans that are screened for genital Chlamydia infections during the measurement year.
4.1 Females aged 16 to 20 years 4.2 Females aged 21 to 24 years |
| 5 | Reduce the proportion of females aged 15 to 44 years who have ever required treatment for pelvic inflammatory disease (PID). |
| 6 | Reduce gonorrhea rates.
6.1 Females aged 15 to 44 years |
| 7 | Reduce sustained domestic transmission of primary and secondary syphilis.
7.1 Among females |
| 9 | (DEVELOPMENTAL) Reduce the proportion of females with human papillomavirus (HPV) infection.
9.1 Females with types 6 and 11 9.2 Females with types 16 and 18 9.3 Females with other types |
| Objective Number | Objective |
| 6 | Increase smoking cessation during pregnancy. |
- Journal of Women’s Health
- CDC Tobacco Free Social Media Toolkit
- Health Insurance Marketplace
- Women’s Health CEUs
- Healthy People 2020
#23 Breast Cancer Screening
- The American College of Obstetricians and Gynecologist (ACOG) and U.S Preventive Services Task Force (USPSTF) both recommend mammography starting at 50 regardless of breast cancer risk. The USPSTF sites high false positive rates in women younger than 50. Breast cancer deaths are significantly higher among African American women than Caucasian women. According to the American Cancer Society, the differences are primarily attributed to delays in follow-up from mammogram screening leading to delayed diagnosis and treatment.
- Women with NO risk factors
- Mammography age 50-74 (every 2 years)
- Women with risk factors
- Start having mammography at age 40
- + BRCA1/2 genetic testing- Specific inherited mutations in BRCA1 and BRCA 2 most notably increase the risk of female breast and ovarian cancers.
- Common risk factors
- Previous history of breast cancer
- >2 first degree relative
- Early menarche, late menopause, nulliparity
- Obesity
#24 Self-breast examination screening recommendations
- S. Preventive Services Task Force
- Recommends against self breast exams. Lack of evidence supporting benefit vs. harm.
- Grade D (moderate or high certainty that service has no net benefit or harm outweigh the benefit)
- American College of Obstetricians and Gynecologists
- Recommends self breast exams for women of all ages regardless of risk.
- American Cancer Society
- No longer recommends self breast exams
#25 Intimate Partner Violence (IPV) Screening
Healthier Pregnancy: Tools and Techniques to Best Provide ACA-Covered Preventive Services
Provider Fact Sheet
Preventive Service: Intimate Partner Violence Screening Grade: B
U.S. Preventive Service Task Force (USPSTF) Recommendation:
Screen women of childbearing age for intimate partner violence (IPV), such as domestic violence
(DV), and provide or refer women who screen positive to intervention services. This recommendation
applies to women who do not have signs or symptoms of abuse.
Why is this important?
- According to the CDC, it is estimated that roughly 1.5 million women are raped and/or physically assaulted each year in the United States.
- Intimate partner violence (IPV) affects as many as 324,000 pregnant women each year.
- Physical violence perpetrated by intimate partners is also often accompanied by emotionally abusive and controlling behavior.
- Although women of all ages may experience IPV, it is most prevalent among women of reproductive age and contributes to gynecologic disorders, pregnancy complications, unintended pregnancy, and sexually transmitted infections.
- Due to underreporting and lack of recognition, IPV may occur more commonly among pregnant women than conditions for which they are currently being screened (i.e. gestational diabetes, preeclampsia, etc.). IPV can have direct and indirect impacts on fetal health, such as spontaneous abortion and maternal stress, which in turn can induce alcohol or drug use or smoking. These behaviors are associated with poor outcomes like low birth weight, fetal alcohol syndrome, and others. Three studies have also found possible associations between IPV and unintended pregnancies. Research has found that IPV rates are highest in families with young children, which supports intervention during the pre and perinatal periods.
- Screening is effective in the early detection and effectiveness of interventions to increase the safety of abused women.
How frequently is this preventive service being provided?
Ninety-six percent of women receive prenatal care, which can consist of 12-13 prenatal visits. As such, it can be an important window of opportunity to screen. Although screening for IPV is recommended by the USPSTF, studies have shown very low screening rates ranging from 1.5%- 12% in primary care settings.
What are the best screening practices identified in the literature?
American Congress of Obstetricians and Gynecologists (ACOG), in line with the U.S. United States Department of Health and Human Services (HHS) and Institute of Medicine (IOM), recommends that IPV screening and counseling should be a core part of women’s preventive health visits and at periodic intervals, including obstetric care (at first prenatal visit, at least once per trimester, and at the postpartum checkup, as disclosure may not occur at the first attempt). Providers should also offer ongoing support, and review available prevention and referral options.
All of the screening tools evaluated by the USPSTF are directed at patients and can be self-administered or used in a clinician interview format. The 6 tools that showed the most sensitivity and specificity were:
- HITS (Hurt, Insult, Threaten, Scream)
- OVAT (Ingoing Violence Assessment Tool)
- STaT (Slapped, Things and Threaten)
- HARK (Humiliation, Afraid, Rape, Kick)
- CTQ-SF (Modified Childhood Trauma Questionnaire–Short Form)
- WAST (Woman Abuse Screen Tool)
Other screening tools for pregnant women include 4 Ps12 and the Abuse Assessment Screen. CDC has compiled a comprehensive list of screening instruments [PDF] that have been tested on various patient populations. Studies have shown that patient self-administered or computerized screenings are as effective as clinician interviewing in terms of disclosure, comfort, and time spent screening.
What are the best interventions identified in the literature?
Evidence from randomized trials support a variety of interventions for women of childbearing age, including counseling, home visits, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, non-clinician mentors, or community workers. Counseling generally includes information on safety behaviors and community resources. In addition to counseling, home visits may include emotional support, education on problem-solving strategies, and parenting support.
A systematic review that evaluated the benefits of IPV interventions in primary health settings showed that 76% of interventions resulted in at least one statistically significant benefit – reductions of violence, improvement of physical and emotional health, safety promoting behaviors, use of IPV community-based resources. It also highlighted the following domains of successful interventions: focusing on self-efficacy and empowerment, focusing on access to IPV resources, and brief non-physician interventions (collaborative multidisciplinary care teams).
What barriers exist for providers?
- Time constraints
- Discomfort with the topic
- Fear of offending the patient or partner
- Need for privacy
- Perceived lack of power to change the problem, and
- A misconception regarding patient population’s risk of exposure to IPV16
#26 Screening for Rubella Immunity
- Rubella is dangerous for pregnant women and the developing fetus
- Most severe damage occurs in the first trimester of pregnancy
- Congenital Rubella Syndrome (CRS)
- Occurs in fetal development of a non-immune exposed pregnant woman infected with the rubella virus
- Risks of infected pregnant women include
- Miscarriage
- Stillbirth
- Birth defects
- Deafness, cataracts, heart defects, intellectual disabilities, liver and spleen damage, low birth weight, skin rash at birth, glaucoma, brain damage, thyroid/hormone problems, inflammation in the lungs.
- Recommendations for Screening
- All women of childbearing age
- Planning to become pregnant
- Women should be screened prior to becoming pregnant
- If not immune, Rubella vaccine should be given and the woman should be counseled not to get pregnant for at least 4 weeks because Rubella is an attenuated vaccine
- Pregnant women
- If not immune, vaccinate in the post-partum period following delivery
#27 Screening for Osteoporosis
- According to the USPSTF 2018 Recommendations:
- Rationale for Guidelines
- By 2020 12.3 million people over the age of 50 will have Osteoporosis.
- Women are at risk for osteoporosis fractures
- Decreased quality of life- loss of mobility, reduced mobility, pain
- Bone measurement tests for men/women are used in preventing bone fractures
- Recommendations
- Women < 65 years should have at least risk factor to qualify for the DXA scanning
- Repeat bone studies have no benefits
- Risk factors for women
- Hx of smoking
- High alcohol consumption
- Low body weight
- Genetic predisposition
- Corticosteroid use
- Falls/injuries
- Age: 50-59 years old (5.1% prevalence); over 80 years (26.2%).
- Race/Ethnicity: highest in Mexican Americans and non-Hispanic Caucasian adults
- Prevention
- Aerobic exercise
- Muscle strengthening
- Calcium and vitamin D
- Screening Tools
- <65 years old at increased risk of osteoporosis- SCORE, ORAI, OSIRIS, OST,
- FRAX model
- DXA scanning (dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine is standard of diagnosing osteoporosis and guiding for clinical decision making and treatment- provides measurement of bone mineral density (BMD), and most treatment guidelines use central DXA to define osteoporosis and the threshold at which to start drug therapies to prevent osteoporotic fractures.
- Drug therapy for Osteoporosis:
- The USPSTF found convincing evidence that drug therapies reduce subsequent fracture rates in postmenopausal women.
- Bisphosphonates: first line therapy, reduce non/vertebral fractures, not hip fractures. By inhibiting bone resorption, bisphosphonates preserve bone mass and can decrease vertebral and hip fractures by up to 50%.
- Alendronate (10 mg once/day or 70 mg po once/wk)
- Risedronate (5 mg po once/day, 35 mg po once/wk, or 150 mg po once/mo)
- Zoledronic acid (5 mg IV once/yr)
- Ibandronate po (150 mg once/mo) or IV (3 mg once every 3 months)
- Raloxifene: in postmenopausal women reduce vertebral fractures, not non-vertebral fractures. a selective estrogen receptor modulator (SERM) that may be appropriate for treatment of osteoporosis in women who cannot take bisphosphonates.
- Denosumab: reduce non/vertebral and hip fractures. may be helpful in patients not tolerant of or unresponsive to other therapies or in patients with impaired renal function. This drug has been found to have a good safety profile at 10 yr of therapy. Denosumab is contraindicated in patients with hypocalcemia because it can cause calcium shifts that result in profound hypocalcemia and adverse effects such as tetany.
- Parathyroid hormone: 1 trial found significant reduction in vertebral fractures, not non-vertebral fractures
- Estrogen: no studies showed prevention of fractures, however many women start it with 4-6 years
- Rationale for Guidelines
#28 DM Screening in Pregnant and Non pregnant Women
- Fastest growing preventative disease in US women 1.4 million newly diagnosed in 2014
- Increases with age
- Affects minority population in lower socioeconomic populations
- USPSTF assigns a “B” for all women who are 40-70 years old with a BMI > 25 and waist circumference of adipose tissue > 35 inches.
- Screening tests
- Fasting plasma glucose- (>126)
- 2 hour post load plasma glucose- (>200)
- Random glucose (>200)
- Hemoglobin A1C- >6.5 evaluated every 3 months after diagnosis
- Additional lab tests
- Fasting lipid panel every 3 months
- Liver function tests
- Serum creatinine and GFR
- Check for renal compromise
- Urine for protein and albumin to creatinine ratio
- Menopausal
- Increases risk for diabetes and further cardio vascular changes
- Increased body weight and production of adipose tissue
- Affects insulin resistance
- Hormonal changes
- Education and management
- Education about weight management, lifestyle changes, medications and surgery
- Initiating metformin as first line treatment
- Initiating statin therapy after 40 years old
- Smoking cessation, control BP
- Increases risk for diabetes and further cardio vascular changes
- Check for renal compromise
Screening for Diabetes in Pregnant women (gestational)
- The increase in maternal metabolism causes increase glucose utilization, but occurs when there is then a carbohydrate intolerance and increased insulin resistance during the pregnancy
- In Fetus-Causes macrosomia, Low blood glucose from increased insulin, jaundice, increase fat disposition
- Usually occurs during weeks 20 and 30 if no other risk factors
- 1-5% of pregnancies
- 90% resolve postpartum
- 50% of these women will develop DM2 22-28 years later
- Strongly influences by body weight
- Complications caused by GDM
- Pyelonephritis, preterm labor, preeclampsia, increase risk for c section
- Screenings (American College of Obs. and Gyn)
- All women who are pregnant without risk factors should be screened at 24 to 28 weeks
- Women who are at risk for GDM should be screened earlier in first trimester
- Testing
- 50-gram glucose screening (One hour glucose challenge test)
- If >200- diagnosis of GDM
- If >130/140 – 3 hour glucose tolerance test for diagnosis
- 1 hour >190
- 2 hour >165
- 3 hour >145
- Random plasma glucose >200
- Fasting glucose >126
- Screening (International Association of Diabetes and preg. American Diabetes Ass.)
- Testing
- 50-gram glucose screening (One hour glucose challenge test)
- Usually occurs during weeks 20 and 30 if no other risk factors
-
-
- Measures A1C and fasting glucose
-
- Overt diabetes if fasting >126 and A1C >6.5%
- Diagnosed if fasting >126 with no A1C
#29 Cardiovascular Health-Women at Increased Risk Factors
- Increased levels of LDL, Cholesterol, Diabetes, Overweight/Obese, physical inactivity, poor diet, physical inactivity,
- Number one cause of mortality and morbidity- risks factors hypertension, valvular heart disease, CHD, CHF, PAD,
- USPSTF- recommends all women overweight with additional risk factors to to be referred to high intensity behavioral counseling
- Lasting over 6 months to one year.
- Conducted by healthcare provider, but may need referral out
- Lesbian, Bisexual, Queer, and transgender (LBQ, TGNC)
- Are at higher risk for cardiovascular disease.
- The use of estradiol administration causes increases risk thrombolytic events
- African American Women
- Are at significant risk for cardiovascular disease.
- Minority stress may be the cause
- Death rates much higher in black women vs white women
- Menopause
- Puts one at significant risk for developing heart disease
- Due to changes in cholesterol levels
- LDL oxidation increased and HDL decreased,
- Changes in the vasculature elasticity and hypertension
- Caused by decreased levels of progesterone, estrogen, and procoagulation
- CVD Biomarkers screened
- Measure and monitor for dyslipidemia, obesity, hypertension, inflammatory biomarkers, thrombolytic markers, CRP,
- Women with PCOS have higher degree of systemic inflammation putting them at risk for CVD.
- Screen for metabolic syndrome
- Triglycerides>150
- Waist circumference >88cm (35in)
- HDL-C<50
- Systolic BP >130 diastolic >85
- Fasting glucose >100
- Pregnancy
- Cardiac output increased 30-50% therefore women with cardiac disease may become symptomatic during first trimester
- Increased stroke volume
- Heart is displaced during pregnancy
- Screening tests and procedures (from midwifery book)
- CBC, UA for microalbumin, CRP, hemo. A1C,
- Further studies with comorbidites
- BUN, CREA, renal hepatic function profile,
- Electrolytes
- Ca and Mg
- TSH
- Chest function and status
- EKG
- Chest XRAY
- Stress test
- Holder monitor
- Fasting lipid profile
- Total cholesterol
- HDL
- LDL
- Triglycerides
- Work flow of Evaluation
- See bottom of page Appendix A
- Screening process Appendix C
- Consider Consultation, Collaboration, or Referral
- Emergency services
- Systolic BP >180 diastolic >110
- Stroke or MI symptoms
- Findings
- Suspected CV dysfunction
- Elevated lipid levels with dyslipidemia
- HTN
- Normal systolic <120 diastolic <80
- Pre-HTN: 120-139; 80-90
- Stage 1: 140-159: 90-99
- Stage 2: >160; >100
- Metabolic syndrome
- Diabetes
- Behavior modifications
- Nutritionist, weight watchers
- Screening limits for hyperlipidemia and/or CVD
- Begin at 20 years old
- Emergency services
- Cardiac output increased 30-50% therefore women with cardiac disease may become symptomatic during first trimester
- Measure and monitor for dyslipidemia, obesity, hypertension, inflammatory biomarkers, thrombolytic markers, CRP,
- Due to changes in cholesterol levels
- Puts one at significant risk for developing heart disease
- Are at significant risk for cardiovascular disease.
Increased risk 55-64 years old
- See appendix B
# 30 Screening for Osteoporosis in Women
- Osteoporosis is a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, deficiency of calcium or vitamin D.
- Women affected more than men by ratio of 5:1
- Risk factors increases with advancing age and menopause.
- Can be caused secondary to medications such as anticonvulsants, corticosteroids, proton pump inhibitors, contraceptive medications, cancer agents and endocrine/metabolic medications is synthroid/Actos
- Signs and Symptoms
- Some patient may exhibit no symptoms until they have a bone fracture.
- Common symptoms are bone fracture or loss of height.
- Screening/Risk
- All women over the age of 65
- Postmenopausal women 60-65 years with
- Fracture after the age of 45
- Hip fracture in a parent
- Tobacco abuse
- BMI of <22
- Extended glucocorticoid use
- Diagnostic Test
- Bone miner density
- DEXA scan
- Bone densitometry
- Prevention/Treatment
- Calcium (1200-1500 mg/day) and Vitamin D supplements (800-2,000 IU/day) (supplements most cost effective)
- Fosamax
- Wt bearing exercise, tobacco cessation 2 or less, limit alcohol consumption, limit caffeine <250 mg/day, sunlight exposure for 30 mins daily, limit PPH’s, fall prevention.
#31 Screening for Thyroid Dysfunction
- A thyroid dysfunction is any disorder of the thyroid gland such as thyroid nodules, hypo/hyperthyroidism, goiter, thyroiditis, thyroid cancer.
- It is recommended to begin TSH screening in all adults over the age of 35 with repeat test occurring every 5 years.
- Signs and Symptoms
- Hypothyroidism
- Fatigue
- Weight gain
- Cold intolerance
- Dry skin
- Constipation
- Brittle dry hair
- Hyperthyroidism
- Heat intolerance
- Excessive hunger
- Mood swings
- Nervousness
- Insomnia
- Irregular menses
- Abnormal eye protrusion
- Weight loss
- Tremors
- Restlessness
- Fast heart rate
- Screening
- Screen in individuals with greater risk of elevated TSH levels such as older age, Caucasian ethnic background, Type 1 Diabetes, Down Syndrome and external radiation of the head or neck
- Screen in individuals with risk factors for low such as female gender, older age, African ancestry, low iodine intake, personal or family history of thyroid disease.
- Diagnostic Tools
- Serum TSH test (multiple test should be done over 3-6 months intervals to confirm or r/o abnormal findings).
#32 Evidentiary Examination
- Evidentiary examination is ideally performed by SANE (Sexual Assault Nurse Examiner) nurses.
- Nurses are all female and on call 24 hrs/day
- Having an evidentiary exam does not obligate you to report your experience to the police.
- When an evidentiary exam is performed confidentiality is kept unless the victim wants to share.
- Procedure: (Recommendations)
- Usually encouraged wait until the exam to change out of the cloths that assault occurred in.
- Patient should bring a change of cloths.
- Patient should try not to eat, drink, douche, wash hand, comb hair, or brush teeth prior to the exam for evidence reasons.
- During the exam:
- The patient should be in control
- Patient should bring a friend or support system
- Patient will be asked about detailed accounts of the assault, then a physical exam will be performed with an evidence collection kit. Will include urine sample, a vaginal swab, penile swab, pubic hair combing, an oral swab, rectal swab and others swabs of areas that may contain evidence and a finger prick for SNA sample and testing for date rape drugs.
- Following the Exam:
- The SANE will discuss any risk the patient may have been exposed to during the assault and will offer treatment for STIs and pregnancy prevention.
#33 Use of Rectovaginal Examination
- Rectovaginal examination allows clinicians to examine and identify abnormalities in the pelvic area, most specifically those of the uterus and ovaries.
- Helps to determine where and how large the pelvic organs are.
- Not an accurate screening usually reserved for women who may have rectal or pelvic pain, diagnosing a tilted pelvis, identifying abnormalities of the ovaries, obtaining fecal blood sample, and to identify scarring or mass that could be cancerous or other disease.
- How to perform a rectovaginal examination
- Re-glove and apply lubricant to index and middle finger.
- Alert the patient that the rectovaginal exam will begin
- Place the middle finger on anus and ask patient to bear down
- Insert middle finger into rectum and index finger into vagina
- Repeat the palpation and characterization of the cervix and other structures from this position
- Sweep posterior pelvic wall with rectal finger
- Remove fingers smoothly
- Help the patient assume sitting position.
#34 Colorectal Cancer Screening (CRC)
- A colorectal cancer screen is performed to evaluate for cancer of the colon or rectum.
- Signs and Symptoms
- Change in bowel habits
- Rectal bleeding with bright red blood
- Blood in stool which makes the stool appear dark
- Cramping or abdominal pain
- Weakness and fatigue
- Unintended weight loss
- Screening
- Screening starting at age 50 years old and continuing until age 75 (earlier if high risk)
- American College of Gastroenterology recommends black patients start screening at 45 years old.
- USPTF recommends stopping screening at age 85.
- Risk
- High Risk
- One first degree relative with colorectal cancer or 2 first degree relatives with advanced adenoma at any age.
- Start colonoscopy at age 40 years or colonoscopy 10 years earlier than the youngest case. Repeat colonoscopy every 5 years.
- Moderate Risk
- family history- one first degree with colorectal cancer or 2 second degree relatives with colorectal cancer or advanced adenoma at any age.
- Start colonoscopy at age 40 years, repeat colonoscopy every 10 years.
- Risk Factors
- Age 50 years
- IBD- Ulcerative Colitis, Crohns Disease
- PMH of adenomatous polyps >55 mm
- Cholecystectomy
- Pelvic irradiation
- Family history
- Tobacco abuse
- Obesity
- High Fat diet (increased saturated fats is associated w adenomatous polyps)
- Prevention:
- High physical activity
- High fruit and vegetable intake
- High dietary fiber intake (long term recommendation)
- High Dietary Calcium intake
- Diagnostic Tools
- Colonoscopy- can be used for screening and diagnosis of colorectal cancer.
- Proctoscopy- performed if rectal cancer is suspected.
- Biopsy- performed if suspected colorectal cancer is found during the screening or diagnostic test.
- CT/CAT scan- can help to diagnosis metastasis
- Endorectal U/S and Intraoperative U/S
- Endorectal MRI
- family history- one first degree with colorectal cancer or 2 second degree relatives with colorectal cancer or advanced adenoma at any age.
- One first degree relative with colorectal cancer or 2 first degree relatives with advanced adenoma at any age.
- High Risk
- Signs and Symptoms
#35 HPV Vaccination
- Gardasil-9 released in 2015, replaced the original Gardasil vaccination. (IM injection)
- Has 5 HPV antigens along with the 4 in the original Gardasil vaccine.
- Protects against HPV 16, 18, 6, 11, 31, 33, 45, 54, and 58)
- Improves risk of cervical cancer by 90%
- Prevention of cervical dysplasia
- Prevention of anal cancer
- Highest efficacy when administered prior to onset of sexual activity (prior to exposure).
- Vaccination Ages/ Dose Ranges:
- Two dose schedule:
- 6-12 months apart
- Indicated for ages 9-14 (older than 15 use 3 dose schedules)
- First dose must be 5 months apart
- Three dose schedule:
- 15 years old or immunocompromised.
- Scheduled 0,2 and 6 months
- If one dose given before age 15 years old, may give a single booster dose age 15-26 years old.
- Two dose schedule:
- Risk:
- Adverse reaction:
- local injection site pain
- fever
- redness
- swelling
- headaches
- syncope
- Contraindication:
- Pregnancy
- Anaphylaxis to yeast
- Adverse reaction:
#36 STI Screening
- Transmission:
- Contact
- Secretions
- Mucus membrane
- Skin abrasion
- Intercourse not necessary for STD transmission
- Herpes Simplex Virus
- Condyloma
- Gonorrhea
- Chlamydia
- Risk Factors:
- Adolescents
- Multiple partners
- Sequential monogamy
- Unconcerned
- Uniformity
- Racial or ethically skewed
- Black (chlamydia more common)
- Homosexual men or women
- Coasts or ports of Entry
- Prostitutes
- Teenage Runaways
- Immigrants
- Low income in urban setting
- Prison inmate (current or former)
- Military recruits
- Mental Illness
- Injection drugs user IV
- Sexual Abuse History
- Adolescents
- Signs/Symptoms:
- Vaginal discharge
- Dyspareunia
- Postcoital spotting
- Genital ulcers
- Cervicitis (erythema of cervix)
- Mucopurulent discharge
- Management:
- Initiating empiric treatment for suspected STD prior to results is appropriate
- Treatment for suspected Chlamydia and Gonorrhea
- Ceftriaxone 250 mg IM and Azithromycin 1 gm orally or Doxycycline 100 mg BID x 7 days of Azithromycin allergy
- Routine rescreening positive STD cases in 3 months to identify new STD infection.
- Expedite partner treatment
- Encourage sexual partners to seek their own evaluation- delayed eval can lead to re-exposure.
- CDC asks physicians to consider treating sexual partners of STD patients w/o visits. (Provider should ask about partner allergies, other medications taking, and pregnancy)
- Patient and their partner should abstain from sex for 7 days after completing course.
- Prevention:
- Assess risk
- Behavioral counseling
- Gonorrhea and Chlamydia screening
- All sexual active adolescents 24 years old and younger
- Women at risk for STI
- HIV Screening
- All patients ages 15 years old to 65 years old
- All pregnant women at first prenatal visit
- Hep B Virus
- All pregnant women, 1st prenatal visit
- Immigrants from Africa, Central and Southeast Asia, China
- Household HBV Contacts
- Syphilis
- All pregnant women at 1st prenatal visit
- Patient at risk of infection
- Herpes Simplex Virus (HSV)
- DO NOT routinely screen HSV serology in asymptomatic patients
- Consider type specific serology in women at time of STI eval.
- LABS:
- Chlamydia –DNA probe
- HIV Test
- Gonorrhea – DNA probe
- Syphilis (RPR)
- Vaginal Wet Prep
- Hepatitis B Testing
- Urinalysis
- Assess risk
#37 Cervical Cancer Screening
- Cervical cancer screening screens for cancer of the cervix (lower part of the uterus.
- Peak: 40-60 years
- Range: 20-80 years
- Lifetime risk
- Increased mortality in Hispanic and black women
- Risk
- Increased sexual partners
- Early age of first intercourse under age 18 yrs
- Male partners w history of multiple partners
- Tobacco use increases risk
- Immunosuppression (HIV infection and chemotherapy)
- Previous abnormal pap smear
- Lack of pap smear
- No pap smear in the last 5 years
- History of STD’s (including HPV)
- Long term oral contraceptive use
- Lower socioeconomic class
- Uncircumcised male partner
- Vitamin D deficiency
- Sign and Symptoms
- Abnormal uterine bleeding
- Large lesions may cause regional symptoms such as bladder obstruction, back pain, or pelvic pain, hematuria, and post renal failure.
- Screening
- Low Risk
- Age under 21 years old
- Hysterectomy for benign disease
- Age 65-70 or over
- Moderate Risk
- Initial screening age 21-30 yrs old
- Pap ever 3 years for those under 30 yrs
- Age 30-65 yrs old with intact uterus and cervix
- Cotesting with cytology and HPV testing every 5 years
- Cytology alone every 3 years or primary HPV testing w/o cytology every 3 years
- Age 65 years and older
- No screening needed if adequate negative pap smear history.
- Moderate risk cervical cancer screening starts at the age of 21 regardless of sexual activity.
- Cervical cancer screening is not needed in very low risk patients
- High Risk
- Start screening immunosuppressed patients within one year of onset of sexual activity such HIV, sexual activity before 20 yrs
- STD prevention
- Patients with 3 or more lifetime partners
- History of HPV or other STD’s
- Tobacco Abuse
- Management:
- Total hysterectomy w/o uterine or cervical cancer
- Continue screening for 20 years
- Obtain vaginal cytology every 3 years or contesting w HPV every 5 years.
- Low Risk
#38. Types of Speculums and Use of different types of Speculums
- Graves Speculum– The bills of the Graves speculum are wider than the bills of the Pederson speculum. The sides of this speculum are also curved. This type of speculum is best used in women who have had sexual intercourse. This is because the vaginal canal may be wider in sexually active women, making the wider bills of the Graves speculum necessary to visualize the cervix and other internal structures of the pelvis. For women with significant pelvic or genital adipose tissue, lax vaginal walls, or grand multiparity, the large Graves speculum will not only allow the best visualization but will also be more comfortable.
- Pederson Speculum (Virgin Speculum)– For individuals who are pre-coitarche but still require an internal examination, nulliparas, postmenopausal women, transgender men on testosterone, or transgender women with neovaginas, the Pederson speculum is the usual choice. Its blades are the same length as those of the Graves speculum but are narrower and flat rather than curved designed for women who have narrow vaginal canals. Narrow vaginal canals can be caused by traumatic injuries and scar tissue. They are also found in elderly women and women who have never had sexual intercourse. Using this narrow speculum can eliminate some of the discomfort of a pelvic exam by minimizing pressure on the anterior and posterior vaginal walls and make it easier to visualize internal structures to ensure they are normal in size and shape. A pediatric speculum may also be considered for these individuals. This shape and size minimize pressure on the anterior and posterior vaginal walls, promoting a more comfortable examination.
- Plastic and metal speculum are equally clean and effective, and their availability is often according to provider or clinic preference.
#39. Sexually Transmitted Infections
- The term sexually transmitted infection does not refer to any one specific disease, but rather refers to “a variety of clinical syndromes caused by pathogens that can be acquired and transmitted through sexual activity. Preventing, identifying, and managing STIs are essential components of women’s health care.
- Infection and the Causative Organism
- Chancroid- Haemophilus ducreyi
- Chlamydia- Chlamydia trachomatis
- Genital herpes- Herpes simplex virus
- Genital warts- Human papillomavirus (HPV)
- Gonorrhea- Neisseria gonorrhoeae
- Hepatitis- Hepatitis B virus (HBV),
- Hepatitis C- virus (HCV)
- Human immunodeficiency virus (HIV)
- Acquired immunodeficiency syndrome (AIDS)
- Molluscum contagiosum- Molluscum contagiosum virus
- Pubic lice- Phthirus pubis
- Syphilis- Treponema pallidum
- Trichomoniasis- Trichomonas vaginalis
- Risk Factors for Sexually Transmitted Infections and HIV
- Previous or current sexually transmitted infection
- Sex with multiple or new partners
- Initiating sex at a young age
- Unprotected sex
- Sex with high-risk partners
- Sex with an partner who has HIV
- Sex in exchange for money or drugs
- Sex while intoxicated
- Illegal drug use
- Injection drug use
- Mental illness
- Age < 25 years
- Living in an area with high sexually transmitted infection/HIV prevalence
- Residing in a detention or correctional facility
- All women who are sexually active should be screened for STI’s regularly through history, physical examination, and laboratory studies based on risk factors.
- Among women who have been sexually assaulted the most common diagnosed STI’s are gonorrhea, chlamydia, and trichomoniasis. Broad spectrum antibiotic treatment is offered to these victims to cover these infections.
- qViral STI’s, such as HSV and HPV, can be spread via skin to skin mucosal contact without penetrative sex.
- HPV
- HPV comprises a group of double-stranded DNA viruses with more than 100 known serotypes, of which more than 40 can infect the genital tract, including the external genitalia, vagina, urethra, and anus. Most HPV infections are asymptomatic, subclinical, or unrecognized, and clear spontaneously. HPV can cause genital warts, and persistent infection with high-risk, oncogenic strains can cause cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Most (90%) genital warts are caused by HPV types 6 and 11, which carry a low risk for triggering invasive cancer. Some other types (i.e., 16, 18, 31, 33, and 35) that are occasionally found in genital warts are associated with cervical intraepithelial neoplasia. Two high-risk HPV types, 16 and 18, cause 70% of all cervical cancers. NURS 6551 Midterm Study Guide. Genital warts in women are most frequently seen around the vaginal introitus, but can also occur on the cervix, vagina, perineum, and anus/ perianal area. Typically, the lesions present as small, soft, papillary swellings, occurring singularly or in clusters on the genital and anal–rectal region. Warts are usually flesh-colored or slightly darker on Caucasian women, black on African American women, and brownish on Asian women. Infections of long duration may appear as a cauliflower-like mass. The most clinically significant HPV types can now be prevented with vaccination. Routine HPV vaccination is recommended for girls aged 11 to 12 years. HPV vaccines can be given to girls as young as age 9 and are also recommended for adolescents and women aged 13 to 26 years who were not vaccinated or did not complete the series earlier. The HPV vaccines are not recommended during pregnancy but can be given during lactation. The primary goals of treatment of visible genital warts are removal or reduction of warts and relief of signs and symptoms, not the eradication of HPV. If left untreated, genital warts may resolve, remain unchanged, or increase in size and number. Treatment of genital warts can be difficult. A woman often must make multiple office visits if clinician-administered regimens are used. Patient applied treatments (Podofilox 0.5% solution or gel) need to be repeated for months.
- Genital Herpes
- Genital herpes is a recurrent, incurable viral infection characterized by painful vesicular eruptions of the skin and mucosa of the genitals. Two types of herpes simplex virus have been identified as causing genital herpes: HSV-1 and HSV-2. HSV-2 is usually transmitted sexually, whereas HSV-1 is transmitted either non-sexually or through oral– genital contact. Systemic antiviral drugs may partially control the symptoms and signs of HSV infections when used for primary or recurrent episodes. Three antiviral medications provide clinical benefits for genital herpes: acyclovir, valacyclovir, and famciclovir.
- Primary Infection- Acyclovir 400 mg orally 3 times a day for 7–10 days
- Recurrent Infection- Acyclovir 400 mg orally 3 times a day for 5 days
- Suppressive Therapy- Acyclovir 400 mg orally 2 times a day NURS 6551 Midterm Study Guide
- Chancroid
- Chancroid is a bacterial infection of the genitourinary tract caused by the gram-negative bacteria Haemophilus ducreyi. Chancroid is a genital ulcer and, therefore, is a risk factor for HIV transmission. The major way chancroid is acquired is through sexual contact and trauma. Most women with chancroid present with a history of a painful macule on the external genitalia that rapidly changes to a pustule and then to an ulcerated lesion. The recommended treatments for chancroid are azithromycin 1 gm orally in a single dose, ceftriaxone 250 mg IM in a single dose, ciprofloxacin 500 mg orally twice a day for 3 days or erythromycin base 500 mg orally 4 times a day for 7 days.
- Pediculosis
- Pediculosis is a parasitic infection caused by any of three species of lice: Pediculosis humanus capitis (head louse infecting the scalp), Pediculosis humanus corporus (body or clothing louse infecting the trunk), and Phthirus pubis (pubic lice or “crabs”). P. pubis inhabits the genital area but may also be found in other hair-bearing areas of the body, including the axillae, chest, thighs, eyelashes, and head. A woman may be infected through sexual transmission or contact with infected clothing or bedding. Diagnosis is made by direct examination of the egg cases (nits) in the involved area. Although the nits are usually visible to the naked eye, a hand lens and light can be helpful in identifying them. Black dots (excreta) may be visible on the surrounding skin and underclothing, and crusts or scabs may be seen in the pubic area. Women with pediculosis pubis should be tested for other STIs. Recommended treatments for pediculosis pubis include permethrin 1% cream rinse and pyrethrins with piperonyl butoxide NURS 6551 Midterm Study Guide
- Trichomoniasis
- Trichomoniasis is caused by Trichomonas vaginalis, an anaerobic one-celled protozoan with characteristic flagellae. This organism most commonly lives in the vagina in women, and in the urethra in men. Trichomoniasis is sexually transmitted during vaginal–penile intercourse or vulva-to-vulva contact. Nonsexual transmission is possible but rare. Trichomoniasis is strongly associated with an increased risk of HIV transmission. Although trichomoniasis is often asymptomatic, women can experience a characteristically yellow to greenish, frothy, mucopurulent, copious, malodorous discharge. Inflammation of the vulva, vagina, or both may be present, and the woman may have irritation, pruritus, dysuria, or dyspareunia. Typically, the discharge worsens during and after menstruation. Diagnosis is usually made by visualization of the typical one-celled flagellate trichomonads on microscopic examination of vaginal discharge. All patients with trichomoniasis should be tested for other STIs, including chlamydia, gonorrhea, syphilis, and HIV. The nitroimidazoles are the only antimicrobial medications that are effective against T. vaginalis. The recommended treatment for trichomoniasis is metronidazole 2 gm orally in a single dose or tinidazole 2 gm orally in a single dose.
- Most reoccurrences of trichomoniasis are thought to be due to reinfection. If single-dose metronidazole treatment fails and reinfection is excluded, metronidazole 500 mg orally twice a day for 7 days should be prescribed.
- Chlamydia
- Chlamydia, which is caused by the bacterium Chlamydia trachomatis, is the most commonly reported nationally notifiable infection in the United States and the most common bacterial STI. Sexually active adolescents and women aged 15 to 24 years of age have nearly three times the prevalence of chlamydia as women aged 25 and 39 years, and women are infected at a rate of two times that of men. The prevalence of chlamydia is six times higher in black women than in white women. Risk factors for this infection include multiple sexual partners and failure to use barrier methods of contraception. The most serious complication of chlamydial infections for women is PID. Women experiencing symptoms may report vaginal spotting or postcoital bleeding, mucoid or purulent cervical discharge, urinary frequency, dysuria, lower abdominal pain, or dyspareunia. Bleeding results from inflammation and erosion of the cervical columnar epithelium. Symptoms of chlamydia infection in women may mimic those of a urinary tract infection (UTI). All sexually active women younger than 25 years should be screened for chlamydia annually. Women 25 years and older with risk factors (e.g., new or multiple partners, partner with an STI, partner with other partners) should also be screened. Chlamydia testing can be performed using first catch urine or swab specimens from the endocervix or vagina. Screening procedures for chlamydial infection include NAATs, cell culture, direct immunofluorescence, enzyme immunoassay (EIA), and nucleic acid hybridization tests. All patients with chlamydia should be tested for other STIs, including gonorrhea, syphilis, and HIV. Recommended treatment is Azithromycin 1 gm orally in a single dose or Doxycycline 100 mg orally 2 times a day for 7 days. Clinicians should advise all individuals with chlamydia to be rescreened 3 months after treatment to assess for reinfection. Women should be advised to abstain from sex until their sexual partners are treated and to wait 7 days after single-dose treatment or until completion of a 7-day regimen before resuming sexual activity.
- Gonorrhea
- Gonorrhea, which is caused by the aerobic, gram negative diplococcus Neisseria gonorrhoeae, is the second most commonly reported bacterial STI in the United States, after chlamydia. Gonorrhea is almost exclusively transmitted by sexual activity, primarily through genital-to-genital contact; however, it is also spread by oral-to-genital and anal-to-genital contact. Sites of infection in females include the cervix, urethra, oropharynx, Skene’s glands, and Bartholin’s glands. The main complication of gonorrheal infections is PID. Women may also develop a pelvic abscess or Bartholin’s abscess. Women with gonorrhea often remain asymptomatic, with as many as 80% of women having no symptoms from this infection. When symptoms are present, they are often less specific than the symptoms in men. Women may report dyspareunia, a change in vaginal discharge, unilateral labial pain and swelling, or lower abdominal discomfort. Later in the infection’s course, women may describe a history of purulent, irritating vaginal discharge, or rectal pain and discharge. Annual screening for gonorrhea is recommended for all sexually active women younger than 25 years. Women who are 25 or older should be screened based on risk factors such as inconsistent or absent condom use, new or multiple partners, partner with an STI or other partners, and exchange of sex for drugs or money. Clinicians should also inquire about recent travel that included sexual partners outside the United States. Gonorrhea testing can be performed by culture and NAATs. NAATs can be performed using urine or swab specimens from the endocervix or vagina. Ceftriaxone 250 mg IM in a single dose or Cefixime 400 mg orally in a single dose, plus Azithromycin 1 gm orally in a single dose is recommended.
- Pelvic Inflammatory Disease (PID)
- Pelvic Inflammatory Disease (PID) occurs in the upper female genital tract and includes any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Multiple organisms have been found to cause PID, and most cases are associated with infection by more than one organism. Common causative agents include N. gonorrhoeae and C. trachomatis. Bacterial vaginosis is common in women with PID and may facilitate the ascent of microorganisms into the upper genital tract. Major health complications are associated with PID. Acute and chronic reproductive sequelae include tubo-ovarian abscess, ectopic pregnancy, infertility, chronic pelvic and abdominal pain, dyspareunia, and recurring PID. A clinical diagnosis of PID is often made based on findings of pelvic organ tenderness and signs of lower genital tract infection, including mucopurulent cervicitis and cervical friability. There is no single laboratory test that can be used to detect upper genital tract infections. Instead, a pH test and wet mount of the vaginal secretions should be performed, along with tests for chlamydia and gonorrhea. Other laboratory tests that are not needed for diagnosis but are recommended for women with clinically severe PID are a complete blood count (CBC) and erythrocyte sedimentation rate (ESR), which, if positive, increase the specificity of the PID diagnosis. Treatment includes Ceftriaxone 250 mg IM in a single dose plus Doxycycline 100 mg orally 2 times a day for 14 days with or without Metronidazole 500 mg orally 2 times a day for 14 days. NURS 6551 Midterm Study Guide
- Syphilis
- Syphilis is a systemic disease caused by Treponema pallidum, a motile spirochete. In contrast to other bacterial STIs that affect mostly adolescents and adults younger than 25 years, syphilis rates are highest among men between the ages of 20 and 29. Transmission is thought to occur by entry into the subcutaneous tissue through microscopic abrasions that can be created during sexual intercourse. The infection can also be transmitted through kissing, biting, or oral–genital sex. Syphilis is characterized by periods of active symptoms and periods of asymptomatic latency. It is divided into stages based on clinical findings, which helps guide treatment decisions.
- Primary syphilis is characterized by a primary lesion, or a chancre, which often begins as a painless papule at the site of inoculation and then erodes to form a nontender, shallow, indurated, clean ulcer that is several millimeters to a few centimeters in size. The chancre contains spirochetes and is most commonly found on the genitalia, although it may also occur on the cervix, perianal area, or mouth.
- Secondary syphilis is characterized by a widespread, symmetrical maculopapular rash on the palms of the hands and soles of the feet and generalized lymphadenopathy. The woman may also experience flu-like symptoms such as fever, headache, and malaise. Condylomata lata (wart-like lesions) may develop on the vulva, perineum, or anus. Some women experience alopecia and have a “moth-eaten” look or lose the lateral one-third of an eyebrow.
- Tertiary syphilis- a woman with syphilis is untreated, she enters a latent phase, which is asymptomatic for the majority of individuals. At this point, if the infection is still not treated, approximately one-third of patients will develop tertiary syphilis. Cardiovascular (chest pain, cough), dermatologic (multiple nodules or ulcers), skeletal (arthritis, myalgia, myositis), and neurologic (headache, irritability, impaired balance, memory loss, tremor) symptoms can all develop in this stage. Neurologic complications are not limited to tertiary syphilis; rather, a variety of syndromes (e.g., meningitis, meningovascular syphilis, general paresis, and tabes dorsalis) may span all stages of the disease.
- Dark-field examination and direct fluorescent antibody for T. pallidum (DFA-TP) of lesion exudates or tissue will provide a definitive diagnosis of early syphilis. RPR ot VDRL are screening tests for syphilis. If positive confirm with FTA-ABS (treponemal test). Benzathine penicillin G 2.4 million units IM in a single dose is the recommended treatment. If the patient has a penicillin allergy the alternate treatment is Doxycycline 100 mg orally 2 times a day for 14 days.
- Syphilis is a systemic disease caused by Treponema pallidum, a motile spirochete. In contrast to other bacterial STIs that affect mostly adolescents and adults younger than 25 years, syphilis rates are highest among men between the ages of 20 and 29. Transmission is thought to occur by entry into the subcutaneous tissue through microscopic abrasions that can be created during sexual intercourse. The infection can also be transmitted through kissing, biting, or oral–genital sex. Syphilis is characterized by periods of active symptoms and periods of asymptomatic latency. It is divided into stages based on clinical findings, which helps guide treatment decisions.
- HIV
- HIV- In the early summer of 1981, the occurrence of several rare illnesses such as Pneumocystis carinii (now called P. jiroveci) pneumonia, Mycobacterium and M. intracellulare infections, cryptosporidiosis, Kaposi’s sarcoma, and non-Hodgkin’s lymphoma in a cluster of gay and bisexual men presented a medical mystery, which was subsequently solved by the identification of a single infectious agent that was destroying the immune system of persons who acquired it—the human immunodeficiency virus. HIV specifically targets CD4 cells, binding to the cell surface protein known as the CD4 receptor. The virus affects the cells in two ways: The absolute numbers of these cells are depleted and the function of the remaining cells is impaired, resulting in a gradual loss of immune function. Progressive depletion of CD4 cells in peripheral blood occurs with advancing HIV infection, such that CD4 cell counts are used to estimate the cumulative immunologic damage caused by HIV. If its course is unimpeded, HIV can destroy as many as one billion CD4 cells per day. In addition to its aggressive destruction of the immune system, HIV is genetically highly variable, mutating with apparent ease. several factors increase women’s risk for acquiring STIs, including HIV. In addition to the anatomically driven susceptibility of the female genitalia, the integrity of the tissues of the lower genital tract influences HIV transmission risk. Trauma during intercourse (including both vaginal and anal-receptive intercourse), STI-related inflammation or cervicitis, and an STI lesion (e.g., HSV ulcer or syphilitic chancre) may all increase susceptibility to HIV infection, as does any activity or condition that disrupts the tissues of the vagina. HIV can also be transmitted through receptive oral sex with ejaculation. Any condition that interrupts the integrity of oral tissues, including periodontal disease, increases the risk of HIV transmission in this manner. The CDC (2015b) now recommends HIV screening be a routine part of clinical care for patients aged 13 to 64 years in all healthcare settings. Patients presenting for STI treatment should be screened for HIV at each visit where they have new symptoms. Individuals at high risk for HIV should be tested for the presence of the virus at least once a year. HIV infection can be diagnosed by serologic tests that detect antibodies to HIV-1 and HIV-2 and by virologic tests that detect antigens to HIV or RNA. HIV screening is conducted with standard enzyme-linked immunosorbent assay (ELISA) or enzyme immunoassay (EIA) tests that are sent to a laboratory, or with newer rapid HIV tests that can be performed at the point of care and yield results within minutes. If the screening test is reactive, then a more specific confirmatory test such as the Western blot (WB) or an indirect immunofluorescence assay (IFA) is conducted. Effective management and treatment of the patient with HIV involves the use of antiretroviral therapy (ART) to improve health, decrease morbidity, prolong life, and reduce the risk of transmission to others. More than 25 different antiretroviral medications are available, which belong to six classes: nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), fusion inhibitors (FIs), CCR5 antagonists, and integrase strand transfer inhibitors (INSTIs). All pregnant women should be tested for HIV at their initial prenatal visit, regardless of whether they were tested previously. Repeat testing at 36 weeks’ gestation can be considered for women at high risk for HIV or for women who live in geographic areas where there is a high incidence of HIV among women. Trichomoniasis is common among women who have HIV. Zidovudine is the drug choice for pregnant women.
- Genital herpes is a recurrent, incurable viral infection characterized by painful vesicular eruptions of the skin and mucosa of the genitals. Two types of herpes simplex virus have been identified as causing genital herpes: HSV-1 and HSV-2. HSV-2 is usually transmitted sexually, whereas HSV-1 is transmitted either non-sexually or through oral– genital contact. Systemic antiviral drugs may partially control the symptoms and signs of HSV infections when used for primary or recurrent episodes. Three antiviral medications provide clinical benefits for genital herpes: acyclovir, valacyclovir, and famciclovir.
#40 Counseling and reduction in STIs
#41 Normal Vs Abnormal Pap Smear
The Pap test is indicated to screen for malignant and premalignant lesions of the cervix. The recommended age at initiation of cervical cancer
Guidelines Papsmear:
Pap smear screening at age at the ag of 21 regardless of sexual history
Abnormal cytology common in young women and mostly resolve byitself
Table. Summary of 2012 Screening Guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology (Open Table in a new window)
| Parameters | ACS Recommendations |
| Age to start screening | Begin screening with cytology at 21 years old, regardless of sexual history |
| Screening interval age 21–29 | Screen with cytology alone every 3 years.* HPV testing should not be used for screening in this age group. |
| Screening interval age 30-65 | Screen with a combination of cytology and HPV testing every 5 years (preferred) or cytology alone every 3 years. Screening by HPV testing alone is generally not recommended.* |
| Age to stop screening | Age 65, if the woman has adequate negative prior screening and is not otherwise at high risk for cervical cancer |
| Screening after hysterectomy | Not indicated for women without a cervix and without a history of a high-grade precancerous lesion (eg, CIN2 or CIN3) in the past 20 years or cervical cancer ever |
| HPV-vaccinated women | Screen according to the same recommendations as for unvaccinated women NURS 6551 Midterm Study Guide |
Interpreting Cytology Results
Results from cervical cytology specimens are reported according to the 2001 Bethesda System Classification, as listed below.
Negative for intraepithelial lesion or malignancy
Epithelial cell abnormality
Squamous cell
- Atypical squamous cells (ASC) of undetermined significance (ASC-US) or atypical squamous cells that cannot exclude HSIL (ASC-H)
- Low-grade squamous intraepithelial lesions (LSIL), includes human papillomavirus (HPV), mild dysplasia, and CIN 1
- High-grade squamous intraepithelial lesions (HSIL), includes moderate to severe dysplasia, carcinoma in situ, CIN 2, and CIN 3
- Squamous cell carcinoma
Glandular cell
- Atypical glandular cells (AGC), specify endocervical, endometrial, or not otherwise specified (NOS)
- Atypical endocervical cells, favor neoplastic, specify endocervical or NOS
- Endocervical adenocarcinoma in situ (AIS)
- Adenocarcinoma
Women aged 20 years or younger with ASC-US or LSIL
- HPV infection and minor abnormal cytology results common in adolescents, but invasive cancer is rare
- Per 2009 ACOG guidelines, Pap tests only recommended beginning at age 21 years, regardless of sexual history; however, Pap tests are still performed in the 20 years or younger age group in some cases because of lack of knowledge of current guidelines
- Conservative management preferred for this group because of the high likelihood of spontaneous resolution within 2 years of initial infection; abnormal cervical cytology in adolescents, therefore, should be followed according to the recommendations for women ages 21-24 years, as described above
Pregnant women with ASC-US
- Managed same as nonpregnant women
- Endocervical curettage (ECC) is contraindicated in pregnant women and should not be collected if colposcopy is performed
- Deferring colposcopy until at least 6 weeks postpartum is also acceptable
Management of women with LSIL
Women aged 25 years or greater with LSIL
- Perform colposcopy
- If HPV co-testing was performed and negative, repeat co-testing in 1 year is preferred
#42 Gynecologic Procedures: Colposcopy, MRI, Ultrasound (Leik)
- Colposcopy is a diagnostic test for cervical cancer done via a biopsy of the cervix.
- A vaginal speculum is placed, and the vagina is evaluated.
- It is washed with 3% to 5% acetic acid (vinegar), which removes mucus and abnormal areas to turn bright-white that resembles leukoplakia (acetowhitening).
- Biopsy samples are obtained from the acetowhite area of the cervix, os, and squamocolumnar junction.
- A small amount of cramping and bloody spotting post procedure is normal for a few days after the procedure.
- Low-Grade Squamous Intraepithelial Lesions and High-Grade Squamous Epithelial Lesions
- HPV testing (if not done). Refer for colposcopy and biopsy
- Koilocytotic changes (large cell nuclei) seen on Pap smear may signify human papilloma virus (HPV) infection.
- Check for HPV and refer for a colposcopy for high-risk strains.
- Fitzgerald
- Ages 21–29 years: Ages ≥30 years:
- for genotype present HPV type 16 or 18, refer for colposcopy
- Negative cytology, positive HPV Ages ≥30:
- If HPV positive or atypical squamous cells of undetermined significance (ASC-US) or greater, refer for colposcopy
- If positive for HPV type 16 or type 18, refer for colposcopy
- ASC-US or LGSIL cytology:
- With results positive of high-risk HPV result, refer for colposcopy Repeat cytology in 1 yr (preferred)
- Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) and high-grade squamous intraepithelial lesion (HSIL), or Atypical Glandular Cells (AGC) Ages ≥21 years:
- Refer for colposcopy
- Leik
- Ultrasound:
- The USPSTF screening recommendation for ovarian cancer is pelvic exam and an ultrasound.
- Positive Signs of Pregnancy include:
- Palpation of fetus by health provider.
- NURS 6551 Midterm Study Guide
- Ultrasound and visualization of fetus.
- Fetal heart tones (FHT) auscultated by health provider).
- 10 to 12 weeks by Doppler/Doptone
- 20 weeks by fetoscope/stethoscope
- Size and Date Discrepancy Defined as a difference of 2 cm (or more) in uterine size from the number of weeks of gestation.
- If present, order an ultrasound for further evaluation.
- Placenta Previa Treatment Plan:
- Refer to ED.
- Avoid bimanual examination since palpation of the uterus may cause severe hemorrhage. Abdominal ultrasound
- No intravaginal ultrasound.
- No rectal exams.
- Avoid any vaginal/rectal sexual intercourse.
- Bed rest. Close fetal and maternal monitoring.
- If contractions, give magnesium sulfate (MgSO4) IV.
- If mild cases, pregnancy can be salvaged, and the placenta will reimplant. Perform C-section if mother’s life is in danger.
- Pelvic MRI is used after ultrasound to better visualize fibroids, cancer, or retained products of conception
- MRI may be used to distinguish between benign (non-cancerous) and malignant (cancerous) lesions for women with breast cancer. (nothing about MRI in Leik or Fitzgerald in women’s health section)
- Ultrasound:
- Ages 21–29 years: Ages ≥30 years:
#43 Common Areas for Breast Malignancies
- Most malignant tumors appear first as SINGLE, HARD LUMPS OR THICKENINGS that are frequently, but not always, painless.
- 50% of malignant lumps appear in the upper, outer quadrant of the breast, extending into the armpit.
- 11% in the lower out quadrant.
- 6 % in the lower inner quadrant.
- Ductal carcinoma in situ (DCIS)
- Earliest sign of breast cancer.
- Confined to the ducts.
- May be too small to see on mammogram
- Referred to as a pre-cancerous condition.
- Lobular carcinoma in situ (LCIS):
- Cells are limited to the breast lobules.
- LCIS does not always progress to invasive cancer.
- LCIS may be bilateral and often an incidental finding when looking for another lesion.
- Invasive or infiltrating Ductal Carcinoma:
- Most common malignancy of the breast.
- Invasive ductal carcinoma usually presents as a discrete, solid mass, with malignant cells escaping the confines of the ducts and infiltrating the breast parenchyma.
- The most common sites of metastatic spread of such cancer are the lymph nodes, bones, liver, and lungs
- Invasive or infiltrating Lobular Carcinoma
- Less common.
- Also, a discrete mass with diffuse margins that are ill defined.
- More often bi-lateral in nature
- Unusual spread of metastases like carcinomatous meningitis, intra-abdominal metastases with ureteral obstruction, and metastases to the uterus and ovaries
- Paget’s Disease
- Rare form of breast cancer (1%of all cases).
- Eczematous nipple changes and ulcerations, itching, erythema, and nipple discharge.
- 50% of patients with Paget’s disease present with a palpable mass that is usually an underlying DCIS or invasive ductal carcinoma.
- Inflammatory Carcinoma
- Rapidly progressive with 50% of all cases having lymphovascular invasion at time of diagnosis
- Diffuse inflammation with erythema, edema, skin thickening and Pue D’orange dimpling.
- Often mistaken for mastitis.
Questions
- You are checking a 75-year-old woman’s breast during an annual gynecological exam. The left nipple and areola are scaly and reddened. The patient denies pain and pruritis. She has noticed this scaliness on her left nipple for the past 8 months. Her dermatologist gave her a potent topical steroid, which she used twice a day for 1 month. The patient never went back for the follow-up. She still has the rash and wants an evaluation. Which of the following is the best intervention for this patient?
- A) Prescribe another potent topical steroid and tell the patient to use it twice a day for 4 weeks
- B) Order a mammogram and refer the patient to a breast surgeon
- C) Advise her to stop using soap on both breasts when she bathes to avoid drying up the skin on her areolae and nipples
- D) Order a sonogram and fi ne-needle biopsy of the breast
- 49-year-old woman is diagnosed with intraductal breast cancer and undergoes a modified radical mastectomy and an axillary node dissection. The pathology report states that she had 6/14 positive nodes. HER2/neu, estrogen receptor, and progesterone receptor staining was negative. She has a younger sister who is 42 and asks what to advise her sister regarding screening. What is the recommendation for screening of family members?
- A) Await routine mammography at age 45
- B) Mammography at age ≥40
- C) Urgent BRCA genetic testing
- D) Yearly clinical breast examination
#44 Methods of abortion
Posted in the group, search “Abortion Methods” NURS 6551 Midterm Study Guide
#45 Menstrual Flow
- Menstrual bleeding patterns are considered relevant indicators of reproductive health, and changes in bleeding patterns may impact the quality of life for pre- and perimenopausal women.
- Menstruation is often irregular among women of early and late reproductive ages, but its variability among women of mid-reproductive age remains unclear.
- Irregular bleeding patterns and midcycle bleeding may be indicative of endocrine dysfunction and uterine abnormalities, and such patterns have been associated with infertility, breast and ovarian cancers, type 2 diabetes, and cardiovascular disease.
- Cycle blood flow was classified as light (≤36.5 mL), medium (>36.5 and ≤72.5 mL), or heavy (>72.5 mL). Individual bleeding days were classified as light (≤4 mL), medium (>4 and ≤14 mL), or heavy (>14 mL) blood flow. Cycle length was defined as the number of days from the first day of bleeding until the day before the next onset of bleeding.
- A normal amount of menstrual fluid loss per period is between 5 mL to 80 mL
- Losing over 80 mL of menstrual fluid per period is considered heavy menstrual bleeding
#46 Perimenstrual symptoms
- Symptoms with a prevalence greater than 30 percent included:
- Weight gain, headache, skin disorders, cramps, anxiety, backache, fatigue, painful breasts, irritability, mood swings, depression, or tension.
- Only 2 to 8 per cent of women found most of these severe or disabling. The exceptions were severe cramps reported by 17 per cent of women and severe premenstrual and menstrual irritability by 12 per cent.
- Cramps, backaches, fatigue, and tension were most prevalent during the menstruum; weight gain, skin disorders, painful breasts, swelling, irritability, mood swings, and depression are more prevalent in the premenstruum.
- Cyclic Perimenstrual Pain and Discomfort (CPPD)
- An evidence-based diagnosis that clarifies the less specific diagnoses of dysmenorrhea, pelvic pain, and PMS.
- Defines perimenstrual symptom clusters—pain, physical discomforts, and mood discomforts
- Differentiates normal cyclic changes from severe, debilitating symptoms as assessed by severity, frequency, and pattern of symptom distress. Affects up to 70% of menstruating women.
- TREATMENT:
- Focuses on singular, usually pharmacologic, therapy for the treatment for perimenstrual symptoms and PMS. Clinical research now suggests that combinations of treatments are more beneficial than are single treatments. Outcomes of symptom management programs suggest that when symptoms are comprehensively managed, people are more likely to remain in treatment and show improved outcomes. New models of symptom management, which combine self-help, social support, medical therapies, and psychosocial strategies applied to specific conditions, have shown promising results.
#47 Secondary dysmenorrhea
Listed under #56
#48 Diagnostic and Statistical Manual IV-TR
- The Diagnostic and Statistical Manual of Mental Disorders is used by clinicians and psychiatrists to diagnose psychiatric illnesses. In 2013, the latest version known as the DSM-5 was released.
- The DSM is utilized widely in the United States for psychiatric diagnosis, treatment recommendations, and insurance coverage purposes. It is non-theoretical and focused mostly on describing symptoms as well as statistics concerning which gender is most affected by the illness, the typical age of onset, the effects of treatment and common treatment approaches.
- The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis, and numerical codes for each disorder to facilitate medical record keeping. The stated purpose of the DSM is threefold: to provide “a helpful guide to clinical practice”; “to facilitate research and improve communication among clinicians and researchers”; and to serve as “an educational tool for teaching psychopathology.”
- DSM-III, DSM-III-R and DSM-IV
- DSM-IV built upon the research generated by the empirical orientation of DSM-III. By the early 1990s, most psychiatric diagnoses had an accumulated body of published studies or data sets. Publications up through 1992 were reviewed for DSM-IV, which was published in 1994. Conflicting reports or lack of evidence were handled by data reanalyses and field trials. The National Institute of Mental Health sponsored 12 DSM-IV field trials together with the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The field trials compared the diagnostic criteria sets of DSM-III, DSM-III-R, ICD-10 (which had been published in 1992), and the proposed criteria sets for DSM-IV. The field trials recruited subjects from a variety of ethnic and cultural backgrounds, in keeping with a new concern for cross-cultural applicability of diagnostic standards. In addition to its inclusion of culture-specific syndromes and disorders, DSM-IV represented much closer cooperation and coordination with the experts from WHO who had worked on ICD-10. A modification of ICD-10 for clinical practitioners, the ICD-10-CM, is scheduled to be introduced in the United States in 2004.
- The symptom-based approach has also made it easier to politicize the process of defining new disorders for inclusion in DSM or dropping older ones. The inclusion of post-traumatic stress disorder (PTSD) and the deletion of homosexuality as a disorder are often cited as examples of this concern for political correctness.
- The criteria sets of DSM-IV incorporate implicit (implied but not expressly stated) notions of human psychological well-being that do not allow for ordinary diversity among people. Some of the diagnostic categories of DSM-IV come close to defining various temperamental and personality differences as mental disorders.
- The DSM-IV criteria do not distinguish adequately between poor adaptation to ordinary problems of living and true psychopathology. One byproduct of this inadequacy is the suspiciously high rates of prevalence reported for some mental disorders. One observer remarked that “… it is doubtful that 28% or 29% of the population would be judged [by managed care plans] to need mental health treatment in a year.”
- The 16 major diagnostic classes defined by DSM-IV hinder efforts to recognize disorders that run across classes. For example, PTSD has more in common with respect to etiology and treatment with the dissociative disorders than it does with the anxiety disorders with which it is presently grouped. Another example is body dysmorphic disorder , which resembles the obsessive-compulsive disorders more than it does the somatoform disorders.
- The current classification is deficient in acknowledging disorders of uncontrolled anger, hostility, and aggression. Even though inappropriate expressions of anger and aggression lie at the roots of major social problems, only one DSM-IV disorder ( intermittent explosive disorder ) is explicitly concerned with them. In contrast, entire classes of disorders are devoted to depression and anxiety.
- The five diagnostic axes specified by DSM-IV-TR are:
- Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.
- Axis II: Personality disorders and mental retardation . This axis includes notations about problematic aspects of the patient’s personality that fall short of the criteria for a personality disorder.
- Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient’s mood or functioning; or that influence the choice of medications for treating the mental disorder. NURS 6551 Midterm Study Guide
- Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient’s mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.).
- Axis V: Global assessment of functioning. Rating the patient’s general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1–100. DSM-IV-TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.
- Diagnostic categories
- The Axis I clinical disorders are divided among 15 categories: disorders usually first diagnosed in infancy, childhood, or adolescence; delirium , dementia , amnestic, and other cognitive disorders; medical disorders due to a general medical condition; substance-related disorders; schizophrenia and other psychotic disorders; mood disorders; anxiety disorders; somatoform disorders; factitious disorders; dissociative disorders; sexual and gender identity disorders; eating disorders; sleep disorders ; impulse control disorders not elsewhere classified; and adjustment disorders.
- The diagnostic categories of DSM-IV-TR are essentially symptom-based, or, as the manual puts it, based “on criteria sets with defining features.” Another term that is sometimes used to describe this method of classification is phenomenological . A phenomenological approach to classification is one that emphasizes externally observable phenomena rather than their underlying nature or origin.
- Another important characteristic of DSM-IV-TR’s classification system is its dependence on the medical model of mental disorders. Such terms as “psychopathology,” “mental illness,” “differential diagnosis,” and “prognosis” are all borrowed from medical practice. One should note, however, that the medical model is not the only possible conceptual framework for understanding mental disorders. Historians of Western science have observed that the medical model for psychiatric problems was preceded by what they term the supernatural model (mental disorders understood as acts of God or the result of demon possession), which dominated the field until the late seventeenth century. The supernatural model was followed by the moral model, which was based on the values of the Enlightenment and regarded mental disorders as bad behaviors deliberately chosen by perverse or ignorant individuals.
- Textual revisions in DSM-IV-TR
- DSM-IV-TR does not represent either a fundamental change in the basic classification structure of DSM-IV or the addition of new diagnostic entities. The textual revisions that were made to the 1994 edition of DSM-IV fall under the following categories:
- correction of factual errors in the text of DSM-IV
- review of currency of information in DSM-IV
- changes reflecting research published after 1992, which was the last year included in the literature review prior to the publication of DSM-IV
- improvements to enhance the educational value of DSM-IV
- updating of ICD diagnostic codes, some of which were changed in 1996
- Critiques of DSM-IV and DSM-IV-TR
- A number of criticisms of DSM-IV have arisen since its publication in 1994. They include the following observations and complaints:
- The medical model underlying the empirical orientation of DSM-IV reduces human beings to one-dimensional sources of data; it does not encourage practitioners to treat the whole person.
- The medical model perpetuates the social stigma attached to mental disorders.
- The symptom-based approach has also made it easier to politicize the process of defining new disorders for inclusion in DSM or dropping older ones. The inclusion of post-traumatic stress disorder (PTSD) and the deletion of homosexuality as a disorder are often cited as examples of this concern for political correctness.
- The criteria sets of DSM-IV incorporate implicit (implied but not expressly stated) notions of human psychological well-being that do not allow for ordinary diversity among people. Some of the diagnostic categories of DSM-IV come close to defining various temperamental and personality differences as mental disorders.
- The DSM-IV criteria do not distinguish adequately between poor adaptation to ordinary problems of living and true psychopathology. One byproduct of this inadequacy is the suspiciously high rates of prevalence reported for some mental disorders. One observer remarked that “… it is doubtful that 28% or 29% of the population would be judged [by managed care plans] to need mental health treatment in a year.”
- The 16 major diagnostic classes defined by DSM-IV hinder efforts to recognize disorders that run across classes. For example, PTSD has more in common with respect to etiology and treatment with the dissociative disorders than it does with the anxiety disorders with which it is presently grouped. Another example is body dysmorphic disorder , which resembles the obsessive-compulsive disorders more than it does the somatoform disorders.
- The current classification is deficient in acknowledging disorders of uncontrolled anger, hostility, and aggression. Even though inappropriate expressions of anger and aggression lie at the roots of major social problems, only one DSM-IV disorder ( intermittent explosive disorder ) is explicitly concerned with them. In contrast, entire classes of disorders are devoted to depression and anxiety.
- The emphasis of DSM-IV on biological psychiatry has contributed to the widespread popular notion that most problems of human life can be solved by taking pills.
- A number of different nosologies or schemes of classification have been proposed to replace the current descriptive model of mental disorders. Three of them will be briefly described.
- The dimensional model
- Dimensional alternatives to DSM-IV would replace the categorical classification now in use with a recognition that mental disorders lie on a continuum with mildly disturbed and normal behavior, rather than being qualitatively distinct. For example, the personality disorders of Axis II are increasingly regarded as extreme variants of common personality characteristics. In the dimensional model, a patient would be identified in terms of his or her position on a specific dimension of cognitive or affective capacity rather than placed in a categorical “box.”
- The holistic model
- The holistic approach to mental disorders places equal emphasis on social and spiritual as well as pharmacological treatments. A biochemist who was diagnosed with schizophrenia and eventually recovered compared the reductionism of the biological model of his disorder with the empowering qualities of holistic approaches. He stressed the healing potential in treating patients as whole persons rather than as isolated collections of nervous tissue with chemical imbalances: “The major task in recovering from mental illness is to regain social roles and identities. This entails focusing on the individual and building a sense of responsibility and self-determination.”
- The essential or perspectival model
- The third and most complex alternative model is associated with the medical school of Johns Hopkins University, where it is taught as part of the medical curriculum. This model identifies four broad “essences” or perspectives that can be used to identify the distinctive characteristics of mental disorders, which are often obscured by the present categorical classifications.
- The four perspectives are:
- This perspective works with categories and accounts for physical diseases or damage to the brain that produces psychiatric symptoms. It accounts for such disorders as Alzheimer’s disease or schizophrenia. Dimensions. This perspective addresses disorders that arise from the combination of a cognitive or emotional weakness in the patient’s constitution and a life experience that challenges their vulnerability. Behaviors. This perspective is concerned with disorders associated with something that the patient is doing (alcoholism, drug addiction , eating disorders, etc.) that has become a dysfunctional way of life. Life story. This perspective focuses on disorders related to what the patient has encountered in life, such as events that have injured his or her hopes and aspirations.
- In the Johns Hopkins model, each perspective has its own approach to treatment: the disease perspective seeks to cure or prevent disorders rooted in biological disease processes; the dimensional perspective attempts to strengthen constitutional weaknesses; the behavioral perspective seeks to interrupt the problematic behaviors and assist patients in overcoming their appeal; and the life story perspective offers help in “rescripting” a person’s life narrative, usually through cognitive behavioral treatment.
- DSM-IV-TR does not represent either a fundamental change in the basic classification structure of DSM-IV or the addition of new diagnostic entities. The textual revisions that were made to the 1994 edition of DSM-IV fall under the following categories:
- Diagnosis of Premenstrual Syndrome
- DIAGNOSTIC CRITERIA
- Symptoms begin up to 7 days prior to menses
- Remission of symptoms occurs from cycle days 4–13
- Symptoms are significant enough to impair activities of daily living
- Symptoms are charted in at least 2 cycles
- Symptoms are not due to another disorder
- Premenstrual Syndrome Symptoms
- Recognized in the 1992 edition of the International Clasification of Diseases manual developed by the World Health Organization, premenstrual syndrome (PMS) describes the cyclical recurrence of symptoms that impair a woman’s health, relationships, and occupational functioning.
- Inclusion of the PMS/PMDD diagnoses in DSM-5 has validated what many women have known for years: Fluctuating hormonal changes have physiologic and behavioral impacts. Differentiating between PMS and PMDD is challenging for many women because the criteria are rather subjective. PMS includes psychological factors that vary in severity and affect women and their ability to cope differently. While now recognized by the scientific community, PMS and PMDD may still be taboo subjects or derisively regarded (Box 23-5).
- PMS PHYSICAL
- Abdominal bloating and pain Mild weight gain from water
- retention Constipation followed by
- diarrhea at the onset of
- the menses Headache
- Pelvic pain and cramping Fatigue
Extremity edema Nausea/food cravings
- PMS PSYCHOLOGICAL
- Depression
Anxiety
Anger/irritability
Insomnia
Changes in libido
Confusion, decrease in mental - sharpness
Social withdrawal
Feelings of low self-esteem/ - poor self-image
- Depression
]
#51 Emergency Contraception
- ***Emergency Contraceptives May Be Used Within 120 hours of Unexpected Pregnancy***
- Levonorgestrel:
- Emergency contraception (EC) method levonorgestrel contains either a 1.5-mg single dose (Plan B One-Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects.
- Effectiveness: Women with a BMI greater than 30 have a 2- to 40-fold higher risk of pregnancy after ECP use. Levonorgestrel may be completely ineffective at reducing pregnancy risk in obese women. Levonorgestrel is no more effective than placebo when used in the critical 5 days preceding ovulation.
- Ulipristal:
- Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. Ulipristal acetate is available only by prescription.
- Effectiveness: More effective than Levonorgestrel. Repeated unexpected pregnancies or sexual intercourse while using the medication decreases the effectiveness of the drug.
- Copper IUD:
- The copper IUD can be inserted as long as 5 days after unprotected intercourse.
- Effectiveness: It has the advantage of being highly effective in obese women and providing ongoing contraception.
- Side Effects of EC’s:
- Nausea
- Vomiting
- Spotting
- Menstrual Changes
- Headache
- Breast Tenderness
- Mood changes
- The copper IUD can be inserted as long as 5 days after unprotected intercourse.
- Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. Ulipristal acetate is available only by prescription.
- Emergency contraception (EC) method levonorgestrel contains either a 1.5-mg single dose (Plan B One-Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects.
- Estrogen replacement therapy and menopausal women
- Estrogen replacement therapy is common for women suffering from side effects of menopause.
- Absolute contraindications to Estrogen use:
- Known or suspected cancer of the breast
- Known or suspected estrogen-dependent neoplasia
- History of uterine or ovarian cancer
- History of biliary tract disorder
- Undiagnosed, abnormal genital bleeding
- History or active thrombophlebitis or thromboembolic disorder
- Adverse Effects of estrogen therapy
- Uterine bleeding
- Breast tenderness
- Nausea
- Abdominal bloating
- Fluid retention in extremities
- Headache
- Dizziness
- Hair loss
- Estrogen replacement therapies can be given oral, topical, and transdermal. They can consist of only estrogens or a combination of estrogen and progesterone.
- Recommendations for hormone therapy (HT) use include
- HT should be individualized and based on personal risk factors and quality of life
- Duration of therapy differs between estrogen therapy (ET) and estrogen progesterone therapy (EPT). EPT has risk for breast cancer and therefore should only be used 3-5 yrs. Longer use with ET is considered in absence of risk factors.
- Low dose local ET is most effective treatment of vulvar and vaginal atrophy
- Appropriate candidates who have undergone early menopause can use HT until 52. Longer treatment is considered based on risk factors
- There is a lack of data to support ET use in breast cancer survivors
- Transdermal and low dose ET is associated with lower risk for venous thromboembolism and stroke than standard dose of oral ET
#53 IUD
- Paragard IUD can be left in place for 10 years. Paragard is a T-shaped device of polyethylene with copper wire wound around the stem and arms. A monofilament polyethylene thread is attached to a ball on the end of the stem. The copper adds spermicidal and other effects that allow the device to be smaller than a plain plastic device. The primary contraceptive effect is provided by the reaction to having a foreign body in the reproductive tract—specifically, a sterile inflammatory response that has spermicidal effects
#54 Diagnostic Test for Abnormal Uterine Bleeding (AUB)
- Laboratory and diagnostic test for AUB, abnormal results, possible diagnoses include:
- Pregnancy test – Pregnant, Missed, threatened, or incomplete spontaneous abortion, Ectopic pregnancy
- May be + or –
- CBC with platelets – Anemia, Clotting abnormalities
- Hgb<10, Platelets < 150,000 cells/mm3
- PT, aPTT, bleeding time – Von Willebrand’s disease, leukemia, prothrombin deficiency
- increased bleeding time
- Thyroid-stimulating hormone (TSH)
- 8 or >4.0
- Prolactin level – Pituitary adenoma
- >100 ng/mL
- Papanicolaou (Pap) test – Dysplasia, Carcinoma
- Atypical cells suggest dysplasia and/or carcinoma
- Nucleic acid amplification test (NAAT) – for gonorrhea and chlamydia
- Microscopy or culture of vaginal secretions w/ normal saline and potassium hydroxide
- Positive test or microscopy
- FSH – Amenorrhea due to menopause, Premature ovarian failure
- >30 mIu/mL
- Progesterone – Anovolatory
- <10 ng/mL
#55 Surgical Abortion:
- Surgical abortion is a method of removing products of conception (POC).
- There are two types of surgical abortion:
- Aspiration abortion: used for first trimester abortions
- Dilation and evacuation (D&E): used for abortions after the first trimester
- Aspiration abortion involves introducing a suction cannula the cervical os into the uterine cavity to remove POC. The cannula is connected to a suction source generated either by manual vacuum aspirator (MVA) or electric vacuum aspirator (EVA). MVA is used only for abortions before 14 weeks gestation. This procedure usually takes 10-15 minutes to complete.
- Dilation and curettage (D&C) are sometimes used to ensure that the procedure is complete. D&C has been associated with increased complication and has not shown any benefit. The WHO does not recommend the use of D&C in aspiration abortion.
- Common side effects include cramping, nausea, sweating and feeling faint. Less frequent side effects include heavy or prolong bleeding, blood clots, damage to the cervix and perforation of the uterus.
- Dilation and evacuation involve the use of forceps in conjunction with suction to remove POC. D&E is considered as safe as labor induction abortion but is less physically and emotionally stressful on patients. The degree of cervical dilation depends on the gestational age of the pregnancy. Dilation can be accomplished either by inserting dilating rods of increasing diameter into the cervical os immediately prior to inserting the cannula or by placing osmotic dilators into the cervix several hours to a day before the procedure. Oral or vaginal pharmacologic agents, such as misoprostol, may be used to promote cervical softening and dilation. This procedure may take 15-30 minutes.
- Common side effects include nausea, bleeding, and cramping that may last for two weeks after the procedure. Less frequent side effects include damage to the uterine lining or cervix, perforation of the uterus, infection, and blood clots.
- Pharmacological pain management for surgical abortions:
- Paracervical block- considered standard of care NURS 6551 Midterm Study Guide
- Intravenous or oral pain medication
- General anesthesia
- Non-pharmacological pain management for surgical abortions:
- Positive suggestion
- Relaxation
- Guided imagery
- The use of “full-spectrum” and abortion specific doula care providers
- Recovery after surgical abortion depends on:
- Type of procedure used (aspiration abortion or D&E)
- Type of anesthesia used
- The gestational age of the pregnancy
- If there were any preexisting medical or psychosocial conditions
- If there were any complications during the procedure
- A patient may leave the facility as early as 20 minutes if the procedure was an uncomplicated early abortion under local anesthesia.
- Patient teaching:
- Patients may resume regular activity as soon as the feel ready but are advised against sexual activity, rigorous exercise or activity, and lifting heavy objects for a few days up to a week after the procedure.
- Patients may be instructed to report any side effects immediately
- Patients may be instructed to return to their PCP in 2-3 weeks for a routine exam to ensure a complete and uncomplicated recovery, assess emotional wee-being, and to initiate or follow up on any newly established contraceptive method.
- Alternative approaches to follow up care include better patient education regarding self-monitoring for post-abortion complications and improved delivery of contraceptive services at the time of the abortion.
#56 Dysmenorrhea
- Painful cramps that occur with menstruation – most common menstrual disorder affecting 81% of women. Dysmenorrhea may be accompanied by heavy bleeding
- Primary Dysmenorrhea:
- Most common
- Begin 6 to 12 months after menarche.
- Symptoms begin with the onset of bleeding and continue for 8 to 72 hours.
- Associated pain caused by increased endometrial prostaglandins production.
- Symptoms:
- Abdominal cramping
- Headache
- Backache
- General body aches
- Continuous abdominal pain
- Other somatic discomforts
- Primary dysmenorrhea is perceived as more severe, with chronic, sometimes debilitating symptoms.
- Increased prevalence of depression and anxiety.
- Abnormal levels of cortisol correlate with pain sensitivity in women diagnosed with dysmenorrhea.
- Secondary Dysmenorrhea:
- Caused by pelvic pathology.
- Diagnosis of secondary dysmenorrhea includes pelvic pathology such as adenomyosis, leiomyomata, IBS, interstitial cystitis, and endometriosis.
- Most common cause: endometriosis, another cause is uterine fibroids.
- Symptoms:
- Dyspareunia
- Postcoital bleeding
- Abnormal uterine bleeding
- Pain may occur before, during, or after menes (or pain that increases over time)
- Risk Factors:
- Age <30 years
- BMI <20
- Smoking
- Early menarche
- History of sexual abuse
- Pelvic pain history
- Depression
- Treatment:
- Nonharmacologic Treatments:
- Heat
- Lifestyle changes – regular exercise
- Vitamin and herbs – vit E
- Acupuncture
- Pharmacologic Treatment:
- NSAIDs:
- Diclofenac
- Ibuprofen
- Meclofenamate
- Mefenamic acid
- Naroxen
- Oral contraceptives:
- Progestin Implants
- Levonorgestrel IUD
- Depot Medroxyprogesterone acetate
- surgical intervention
- NSAIDs:
- Nonharmacologic Treatments:
- Contraceptive methods advantages and disadvantages of different methods (Hollier 3rd)
Estrogen+progestin:
- NOT for migraine w/ aura, breast ca or high risk, SLE, liver cirrhosis/cancer, uncontrolled HTN
- Combined oral contraceptives:
- Advantages
- Reliable, no interference w/ sexual activity
- Decreased menstrual flow, improved menstrual symptoms, and dysmenorrhea
- Improved acne, regular menses, anemia protection
- Reduced: gynecologic disease incidence that can cause infertility, ovarian cysts, and incidence of endometrial/ovarian/colorectal cancers
- Disadvantages
- Must take pill everyday
- No protection against STDs
- Decreased milk production in lactating women
- Risk of thromboembolism and stroke /liver dx or cancer/ gallbladder dx/ HTN
- Reduced efficacy w/ some abx and psych meds
- Contraceptive patch
- Advantages
- Weekly application, reliable when used properly, no interference w/ sexual activity
- Decreased menstrual flow, improved menstrual symptoms, and dysmenorrhea
- Improved acne, regular menses, anemia protection
- Reduced ovarian cysts
- Disadvantages
- Reduced effectiveness if wt >198lbs
- Similar to combined OCs such as:
- No protection against STDs
- Decreased milk production in lactating women
- Risk of thromboembolism and stroke /liver dx or cancer/ gallbladder dx/ HTN
- Contraceptive vaginal ring
- Advantages
- Monthly insertion, reliable when properly used, no interference w/ sexual activity
- Non-contraceptive health benefits same as contraceptive patch
- Disadvantages
- Must remember to remove and replace every month (3 weeks on 1 week off)
- Same as contraceptive patch disadvantages (except wt limit)
- Advantages
- Advantages
- Advantages
Progestin only:
- Progestin only pills (mini pill)
- Advantages:
- Ok to use for lactating women (quality and quantity of breast milk not affected)
- May be used in women with CV risks
- Protection against developing endometrial ca and decrease risk of PID
- Decreased: menstrual cramps, PMS, breast tenderness
- Eventually less heavy bleeding and shorter menses
- Disadvantages
- Must take every day at the same time
- Missing only 1 pill greatly increases pregnancy risk
- Increased (although rare) chance of ectopic pregnancy
- Menstrual cycle changes initially (spotting, breakthrough bleeding, amenorrhea)
- Medroxyprogestrone acetate (Depo Provera)
- Advantages
- Advantages same as mini pills
- Good choice for women with physical/intellectual difficulties (q13wk IM shots- effective for 13 wks)
- Disadvantages
- Fertility may not return for up to 2 years after last injection
- Requires IM injections
- Etonogestrel implant (Nexplanon)
- Advantages
- Effective for up to 3 years, no need for additional attention after insertion. Effectiveness 99.9%!!
- Safe for women of all body weights
- OK for lactation
- quick return to fertility
- Disadvantages
- Needs office procedure for insertion
- Side effects may require removal of device
- Emergency contraception (Levonorgestrel 1.5mg)
- Advantages
- Backup method when barrier method fails
- Available w/o prescription (Plan B)
- Can use this method more than once in a cycle
- No teratogenic effects if contraception fails
- Disadvantages
- Limited window for use (<72 hrs of unprotected intercourse)
- Advantages
- Advantages
- Advantages
- Advantages:
Long-acting reversible contraception:
- ParaGard (copper IUD)- May use as emergency contraceptive
- Mirena, Skyla, Liletta (levonorgestrel only)
- Advantages
- Undetectable during intercourse
- No systemic effect on hormones!
- Long-term, cost-effective w/ long term use (change q3-10 year depending on which IUD)
- Ok for lactation
- Progesterone IUD decreases bleeding
- Disadvantages
- Can spontaneously expel IUD
- NO protection against STDs
- Advantages
Barrier methods:
- Diaphragm
- Advantages
- Helpful in STD prevention
- No serious side effects, no impact on future fertility
- Insertion may be incorporated into foreplay
- NURS 6551 Midterm Study Guide
- Decreased incidence of cervical neoplasia
- Disadvantages
- Not as effective as hormonal contraceptives
- Must be refitted with wt loss or gain, delivery or cervical surgery
- Must be used each time intercourse occurs and be left in place for 6 hours after intercourse
- Spermicide with every use required
- Decreased effectiveness with increased frequency of intercourse
- Requires dexterity to insert it properly
- May be embarrassing/ considered “messy” for women who dislike touching their genitals
- Vaginal sponge
- Advantages
- Alternative for women who do not wish to use condoms/hormonal methods
- Provides 24 hours of contraception
- Inexpensive, no need for Rx
- Disadvantages
- No protection against STIs
- Low rates of efficacy for parous women
- Requires dexterity to place correctly
- Male condoms
- Advantages
- most effective method for preventing STD
- Relatively inexpensive, no Rx needed
- Disadvantages
- May decrease sexual pleasure, may interrupt foreplay
- Possibility of breakage
- Female condoms
- Advantages
- Effective for preventing STDs
- Relatively inexpensive, no Rx needed
- Does not limit sensation for men as much as male condoms
- Safe for ppl w/ latex allergies
- Can be used with water based or petroleum based lubricants
- Disadvantages:
- More difficult to place and remove than male condoms
- may interrupt foreplay
- Possibility of breakage
- May not be suitable for women not comfortable with touching their genital area
- Spermicides
- Advantages
- helps prevent STDs
- OTC, relatively inexpensive, can be used as backup for other contraceptives
- Does not affect fertility/lactation
- Provides lubrication
- Disadvantages
- Some women consider the foam “messy”
- Requires use with each act of intercourse
- High rate of use failure
- 99% effective when used with condom!
- Advantages
- Advantages
- Advantages
- Advantages
- Advantages
Natural family planning:
- Advantages: No chemical/devices, few religious objections, low cost
- Disadvantages: Requires regular menstrual cycles, both partners’ commitment needed, not as reliable, require long periods of abstinence
#58 Sterilization
- Tubal sterilization is a highly effective form of permanent contraception that involves blocking the fallopian tubes to prevent sperm from ascending the reproductive tract and fertilizing an egg. Tubal sterilization can be performed postpartum, post abortion, or as an “interval” procedure unrelated to pregnancy. About half the tubal sterilizations occur postpartum, half as an interval procedure, and rarely done post abortion.
- Surgical approaches:
- Laparoscopy
- Mini-laparotomy
- Transcervical (least effective)
- Hysteroscopic
- Concurrent with a cesarean section
- Methods for occluding the fallopian tubes:
- Unipolar or bipolar electrocoagulation
- Mechanical occlusion using clips, rings, or bands
- Ligation or salpingectomy
- The only FDA approved transcervical sterilization is Essure. Essure is performed via hysteroscopy and can be done in the office. Essure involves placing micro-inserts of metal and fibers in the fallopian tubes. After placement, tissue grows into the insert, effectively blocking the tubes. A hysterosalpingogram (HSG) must be performed 3 months after the procedure to confirm tubal occlusion. Women should continue using contraception until sterilization is confirmed with the HSG.
- Efficacy and effectiveness:
- Overall failure rate is low. Most failures occur more frequently in women who are younger at the time of the sterilization.
- It is recommended timing an interval procedure during the follicular phase of the menstrual cycle and using a highly sensitive pregnancy test prior to surgery to reduce the risk of pregnancies that are conceived but not recognized before sterilization is performed.
- Safety and side effects:
- Related to surgery- occurs less than 1%
- Infection
- Hemorrhage
- Anesthesia complications
- Surgical trauma or injury
- Ectopic pregnancy-occurs in 2.4 to 2.9 per 1,000 procedures, rate is 3.5 times higher in women who were sterilized before the age of 28 years than in women who were sterilized after age 33 years.
- “Post-tubal syndrome”-dysmenorrhea and abnormalities in the menstrual cycle. Most authorities believe the symptoms are due to the discontinuation of hormonal contraceptives or simply getting old and entering perimenopause.
- Related to surgery- occurs less than 1%
- Noncontraceptive benefits:
- Decreased risk of ovarian cancer
- Lower risk of PID
- Disadvantages of tubal sterilization:
- Surgical procedure is expensive
- Required waiting period after signing the consent
- Minimum age requirement
- Women who are young when the procedure is performed may regret having the procedure and seek a reversal of the procedure
- Women who have had the tubal sterilization are less likely to:
- Return for yearly checkups and Pap smears
- To use condoms to prevent STIs
- Counseling for women contemplating or undergoing sterilization should include the continued need for preventive health services.
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#59. Progestin only pills
- Progestin-only oral contraceptives (mini pills)
- Suppresses ovulation
- Creates thin atrophic endometrium
- Thickening of cervical mucus >> making sperm penetration difficult
- Actual effectiveness 91% (theoretical 99.7%), failure rate high in women <40 yo
- Side effects >> spotting, breakthrough bleeding, prolonged cycles then amenorrhea, breast tenderness, headaches, mood changes
- Indicated for women who cannot tolerate estrogen containing OCs (severe HA, HTN, libido changes, GI upset, breast tender)
- For women who have absolute contraindication to estrogen such as:
- age >45
- breastfeeding
- smokers
- mild-mod HTN
- well controlled DM
- hx stroke
- depression
- Absolute contraindications: pregnancy, breast CA, CHF/mitral stenosis/pulmonary HTN (worsens with fluid retention)
- Relative contraindications: thromboembolic disorder, DVT/PE, severe cirrhosis/liver CA, use of rifampin/barbiturates/phenytoin/carbamazepine/phenylbutazone
- Patient education:
- No hx unprotected intercourse and not on oral contraceptives >> start mini pills immediately
- If changing from combined to mini pills>> start pill on first day of menses or anytime during combined OC cycle
- Use backup method for 1mo after pill initiation
- if one pill missed >3 hrs, take it ASAP, use backup method for remainder of pill pack
- Consider d/c with new onset migraine with aura or with CV disease/stroke
#60 STIs (causative agent and treatment)
- Bacterial Vaginosis:
- Causative agent: anaerobic pathogens increase.
- Treatment: Metronidazole 0.75% gel intravaginally twice a day for five days or Metronidazole 500 mg by mouth twice a day for seven days.
- Trichomoniasis:
- Causative agent: vaginalis bacteria
- Treatment: Metronidazole 2 grams in a single oral dose or clindamycin 2% gel if allergic
- Gonorrhea:
- Causative agent: bacterium Neisseria gonorrhoeae
- Treatment: Ceftriaxone 250 mg IM plus Azithromycin 1 gram single dose
- Chlamydia:
- Causative agent: Chlamydiatrachomatis
- Treatment: Azithromycin 1gram single dose or Doxycycline 100 mg BID x 7 days
- Alternative treatment is Erythromycin 100 mg QID x 7 days
- Genital Herpes:
- Causative agent: herpes simplex virus
- Treatment: First clinical episode 400 mg orally 3xday for 7-10 days or 200 mg 5xday
- HPV:
- Causative agent: human papillomavirus
- Treatment: Provider applied – cryotherapy or trichloroacetic acid
- Patient applied – imiquimod, podofilox NURS 6551 Midterm Study Guide
- Syphilis:
- Causative agent: Treponema pallidum
- Treatment: Penicillin G 2.4 million units IM once
#61 Hepatitis in women
https://www.healthywomen.org/condition/hepatitis#tab
- Common STI in United States
- HPV is the most common STI with 6 million people becoming infected each year. Almost all sexually active adults will have HPV at some point in their life. Most genital warts are caused by strand 6 and 11. Most cervical cancers are caused by 16 and 18.
#63 HPV Prevalence
- Human papillomavirus (HPV) is a very common STD, with an estimated 80 percent of sexually active people contracting it at some point in their lives; 14 million new infections occur yearly in the United States. About 79 million people — men and women — are thought to have an active HPV infection at any given time
- Some HPV types can cause genital warts and are considered low risk, with a small chance for causing cancer.
- Other types are considered high risk, causing cancer in different areas of the body including the cervix and vagina in women, penis in men, and anus and oropharynx in both men and women
- HPV is spread through skin-to-skin contact, not through an exchange of bodily fluid.
- During 2011–2014, prevalence of any oral human papillomavirus (HPV) for adults aged 18–69 was 7.3%; high-risk HPV was 4.0%
- Overall, prevalence of any and high-risk oral HPV was lowest among non-Hispanic Asian adults; any oral HPV was highest among non-Hispanic black adults.
- Prevalence of any and high-risk oral HPV was higher in men than women except for high-risk HPV among Asian adults.
- During 2013–2014, prevalence of any and high-risk genital HPV for adults aged 18–59 was 45.2% and 25.1% in men and 39.9% and 20.4% in women, respectively.
- Prevalence of any and high-risk genital HPV was lower among non-Hispanic Asian and higher among non-Hispanic black than both non-Hispanic white and Hispanic men and women.
- In most cases, the virus is harmless, and most people have no symptoms. The body clears most HPV infections naturally.
- HPV can be contracted from one partner, remain dormant, and then later be unknowingly transmitted to another sexual partner, including a spouse.
- If an HPV infection is persistent past the age of 30, there is a greater risk of developing cervical cancer.
- Latex condoms can reduce–but not totally eliminate–the risk of HPV transmission
- Thirty percent of oral cancers is related to HPV. It is commonly seen in ages 20-39
- There are about 100 types of HPV that affect different parts of the body. About 30 types of HPV can affect the genitals — including the vulva, vagina, cervix, penis and scrotum — as well as the rectum and anus.
- Of those, about 14 types are considered “high risk,” for leading to cervical cancer
- In many cases, HPV causes no symptoms. When they do occur, the most common symptom is warts in the genital area.
- There is no cure for the virus itself, but many HPV infections go away on their own. In fact, about 70 to 90 percent of cases of HPV infection are cleared from the body by the immune system.
- When treatment is needed, the goal is to relieve symptoms by removing any visible warts and abnormal cells in the cervix.
- Treatments might include: Cryosurgery, Loop electrosurgical excision procedure, Electrocautery, Laser therapy, and prescription cream.
#64 Menstrual Dysfunction
- This is a blanket term for disorders that affect the menstrual cycle. These might include:
- Oligomenorrhea:
- cycle length greater than 35 days
- Polymenorrhagia
- cycle length less than 21 days
- Amenorrhea:
- absence of menses for 6 months or absence of menstrual cycle for three cycles
- Menorrhagia:
- heavier and increased amount of flow occurring at regular intervals or loss of more than 80mL of blood
- Metrorrhagia:
- irregular episodes of bleeding
- Menometrorrhagia:
- longer duration of flow occurring at unpredictable intervals
- Postmenopausal bleeding:
- bleeding that occurs more than 12 months after the last menstrual cycle
- Menstrual dysfunction is common, with approximately 9–30% of reproductive-aged women presenting with menstrual irregularities requiring medical evaluation.
- Oligomenorrhea:
#65 Bacterial Vaginosis
- Overgrowth of anaerobic bacteria in the vagina.
- Risk Factors
- Sexual Activity
- New or multiple sexual partners
- Douching
- Menstrual Bleeding
- Smoking
- Lack of condom use
- Race/ethnicity (increased in black/ Mexican American)
- Symptoms
- Malodorous discharge “fishy” odor
- Copious discharge with milk-like consistency
- Irritation, vulvar pruritus
- Postcoital spotting, irregular bleeding episodes
- Vaginal burning after intercourse and urinary discomfort
- Assessment
- Gold Standard diagnosis is Gram stain
- Gathering a reported history or previous occurrence
- Speculum Exam
- Wet Smear with microscope
- Clue cells (vaginal epithelial cells coated with bacteria that obscure cell borders) and few WBCs
- Whiff Test
- Apply drop of KOH to swab soaked with discharge.
- Fishy odor would indicate +
- Vaginal pH
- Normal vagina is acidic between pH 3.5-4.5 (course textbook) 4.0-4.5 (Leik)
- BV vagina becomes alkaline or pH above 4.5
- Nitrazine paper can detect pH of 4.5 or greater. Best sample is from lateral walls of vagina. Presence of blood can alter results.
- Clinical diagnosis calls for 3 out of 4 of the Amsel criteria:
- White, thin adherent vaginal discharge
- pH greater than or equal to 4.5
- Positive whiff/ KOH test
- Clue cells on microscopic examination (more than 20% of epithelial cells are clue cells)
- Management
- Metronidazole 500 mg PO BID for 7 days or Metronidazole gel 0.75%, one full applicator intravaginally, daily for 5 days
- Clindamycin cream 2%, one full applicator (5g) intravaginally HS for 7 days
- Abstain from sexual intercourse until treatment is done.
- Treatment for sexual partners is not needed or recommended by CDC because BV is NOT an STD.
- BV is recurrent in as many as 70% of women within 3-6 months
- Special Considerations for Pregnant Women
- BV associated with chorioamnionitis, premature rupture of fetal membranes, preterm labor and birth, postpartum endometritis.
- Treatment recommended for pregnant women with BV who exhibit symptoms.
- Clindamycin vaginal cream is NOT recommended in pregnancy- associated with low birth weight and neonatal infections.
- Differential Diagnoses
- Trichomoniasis,
- VVC
- Presence of foreign body
- Chemical or contact vaginitis
- Genital herpes
- Chlamydia
- Gonorrhea
- Cervicitis
- Normal physiologic discharge
#66 Vulvovaginal candidiasis (Yeast Infection)
- This condition is cause by C. albicans that colonize in the vaginal tract.
- Risk Factors
- Diabetes
- Recent use of Antibiotics
- Pregnancy
- Tight Fitting Underwear
- Immunocompromised Patient
- IUD
- Signs and Symptoms
- Pruritis
- Burning
- Irritation
- Thick White Vaginal Discharge
- Diagnostics
- Vaginal PH less than 4.5
- Wet Prep (Hyphae Cells Present)
- NURS 6551 Midterm Study Guide
- Budding yeast or hyphae present
- Uncomplicated
- Treatment Oral or Intravaginal
- Oral Treatment Option: Fluconazole 150 mg PO one time dose
- Intravaginal Treatment Option: Miconazole 2% 5g daily for 7 days.
- Complicated
- Four or more episodes in 1 year.
- Treatment: Fluconazole weekly for 6 months
- Four or more episodes in 1 year.
- Treatment Oral or Intravaginal
#67 Primary Amenorrhea
listed under #77
#68 Hyperandrogenism
- Pathophysiology
- androgen excess, is a medical condition characterized by excessive levels of androgens (male sex hormones such as testosterone) in the female body and the associated effects of the elevated androgen levels. It is an endocrinological disorder similar to hyperestrogenism.
- Symptoms
- muscular male body habitus, deepening voice, clitoromegaly, increased libido, menstrual irregularity, hypertension, hyperlipidemia, glucose intolerance, hirsutism, alopecia, acanthosis nigricans, oily skin, acne vulgaris;
- Diagnosis
- serum testosterone
- (normal 20-80)
- serum 17a-hydroxyprogesterone
- (normally <2),
- dehydropiandrosterone
- (normal 250-300),
- Dexamethasone Suppression Test, LH, Lipid profile
- serum testosterone
# 69 Polycystic Ovary Syndrome (PCOS)
- PCOS is a Hormonal abnormality marked by anovulation, infertility, excessive androgen production, and insulin resistance. The relationship between insulin and androgens is believed to be an underlying cause.
- Affects about 7% of women of childbearing age.
- PCOs increases a patient risk for developing
- Coronary Heard Disease (CHD)
- Type 2 diabetes mellitus and metabolic syndrome
- Cancer of the breast and endometrium
- Central obesity
- Infertility
- Signs and Symptoms
- Typically presents as obese young woman with complaints of excessive facial and body hair, bad acne, abnormal uterine bleeding and infertility. Dark thick hair is often seen on the face neck and cheeks.
- Diagnostic Tests
- Transvaginal ultrasound: Enlarged ovaries with multiple small follicles or one ovary that has a volume of greater than 10mls.
- Serum testosterone, DHEAs, and androstenedione are elevated. FSH levels normal or low.
- Fasting blood glucose and 2-hour oral glucose tolerance test (oGTT) are abnormal.
- Diagnosis Criteria
- Diagnosis requires the presence of at least two of the following three findings
- Hyperandrogenism
- Ovulatory dysfunction
- Polycystic ovaries
- Management
- Lowering insulin levels
- Restoration of fertility
- Treatment of hirsutism or acne
- Restoration of regular menstruation
- Treatment
- Oral Contraceptives: Progestins helps to suppress pituitary LH and FSH
- Metformin: decreases insulin resistance
- Spironolactone: decrease and control hirsutism.
- Weight loss reduces androgen and insulin levels.
- Letrozole is the first-line medication for ovulation induction.
- Diagnosis requires the presence of at least two of the following three findings
# 70 Hirsutism and combined oral contraceptives
- Hirsutism: Excessive hair growth in women occurring in anatomic areas where the hair follicles are most androgen sensitive. Ie: face, chin, upper lip, areola, lower abdomen, inner thighs, and perineum.
- Present in approximately 70% of women with PCOS
- Nearly all cases have increased rate of androgens, usually testosterone.
- The sensitivity of the hair follicle to the effect of androgens depends on the degree of
5α-reductase.
- Some women are genetically predisposed to having more 5α-reductase (certain ethnic backgrounds)
- Treatment
- Combined oral contraceptives: treats hirsutism by treating the hyperandrogenism. Combined oral contraceptives inhibit LH secretion and LH dependent ovarian androgen production.
- A combined oral contraceptive with 20 – 35 mcg of ethinyl estradiol and a non-androgenic progestin is best
- Some low androgenic progestins include desogestrel, norgestimate, or drospirenone
- Some common combined oral contraceptive brands with the above progestins are YAZ, Yasmin, TriNessa, Sprintec, Cyclessa and Ortho Tri-Cyclen Lo among others.
- May take as long as 9 to 12 months to see results
- Other treatments
- Antiandrogens (Spironolactone)
- Gonadotropin-releasing hormone analogs (Leuprolide)
- Oral antihyperglycemic (Metformin)
- NURS 6551 Midterm Study Guide
- Combined oral contraceptives: treats hirsutism by treating the hyperandrogenism. Combined oral contraceptives inhibit LH secretion and LH dependent ovarian androgen production.
Questions
- What is the first-line treatment for hirsutism in patients with polycystic ovarian syndrome (PCOS) who are already taking an oral contraceptive pill?
- Flutamide
- Finasteride
- Spironolactone
- Drospirenone
- A 24 year old woman presents with a history of secondary amenorrhea. She had regular menses after menarche until the past few years. She has not had a period in the past 6 months. She has noted the presence of chin hair and a resurgence of acne. Her primary care doctor told her that she has high cholesterol at her last yearly checkup. She denies cold intolerance, fatigue, or the presence of nipple discharge. On exam, you note the presence of chin hair, normal abdominal exam, the presence of pubic hair which extends to the umbilicus, and normal pelvic examination. Vitals show PB 140/78, P 64, Wt 148, Ht 5’5″. A pregnancy test in the office is negative. According to the NIH, which of the following is always associated with PCOS?
- Obesity
- Androgen excess without other causes
- Diabetes Mellitus
- “String of pearls” sign on ultrasound
- Virilization
#71 Uterine Fibroids Page 637
Uterine fibroids (Myomas or leiomyomatas) are benign growths that arise from the smooth muscle of the uterus.
- Subserosal fibroids – external surface of the uterus
- Intramural or myometrial fibroids – lie within the myometrium
- Submucosal fibriods – make contact with the endometrium.
- Peduncuated fibroids – vulnerable to torsion, necrosis, or prolapse through the cervical canal
Fibroids are the most common indication for hysterectomy
Diagnostics:
- A mass may be palpable on pelvic exam
- Ultrasound or pathology
Clinical Presentation:
- Heavy bleeding
- irregular menses
- dysmenorrhea
- pelvic pressure or pain – dull and crampy
- dyspareunia
- change in urine or bowel control
- Associated pregnancy-related problems – infertility and pregnancy loss
- Fibroids may involve the cervix or protrude through the cervical canal
- However, the majority of fibroids are asymptomatic
Management:
No effective prevention or early intervention
- For symptomatic fibroids:
- medical therapies
- Progestogens – used for heavy bleeding
- Gonadotropin-releasing hormone agonist – used to shrink fibroids prior to fertility treatment or surgery (may also control heavy bleeding)
- Selective estrogen reuptake modulators – shrink fibroid volume
- Selective progesterone receptor modulators – shrink fibroid volume
- Aromatase – shrink fibroid volume
- Combined oral contraceptives – may improve periodic bleeding control and/or dysmenorrhea
- Nonsteroidal antiinflammatory drugs – May improve periodic bleeding control and/or dysmenorrhea
- surgery – minimally invasive procedures or hysterectomy
- uterine artery embolization
- magnetic resource imaging – guided focused ultrasound
Pregnancy Complications:
Monitor pregnant women more closely as it may cause complications during a pregnancy such as:
- infertility
- failed implantation
- spontaneous abortion
- preterm labor
- placental abruption
- malpresentation
- cesarean birth
- peripartum hysterectomy
- postpartum hemorrhage
Pre-pregnancy, fibroidectomy may be considered if there are concerns about impaired fertility.
# 72 Lichen sclerosis
- Pathophysiology
- Idiopathic chronic inflammatory condition of the peri-mucosal skin
- Signs and Symptoms
- Asymptomatic in 1/3 of patients
- Pruritic genital lesions involving the vulva or foreskin
- Dysuria
- Painful Intercourse
- Painful Defecation
- Initially vulva skin is thick and white
- Later will be wrinkled and hypopigmented
- Diagnostics
- Biopsy
- Indicating squamous cell hyperplasia is present
- Treatment
- Topical Corticosteroid
- Initially High Dose Temovate
- Later Taper Down Potency to Valisone
- Cryotherapy
- Topical Corticosteroid
- Biopsy
# 73 Adenomyosis
- Pathophysiology
- Endometrial glands and stroma embed within the myometrium of the uterus – known as endometriosis of the uterus
- Signs and Symptoms
- Dysmenorrhea
- Menorrhagia
- Metrorrhagia
- Enlarged uterus that is tender and boggy;
- Diagnostics
- Transvaginal Ultrasound
- MRI of pelvis if ultrasound is not diagnostic
#74 Physiologic menopause
- Signs and Symptoms
- Disturbance of Menstrual Pattern
- Hot Flashes
- Atrophic Vaginal Mucosa
- Depression
- Insomnia
- Diagnostics
- Follicle Stimulating hormone (FSH) – not necessary to confirm diagnosis, may be indiciated if patient is < 45 years old
- TSH – consider if atypical age or vasomotor symptoms
- Vaginal PH <4.5
- Management
- Estrogen replacement therapy – consider in women under 60 years old
- Preventive Management
- Osteoporosis
- Cardiovascular
- Breast Cancer
- Cervical Cancer prevention
#75 Endometriosis
- Peak diagnosis age 20-40 years old
- Risk factors
- Early or late menarche
- Nulliparity
- Menstrual flow >6 days
- Menstrual cycle <28 days
- Signs and Symptoms
- Chronic pelvic pain
- Dysmenorrhea
- Infertility
- Ovarian cyst
- Heavy periods
- Tender nodular ligaments
- Fixed uterine retroversion
- Diagnostics
- Histological diagnosis
- hemosiderin-laden macrophages
- Laparoscopy
- Endometrial tissue
- Imaging
- Transvaginal ultrasound
- Management
- 1st line GnRH therapy
- NSAID
- Oral contraceptives
- Use at least 3-4 months
- Norethindrone Acetate for osteoporosis
- Histological diagnosis
#76 Cancer Facts for Women
- Some of the cancers that most often affect women are breast, colon, endometrial, lung, cervical, skin, and ovarian cancers.
- Breast cancer
- Breast cancer is the most common cancer that women may face in their lifetime (except for skin cancer). It can occur at any age, but the risk goes up as you get older. Because of certain factors, some women may have a greater chance of having breast cancer than others. But every woman should know about breast cancer and what can be done about it.
- American Cancer Society Recommendation:
- The best defense is to find breast cancer early – when it’s small, has not spread, and is easier to treat. Finding breast cancer early is called “early detection.” The American Cancer Society recommends the following for breast cancer early detection:
- Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so.
- Women age 45 to 54 should get mammograms every year.
- Women 55 and older should switch to mammograms every 2 years or can continue yearly screening.
- Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
- All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening.
- Women should also be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.
- Some women at high risk for breast cancer – because of their family history, a genetic tendency, or certain other factors – should be screened with MRIs along with mammograms. (The number of women who fall into this category is very small.)
- Colon cancer
- Colon cancers are commonly called cancers of the colon and rectum. People with a personal or family history of this cancer, or who have polyps in their colon or rectum, or those with inflammatory bowel disease are more likely to have colon cancer. Also, being overweight, eating a diet mostly of high-fat foods (especially from animal sources), smoking, and being inactive can make a person more likely to have this cancer.
- Screening
- Colon cancer almost always starts with a polyp – a small growth on the lining of the colon or rectum. Testing can save lives by finding polyps before they become cancer. If pre-cancerous polyps are removed, colon cancer can be prevented.
- For people at average risk of colon and rectal cancer, the American Cancer Society recommends starting regular screening at age 45. People older than 75 should talk with their health care provider about whether continuing screening is right for them.
- Screening can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum (a visual exam).
- Stool-based tests
- Yearly fecal immunochemical test (FIT) *, or
- Yearly guaiac-based fecal occult blood test (gFOBT) *, or
- Multi-targeted stool DNA test (MT-sDNA) every 3 years*
- Visual (structural) exams of the colon and rectum
- Colonoscopy every 10 years, or
- CT colonography (virtual colonoscopy) every 5 years*, or
- Flexible sigmoidoscopy every 5 years*
- If a person chooses to be screened with a test other than colonoscopy, any abnormal test result should be followed up with colonoscopy.
- If you are at high risk of colon cancer based on family history or other factors, you may need to start testing before age 45. Talk to a health care provider about your risk for colon cancer to know when you should start testing.
- Endometrial cancer
- Endometrial cancer (cancer of the lining of the uterus) occurs most often in women age 55 and older. Taking estrogen without progesterone and taking tamoxifen for breast cancer treatment or to lower breast cancer risk can increase a woman’s chance for this cancer. Having an early onset of menstrual periods, late menopause, a history of infertility, or not having children can increase the risk, too. Women with a personal or family history of hereditary non-polyposis colon cancer (HNPCC) or polycystic ovary syndrome (PCOS), or those who are obese are also more likely to have endometrial cancer. NURS 6551 Midterm Study Guide.
- American Cancer Society Recommendation
- The American Cancer Society recommends that at the time of menopause, all women should be told about the risks and symptoms of endometrial cancer. Watch for symptoms, such as unusual spotting or bleeding not related to menstrual periods, and report these to a health care provider. The Pap test is very good at finding cancer of the cervix, but it’s not a test for endometrial cancer.
- The American Cancer Society also recommends that women who have or are likely to have hereditary non-polyposis colon cancer (HNPCC) be offered yearly testing with an endometrial biopsy by age 35. This applies to women known to carry HNPCC-linked gene mutations, women who are likely to carry such mutations (those who know the mutation runs in their families), and women from families with a tendency to get colon cancer where genetic testing has not been done.
- Lung cancer
- At least 8 out of 10 lung cancer deaths are thought to result from smoking. But people who don’t smoke can also have lung cancer.
- Lung cancer is one of the few cancers that can often be prevented simply by not smoking. If you are a smoker, ask a health care provider to help you quit. If you don’t smoke, don’t start, and avoid breathing in other people’s smoke. If your friends and loved ones are smokers, help them quit. For help quitting, call your American Cancer Society at 1-800-227-2345 to find out how we can help improve your chances of quitting for good.
- If you are a current or former smoker aged 55 to 74 years and in fairly good health, you might benefit from screening for lung cancer with a yearly low-dose CT scan (LDCT). The American Cancer Society recommends screening for certain people at higher risk for lung cancer. Talk to a health care provider about your risk of lung cancer, and about the possible benefits, limits, and harms of getting tested for early lung cancer.
- Cervical cancer
- Cervical cancer can affect any woman who is or has been sexually active. It occurs in women who have had the human papilloma virus (HPV). This virus is passed during sex. Cervical cancer is also more likely in women who smoke, have HIV or AIDS, have poor nutrition, and who do not get regular Pap tests.
- In the United States, approximately 14,500 new cases of cervical cancer occur annually. Among these cases, 4,800 deaths occur. Cervical cancer is the 7th most common cancer in women (Glass and Cash, 2014).
- Screening Tests
- A Pap test can find changes in the cervix that can be treated before they become cancer. The Pap test is also very good at finding cervical cancer early, when it can often be cured. There has been a 70 percent reduction in the incidence of cervical cancer due to Pap smear screening (Glass and Cash, 2014). The American Cancer Society recommends the following:
- Cervical cancer testing should start at age 21. Women under age 21 should not be tested.
- Women between ages 21 and 29 should have a Pap test done every 3 years. There’s also a test called the HPV test. HPV testing should not be used in this age group unless it’s needed after an abnormal Pap test result.
- Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) done every 5 years. This is the preferred approach, but it’s OK to have a Pap test alone every 3 years.
- Women over age 65 who have had regular cervical cancer testing in the past 10 years with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65.
- A woman who has had a total hysterectomy (removal of her uterus and her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.
- A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.
- Some women – because of their history – may need to be tested more often. They should talk to a health care provider about their history.
- Post hysterectomy: Stop screening for total hysterectomy. However, if the patient had a history of high grade lesions prior to surgery, then cytology screening every 3 years for the next 20 years is recommended.
- Risks for Cervical Cancer
- Early age at first intercourse
- Multiple sex partners
- High parity
- Lower socio- economic status
- Advanced age
- Compromised immune system: HIV infection
- Male partner with history of multiple partners or STIs
- History of STI especially HPV
- Cervical dysplasia: risk for carcinoma is 100 times greater in women with dysplasia than in those with normal cervix
- Bethesda System: the most current classification system used to interpret cytologic findings.
- Skin cancer
- Risk Factors for Skin Cancer:
- Fair complexion
- Advanced age with sun damaged skin
- A history of severe sun burn
- History of spending long time outdoors
- Having a history of xray procedures for skin conditions
- Genetic susceptibility
- ABCDEs of Skin Cancer
- Asymmetry- shape of the mark should be noted.
- Border- Look carefully at the border of the mark. If ragged, notched, not smooth
- Color- note color of the moles, note any change in size, if it changes in color, or if it has several colors (brown, black, tan , red
- Diameter: Measure the size of the mark and document, if it is greater than 6 mm
- Elevation: Note elevation of lesion, change in size, and any evolving changes in lesion
- Risk Factors for Skin Cancer:
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#77 Amenorrhea
- Primary amenorrhea is the absence of menarche by the age of 16.
- Teens experiencing primary amenorrhea should be referred and evaluation for chromosomal defects, anatomic anomalies, hormonal imbalances, tumor, and trauma.
- Primary amenorrhea could be due to a dysfunction in the hypothalamus, pituitary gland, ovaries (HPO axis), or vagina.
- Signs and symptoms
- Absence of menarche
- Absence of secondary sex characteristic
- Abnormal growth and development
- Diagnostic test
- Pregnancy Test
- Refer to Endocrinologist
- Secondary amenorrhea is the cessation of menstrual flow after the establishment of normal menstrual cycling.
- Pregnancy is the most common cause of secondary amenorrhea.
- Signs and symptoms
- Absence of expected menses with a history of regular cycles
- Diagnostic test
- Pregnancy test
- Refer to other studies
Question
- The most likely cause of amenorrhea is:
an anatomical deviation
b. a genetic factor
c. an endocrine abnormality
d. pregnancy - NURS 6551 Midterm Study Guide