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U of C Well Woman 8063 Exam 1
Terms in this set (161)
Normal Menstrual cycle physiolgy
Menarche-avg age is 12-13 yrs---if no pubertal development by 13 or menses by 15--work up for pubertal delay
Normal Cycle length
First year: avg of 32 days (range of 20-60 days)
Least variable between ages of 20-40 years--then it is 21-35 days with no more than 7 days variability
First year: 2-7 days, ABNORMAL if less than 2 or greater than 8 days in length, flow amount 20-80 mL, 2nd day is heaviest, Crescendo-Decrescendo pattern is normal, greater than 3 days of light spotting before onset of heavy flow is abnormal--as well as prolonged light or brown at tail end of flow is abnormal
What does the hypothalamus release?
GnRH (gonadotropin releasing hormone)
What does the anterior pituitary secrete?
FSH and LH
What does the Ovary secrete?
estrogen and progesterone
Growing follicle secrete estrogen, with higher levels of estrogen this tells the anterior pituitary to release LH--this LH surge allows ovulation to occur--the Corpus Luteum now releases progesterone which thickens the endometrial lining,
How does too much Cortisol effect ovulation?
high stress states increase Cortisol--this causes a decrease in GnRH, LH, and FSH which leads to Anovulation
How does Hyperprolactinemia effect ovulation?
decreased GnRH, LH, and FSH--increased testosterone, decreased estrogen--shortens the luteal phase and amenorrhea
How does Hyperthyroid effect ovulation?
increased SHBG, total Testosterone and Estrogen are decreased, Loss of pre-ovulatory LH surge--irregular menses, anovulation, infertility
How does Hypothyroid effect ovulation?
decrease SHBG, increase Total Testosterone and Estrogen, increase in TRH, increase in TSH and PRL, increase dopamine, decrease GnRH, heavy breakthrough bleeding, spotting, infertility
How does a Vit D deficiency effect ovulation?
decreases Estrogen and Progesterone, increases LH and FSH and Testosterone--leads to ovulatory dysfunction
What is hyperandrogenism?
The ovaries produce excess androgens in response to high insulin, pt. starts to display male characteristics
--congenital adrenal hyperplasia, PCOS, obesity, adrenal and ovarian cancers
What is the obesity hormone?
What is hyperleptinemia?
increased fat, continuous estrogenic mucous, oligo/amenorrhea, breakthrough bleeding
What is hypoleptinemia?
decreased fat, amenorrhea, anovulation, by inactivating Kisseptin (important link b/w reproduction and nutrition--low kisseptin--low GnRH,
How do both hyperinsulinemia and insulin resistance effect ovulation?
Increased GnRH, LH, and FSH, increased Testosterone and Estrogen, continuous estrogenic mucous, amenorrhea, breakthrough bleeding, ovulatory dysfunction
What is the main hormone of the follicular phase?
What is the main hormone in ovulation?
LH surge (then body temp rise)
What is the main hormone of the luteal phase?
Rise and fall, 24-36 hours before Ovulation
LH (luteinizing hormone)
Surges in blood prior to ovulation, tells ovary to release mature follicle--35 hours before ovulation (peak LH value is 10-14 hours before ovulation)
pre-ovulatory rise 24 hours before ovulation
post ovulatory rise
maintains the pregnancy (corpus luteum)
Peak Day, +/- 3 days
Endometrial phases of menstrual cycle
-Menses (day 1-5), low E and P levels
-Proliferative (days 6-13), endometrium thickens d/t increasing Estrogen levels
-Secretory phase (days 14-28)--begins at ovulation, Progesterone is produced by the corpus luteum--endometrial lining gets thicker for a fertilized ovum to implant
Ovarian Cycle Phases
Follicular-day 1 of menses to just before ovulation (about 14 days--this phase can vary in time)
Ovulatory-High Estrogen levels and LH surge-then ovulation (if no LH surge, no ovulation)
Luteal-Progesterone produced by corpus luteum, negative feedback to Hypothalamus and Ant Pituitary prevents further ovulation--this phase is constant in terms of number of days--usually 14--depends on woman)
What are some physiologic biomarkers of ovulation?
Increased temp due to progesterone once ovulation occurs, Estrogen causes: thin, watery, slippery, egg white, cervical mucous--easy for sperm to swim through--last day of this type of cervical mucous in about 12 -24 hours after ovulation, mittleschmerz (sharp pain on either side where ovary is)
What type of cervical mucous does progesterone produce?
thick, not good for sperm to swim through, not fertile, forms a barrier
What type of menstrual cycle would you expect with a woman with PCOS?
Anovulatory with high constantly Estrogen levels
Breast A and P
Large Sebacious glands, Human placental lactogen stimulates mammary glands during pregnancy
Ovaries: Estrogen: stimulates growth of glands and ducts Progesterone: stimulates growth of milk producing cells
Anterior Pituitary: Prolactin: mammary gland development, milk production
Growth Hormone (GH): mammary gland development
Posterior Pituitary: Oxytocin: milk ejection in response to sucking
G = gravidity (# of times pregnant)
T = term (37-42 weeks)
P = preterm birth (less than 37 weeks)
A = abortion (< 20 weeks)
L = living children
What are examples of teratogenic meds to discontinue in pregnancy or when a woman is trying to conceive?
ARB, ACE inhibitors, Paroxetine (Paxil), Coumadin, Depakote
What can you give a pregnant woman with HTN instead of ACE and ARBs?
1st line: Labetalol, Nifedipine
Order of gyn exam
1 External inspection and palpation
What are benefits associated with preconception counseling and care visits?
Improved outcomes associated with early health screening, prevention and management of chronic illnesses
28 year old with 6 month old twin delivered at 34 weeks, miscarriage at 12 weeks 2 years ago: Record using GTPAL
G2, T0, P1, A1, L2 Twins = 1 gravida
You are reviewing med list during a preconception visit. Which med is safe to continue?
Fluticasone HFA inhaler
Name the parasitic infection transmitted by contact with contaminate food and animals? think cat litter
Folic Acid recommendation in woman with no added NTD risk?
0.4 to 1.0 mg of folic acid per day at least 2-3 months before conception and through pregnancy and lactation
What tests should all women who have risk factors be tested for at first prenatal visit?
Chlamydia, Hep B, HIV, and Syphillis
Criteria for satisfactory PAP smear:
Done to see change in endocervical area, use endocervical spatula THEN the brush--stay in contact with the inner surface of the OS, liquid cytology--sample can be used to test for pap test, HPV, Gonorrhea, and Chlamydia testing
Differentiate between subjective and objective data:
Subjective: What patient tells provider
Objective: Data and information provider collects upon exam
Where do most injuries occur to a domestic abuse woman?
chest, face, breast, abdomen
Leading cancers for women that cause death:
Lung--leading cancer that causes death, followed by breast cancer then colorectal cancer then cervical cancer, Skin cancer is most PREVALENT cancer among women, followed by breast cancer
When does ACOG say to begin HPV/PAP testing?
Age 21 and continue every 3 years until age 29, then between ages 30-59 done every 5 years with HPV DNA testing (if not DNA testing not available--PAP every 3 years between ages 30-65), after age 65 stop if all prior PAPs normal or total hysterectomy
What is the number 1 reported STI?
most common, bacterial, AA's more likely, adolescents and young adults
S/S: usually none, women: vaginal d/c, postcoital bleeding, vague lower abdominal pain, mucopurulent cervical d/c, bimanual tenderness, WBC's wet mount, chlamydia cervicitis; Men: cloudy, watery d/c from tip of penis, pain, discomfort, burning with urination
***TX: Axithromycin 1 G PO single dose OR Doxycycline 100mg PO BID 7 days
List some risk factors for STI's:
multiple sex partners, sex young age, sex with HIV infected, sex in exchange for money, sex while intoxicated, illicit drug use, mental illness, less than 25 years of age, prisons, pornography
What is abnormal for cycles?
3 or more abnl cycles in 1 year OR 2 consecutive abnormal cycles as defined by cervical mucous
What does an abnormal cycle look like?
Less than 24 days, greater than 36 days--OR normal length (24 to 36 days) but short luteal phase (less than 10 days) or absent LP
Normal Follicular phase length?
Normal Luteal phase length?
11-17 days by urinary Estrogen
9-18 days by cervical mucous peak
When is LH SURGE?
35 hours before ovulation
When is LH PEAK?
10-14 hours before ovulation
When to give TDap in pregnancy?
27-36 weeks to give passive immunity to baby
What type of flu shot to give in pregnancy?
Inactivated form (not live)
Max of Vitamin A to give in pregnancy?
8000 IU/day--more can cause birth defects
How much Folic Acid for High Risk mom (Hispanic, IDDM, Epileptic, BMI >35, Family History of NTD or personal history of prior NTD)
4.0 mg 2-3 months prior to conception until 12 weeks gestation then decrease to 0.4 mg per day
Ovaries: Estrogen: stimulates growth of glands and ducts Progesterone: stimulates growth of milk cells
Anterior Pituitary: Prolactin: mammary gland development Growth Hormone: mammary gland development
Posterior Pituitary: Oxytocin: milk ejection in relation to suckling
First line use in HTN in pregnancy:
Labetolol and Nifedipine (NO ACE/ARB)
May use Methyldopa but not as effective
Derm: in pregnancy--do NOT use:
Accutane for acne OR Soriatane for severe psoriasis
DM in pregnancy:
NO Statins, A1C goal is 6.5 or less
Epilepsy in pregnancy:
No Depakote or Tegretol
Heart disease or CHF in pregnancy:
At higher risk of CV events
**Watch if NYHA Class 2 or higher, also if EF less than 40%
Hypothyroidism in pregnancy:
may need to increase Thyroxin dose
Hyperthyroidism in pregnancy:
may need to stop Thyroxin--pregnancy may put woman in remission for pregnancy duration
Mental illness in pregnacy:
NO Lithium, NO paxil
What are the reportable STI's?
G and C, Syphilis, Chancroid, HIV, Hepatitis
5 P's of sexual health:
Prevention of Pregnancy
Protection from STI's
Practices -sexual practices
Past history of STI's
What are the bacterial and protozoal STI's?
#1 Reportable: Chlamydia (chlamydia Trachomatis)
#2 Reportable: Gonorrhea (neisseria gonorrhea)
Syphilis (Trepanema pallidum)
Chancroid (Haemophilus ducreyi)
Trichomoniasis (Trichomonas Vaginalis)
Treatment for Chlamydia:
Doxyclyline 100mg BID 7 days
treatment for gonorrhea
Ceftriaxone 500mg IM for one dose if less than 150kg
If > 150kg: Ceftriaxone 1 G --one dose
Give Doxy if Chlamydia not excluded
Primary Syphilis symptom and treatment:
Primary: Painless Chancre
Adults: Benzathine PCN G 2.4 million units IM times one dose
Infants and Children: Benzathine PCN G 50,000 u/kg IM up to max adult dose of 2.4 m units--single dose
Alternate if PCN allergy: Doxycline 100mg PO BID for 14 DAYS OR Tetracycline 500mg PO QID 14 DAYS
Secondary syphilis symptoms
Maculopapular rash--on chest or elsewhere
tertiary syphilis symptoms
-Gummatous lesions (skin and bone nodules)
-Cardiovascular problems (aortic regurg or aneurysm)
Neuro symptoms may develop at any time--increase risk of getting HIV
Treatment for Syphilis: Primary, Secondary, and Early Latent (within 12 months)
Adults: Benzathine PCN G 2.4 million units IM times one dose
Infants and Children: Benzanthine PCN G 50,000 u/kg IM up to max adult dose of 2.4 m units--single dose
Alternate if PCN allergy: Doxycline 100mg PO BID for 14 DAYS OR Tetracycline 500mg PO QID 14 DAYS
How to treat Late Latent Syphilis or Unknown stage:
3 doses of Benzathine PCN G 2.4 million units IM each at 1 week intervals
Alternate: Doxycycline 100 mg PO BID for 28 days OR Tetracycline 500mg PO QID 28 days
How to treat tertiary syphilis?
With normal CSF: Benzathine PCN G 7.2 million units total, administer as 3 doses: 2.4 units each 1 week intervals--ID referral
How to treat reportable Chancroid:
PAINFUL Genital ulcer WITH positive suppurative inguinal adenopathy **Ask about travel to Africa or Carribean
Clinical Criteria: 1 or more PAINFUL genital ulcers
POSITIVE reginal lymphadenopathy
NO evidence of T. Pallidum at least 7 days after onset
HSV PCS or HSV culture of exudate negative
Treatment: Azithromycin 1 G PO x 1 dose
Facts for Trichomonas Vaginalis:
Anerobic flagulated Protozoan (one cell)
70 % of people asymptomatic
Women: Strawberry Cervix, Increased vaginal fluid pH, Amine odor with KOH
How to diagnose: NAAT: Women: Vaginal Swab, wet mount Men: 1st catch urine
Treatment: Woman: Metronidazole (Flagyl) 500 mg BID 7 days
Men: Metronidazole 2 G PO one dose
Viral and parasitic STDs' NO cure
Genital Herpes (HSV)
Genital Warts (HPV)
Hepatitis-Hep B, C--viruses
How to treat Genital Herpes (HSV 2 most common cause) 1st episode:
1st episode: Acyclovir 400mg PO TID 7-10 days
Treatment can be extended if healing not complete after 10 days
How to treat Genital herpes--Suppressive Treatment:
Acyclovir 400 mg PO BID per Epocrates reassess treatment need at 1 year
How to treat Genital Herpes--Episodic treatment (within one day of prodrome)
Acyclovir 800mg PO BID 5 days
Facts about Genital Warts--HPV:
Most common STD in US
HPV 16 and 18 causes oral, anal and genital cancers (Gardisil vaccine)
HPV 6 and 11 is a lower risk infection, causes genial warts
Facts about Molluscum Contagiosum: Pox Virus
White/Pink Pearly White head
occurs anywhere on body
resolves after 12-14 months or up to 4 years
can get with close contact, sharing towels etc..
Facts about Pubic Lice:
NOT spread by dogs and cats
TREATMENT: Permethrin 1 % cream, rinse and wash off after 10 min
Facts about Scabies:
Prolonged skin to skin contact
Close body contact
TREATMENT: Permethin 5% (Elimite) leave on 8-14 hours; may give with oral Ivermectin, itching may persist even after effective treatment
Facts about PID:
upper genital tract
G or C untreated
Fallopian tubes abscess and scar--increase r/o ectopic
**Increased r/o PID within fist 21 days of IUD insertion
Early treatment is critical
S/S: G and C is asymptomatic, Abdominal, pelvic, and low back pain, abnormal vaginal discharge, post coital bleed, fever, n/v
TREATMENT: Ceflasporin (3rd Gen) 500mg IM one dose PLUS Doxycyline 100mg PO BID 14 days, PLUS metronidazole (Flagyl) 500mg PO BID 14 days
May need IV antibiotics
Facts about Bacterial Vaginosis (BV):
Vaginal pH is > 4.5 (normal pH is 3.5 to 4.5)
Wet prep (saline) + clue cells, decreased amount of lactobacilli
D/C is thin, gray-white
Add KOH: Amine fishy odor, "whiff test"
occasional dysuria and dyspareunia
Facts about Vulvovaginal Candidiasis:
Vaginal pH < 4.5 (normal 3.5 to 4.5)
Wet prep (KOH) to SEE pseudohyphae with yeast buds
D/C is thick or thin, white, curd like or cottage cheese like, adherent
NO FISHY ODOR
POSITIVE ULCERATION IF SEVERE
NO PELVIC PAIN, NO PID RISK
POSITIVE DYSURIA IF SEVERE
Treatment for BV:
Metronidazole 500mg PO BID 7 days or 250 mg TID 7 days
Clindamycin 300mg PO BID 7 days
Metronidazole get 0.75 % 5G Intravaginal daily for 5 days
Clindamycin cream 2%, 5G Intravaginal at bedtime for 7 days
CDC recommends oral (more effective) OR topical treatment in pregnancy: Ok in all trimesters
Treatment for Vulvovaginitis Candidiasis:
Fluconazole 150mg PO single dose
--may repeat 2nd dose 72 hours later if severe
VAGINAL CREAMS: Butoconazole 2% 5G single dose
Terconazole 0.4% 5G 7days
Terconazole 0.8% 5G 7days
Terconazole 80mg vag supp. daily for 3 days
OTC Azole vaginal creams or suppositories OK in pregnancy!
Facts about Asymptomatic Bacteriuria:
+ bacteria in urine but no symptoms
only complicated in pregnancy
Facts about Cystitis:
Involves urinary bladder AND urethra
Uncomplicated: NO fever, CVAT, or flank pain
COMPLICATED: pregnant, recent antibiotics, recent UTI's, decreased immunity, fever, CVAT, + flank pain
Facts about Pyelonephritis:
Involves 1 or both kidneys
Uncomplicated: fever, CVAT, + flank pain, not pregnant, no vomiting, no underlying chronic dz
COMPLICATED: Pregnant, Vomiting, Immunodeficient.
How to treat Acute Simple Bacterial Cystitis:
Fist line: Macrobid Nitrofurantion 100mg PO BID 5-7 days
Bactrim DS 160/800mg PO BID 3 days if uncomplicated
Monural 3G powder mixed with water in single PO Dose
How to treat UTI in pregnancy:
E coli is most common pathogen
GBS + in 15-25 % of all women
TREAT ALL GBS + Bacteriuria > 1M cfu./mL with antibiotics--Macrobid (nitroruantoin) 100mg PO every 12 hours 5-7 days--NOT in first trimester or at term if other options available
25 % of asymptomatic GBS bacteriuria will progress to acute Pyelonephritis--very sick, systemic symptoms
Acute Cystitis: + 100,000 cfu/mL with symptoms
What is a leiomyoma?
benign uterine fibroid of the smooth muscle, classified based on location, seen in women by menopause and the main reason for hysterectomy in US, Diagnosed by ultrasound, 25 % of women symptomatic, genetic, cumulative Estrogen exposure increased prevalence
What is the adnexa?
ovaries, fallopian tubes and supporting ligaments
Facts about Endometriosis:
Cyclic organ pain, occurs in ovulating women usually, can cause infertilty, increased risk with genetics, white, early menarche
Gluten free diet can help
What is a functional ovarian cyst?
Follicular, no rupture, can hemorrhage, torsion--severe pain is emergent
What is a mature cystic teratomas?
Dermoid cyst, sebacious cyst, get very large, may be benign
What is a serous cystadenoma?
glandular tissue with ovarian epithelium, thin walled 5-less than 20cm
Facts about chronic pelvic pain:
lasts at least 6 months, can be sudden or gradual, 15-20% of women ages 18-60, do not assume gyn related--use a holistic multidisciplinary approach
What is Nociceptive pain with CPP?
"pain with purpose", indicating inflammation, injury, or disease
What is Neuropathic pain with CPP?
"pain without purpose", direct impact of lesion or disease on somatosensory pathway, burning, paresthesia, lancing
Facts about stress incontinence:
involuntary leakage of urine with increase in intraabdominal pressure by sneezing, coughing, laughing, without bladder contraction--most common in younger women--highest in ages 45-49--do Kegels!
Facts about Urgency incontinence:
urge to void after leakage of urine, overactive bladder, common in older women, associated comorbidities
Facts about Mixed incontinence: Stress and Urgency
continuous urinary leakage or dribbling in setting of incomplete bladder emptying, caused by detrusor underactivity or bladder outlet obstruction, associated symptoms: weak, intermittent stream, hesitancy, frequency and nocturia
Criteria for satisfactory PAP sample:
use spatula, then brush-stay in contact with the inner surface of os--liquid cytology--pap test, HPV, G and C testing
***Adequate cells from the cervical squamocolumnar junction AKA: Transformation zone
What is the leading cause of cancer DEATH in women?
lung cancer followed by breast
What is the most PREVALENT cancer in women?
skin cancer followed by breast
What are the PAP guidelines
start at age 21 and continue every 3 years until age 29; between ages 30-65 done every 5 years with HPV DNA testing--if no HPV DNA testing conduct PAP every 3 years between ages of 30-65, after age 65 stop if all PAPs have been normal or pt had total hysterectomy
Categories 1 and 2 Prescribe
Categories 3 and 4 Avoid
Cat 1: A condition for which there is no restriction for the use of the contraception method
Cat 2: A condition where the ADVANTAGES of using the method outweigh risks
Cat 3-Avoid--Risks outweigh advantages
Cat 4-Avoid-unacceptable health risk of contraceptive method used
Family Planning Effectiveness: Tiers 1
Tier 1--most effective, male vasectomy, female tubal ligation, IUD's LNS-Mirena (5 years-thickens Cervical Mucous) Paragard (copper is released to decrease sperm motility), Implant-Nexplanon (releases Progestin only for 3 years-effective immediately-suppresses ovulation--irregular bleeding is common)
Family Planning Tier 2
Tier 2-depends on patient adherence, Patch, ring, pill, minipill, OCP: Estrogen and Progestin combined or mono/bi/triphasic OR Progestin ONLY: depo-provera -inhibits ovulation, CM thickens; Norethindrone-thickens CM **BBW: Decreases bone mineral density, ADE: Weight gain, irregular bleeding
Family Planning Tier 3
Tier 3 least effective: Barrier methods-condoms, diaphragms, cervical caps, sponges, spermicide withdrawal method, non hormonal
Hormonal contraceptive adv and disadv:
Advantages: decreased r/o PID and ectopics, decreases r/o colon, ovarian and endometrial Ca, decreases r/o endometriosis, adenomyosis, RA and asthma
Disadvantages: NO STI protection, increased r/o VTE
Non-hormonal contraceptives adv and disadv:
Advantages: no ADE, No clinical involvement
Disadvantages: need motivated users, less effective
Absolute Contraindications of IUC's
acute pelvic infection, reproductive tract abnormalities, cervical, endometrial, or breast cancer, Don't use Paragard with Wilson's dz or copper allergy
When to NOT use Oral contraceptives?
Smokers, CVD risk, HTN, DVT/PE, Current or past Breast cancer in last 5 years
Facts about Depo-Provera:
Given every 12 weeks, Progestin only, may still ovulate, decreases bone mineral density, Tier 2 method, may cause migraines, may increase depression, Do not give if history of DVT, PE, CVD, associated with decreased risk of endometrial cancer
hirsutism, facial acne, alopecia-crown of hair thinning, long irregular cycles, infertility, at risk for metabolic syndrome, DM2 and CVD--excess androgens
Testosterone most potent androgen, decrease in SHBG, ovaries are most common source of increased Testosterone and androstenedione (adrenal causes are rare)
LH levels are high but no surge this inhibits ovulation
increase insulin due to increased LH levels; no FSH, no follicular rupture or ovulation
Acanthosis--dark patches in body folds--classic for metabolic dysfunction and increased insulin
What is the Hallmark sign of PCOS?
usually long periods
Clinical Presentation of PCOS:
Obesity: apple shape
Acne, excess facial hair
increased insulin, increased Estrogen and Testosterone
Insulin resistance-- can occur in normal weight women
but mainly seen in obese women
impaired glucose tolerance: increased Type 2 DM
Metabolic Syndrome (obesity-apple shape)
Psychologic impact: increased depression/anxiety, eating disorders
Cancer:3 times increased risk of endometrial cancer but NO increased r/o breast or ovarian cancer
PCOS Physical Exam:
Acne, hirsutism, alopecia, acanthosis on neck or under breast, thyroid enlargement/nodules, breast: galactorrhea, Cushings signs: moon face, buffalo hump abdominal striae, clitoral hypertrophy, check uterine size, ovarian size, check for masses
PCOS Diagnostic Testing:
Serum HCG, Prolactin level, TSH, fasting lipid profile, 2 hour oral GTT, and FSH, Serum total Testosterone, SHBG
***Gold Standard: Transvaginal U/S to identify polycystic ovary
May need to refer for Endometrial biopsy
Diagnostic Criteria for PCOS:
1. Oligo-and/or anovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovary morphology by ultrasound
1 Androgen excess + ovulatory dysfunction
2 Androgen excess + polycystic ovarian morphology
3 Ovulatory dysfunction + polycystic ovarian morphology (skinny PCOS)
4 Androgen excess + ovulatory dysfunction + polycystic ovarian morphology
PCOS pharmacologic treatment options:
• Hormonal birth control: COCs (this is only symptom mgmt--but this also increases DVT and PCOS increases DVT)
• Clomiphene: 1st choice to stimulate ovulation
• Spironolactone-decreases testosterone
• Metformin-increases ovulation, decreases androgen ***1500-2550 mg per day, start at 500mg and titrate up as tolerated, take with food
PCOS non-pharm management:
lifestyle modification, decrease weight, healthy diet, increase exercise
Heavy menstrual bleeding (HMB)
heavy prolonged cyclic menses
bleeding between periods; anemia not usually a concern
PALM: Structural Abnormalities
P: Polyps AUB-P
A: Adenomyosis: AUB-A
L: Leiomyoma: AUB-L
M: Malignancy and hyperplasia AUB:M
PALM: Structural: AUB: P
Polyps: Benign cervical or endometrial, bleed after intercourse
PALM: Structural: AUB-A
Adenomyosis: endometrial tissue within myometrium
Common in over 40years of age and multiparous
Assoc. with miscarriage and any type of trauma: Currettage, C Section, Tamoxifen use
Dx: US and MRI
PALM: AUB: L
Leiomyoma: submucosal (endometrial) fibroid--causes bleeding, benign pelvic tumor, classified by location in uterus
#1 cause of hysterectomy
PALM: AUB: M
Malignancy and hyperplasia
rare in reproductive age women, normal BMI without PCOS
Increased r/o endometrial Cancer with obesity and PCOS
Most common sign of endometrial cancer: AUB and post menopausal bleeding
COEIN: nonstructural causes
Not yet classified
COEIN: AUB: C
Coagulopathy: genetic, Von Willibrands disease:common inherited bleeding disorder: Screen for this with those with heavy menses: check Von Willibrand factor, check factor 8
Iatrogenic cause: Coumadin or any med
Leukemia coag problem: thrombocytopenia, anemia, and leukocytosis---check Hgb/Hct, CBC with diff, PT/PTT, FOB, platelets, and Factor V Liden
1 Irregular, Anovulatory (non cyclic) Uterine bleeding
Physiologic--pregnancy, lactation, Obesity, or BMI <18
Pathologic cause: PCOS, Hyperprolactinemia
2 Amenorrhea: Primary: Failure to begin menses by 16 yrs old Secondary: 3 month without menses after menses established
3 Ovulatory AUB: PCOS most common pathologic cause, intact HPOA, Normal hormone profile
COEIN: AUB: E
Endometrial: predictive, cyclical, with heavy menses, intermenstrual-prolonged, Endometriosis, chlamydia trachomatis infection
COEIN: AUB: I
Iatrogenic, IUD, Depo, Antidepressants disrupt HPOA
COEIN: AUB: N
Not yet classified: all other causes: arterio-venous malformation in the brain can impact the Hypothalamus
Physical Exam for AUB:
CV, Thyroid, Neurological, Pelvic Exam, Rectal Exam
Severity of bleeding--check for anemia
any associated symptoms? pelvic pain? Infertility?
Step wise approach to control bleeding and anemia
Naproxen can be very helpful
Possible surgical need depending on cause
Most important AUB question?
Have you ever had this before?
Facts about Mastalgia:
AKA: Breast pain, mastodynia, chest wall pain, common breast complaint, 90 % benign
Cyclic pain--common, in Luteal Phase--starts after ovulation and stops when menses begins, mild cyclic pain is normal! soreness or ache bilaterally, poorly localized
Non-cyclic pain--peaks in women in 40's, sharp, burning, unilateral, constant or intermittent, unrelated to cycle
Chest wall pain: localized, worsens with movement
Assessment of Mastalgia:
Physical Exam: inspect and palpate breast in upright and supine exam, note any change in breast tissue both visually and with palpation
**Rule out pregnancy! Rule out malignancy!
Rule out: Tietze syndrome, Shingles, MI or heart related
Treatment of Mastalgia:
Rule out malignancy and non breast issue first!
Decrease caffeine and fat intake. Supportive bra. May d/c HRT for a post menopausal woman.
**Danazol-NOT in pregnancy: for pain in fibrocystic breast disease--only for severe cases. Start during menses.
Facts about nipple discharge:
Usually benign-not normally seen in breast cancer (but can be in small numbers), Galactoria--hyperprolactinemia--is there a Pituitary tumor? Is it bilateral? Physiologic nipple discharge--both nipples with manipulation, more than 1 duct--are they pregnant? check prolactin level, check TSH
Look at patient med list: any TCA's?
***Non-milky discharge is always pathologic--unilateral, clear or bloody, spontaneous--no milking needed to get it out, draining--possible cancer--refer for mammogram
****Key differentiator: Does it only happen with manipulation? If so--may be physiologic.
Facts about benign breast masses:
Most common are fibroadenomas--due to estrogen--non tender, mobile, round, firm, common in adolescents, decreases with age, ultrasound is needed
Cysts: fluid filled masses, lipoma--older women
Fat necrosis may happen, fibrocystic changes, infection, malignancy-- refer to GYN
*** If a post-menopausal woman with a breast mass--assume malignant until proven otherwise.
Facts about breast cancer:
2nd most common cancer for prevalence and death
***Assess risk: advancing age, early menarche before age of 12, having babies after age of 30, Combined oral contraceptives are a high risk --as high as smoking. Post menopausal hormone therapy increases risk, obesity, ETOH use, Jewish at higher risk, Northern European risk, BRCA 1 and 2 (only 10% of breast cancers), dense breast tissue, cigarette smoking, shift work, elective abortion ( increases risk 25% -40%)
***Protective: having babies young and breastfeeding at least 12 months, normal weight, exercise
Breast condition facts and breast cancers:
Peau de Orange--orange breast, taught, visible pores--commonly seen in breast cancer
Padgets Disease--nipple effected, eczema around nipple and discharge, scaly appearance--associated with breast cancer
Facts about Menopause:
normal physiologic event, def: cessation of menstruation for 12 consecutive months, Premature if less than 40 years, Diagnosed retrospectively, FSH > 25 indicates entry into menopausal transition Perimenopause is 2-8 years before LMP and the 12 months of amenorrhea preceding menopause, average age is 52 years
STRAW stages--stages of reproductive aging workshop--woman greater than 45 yrs with amenorrhea of 60 days or more = late menopause or transition stage, Early menopause transition = cycle irregularities > 7 days in the 40's
Issues in Menopause:
Weight, CV Disease, DM, Cancer--lung cancer is leading cause of death in women--77 % diagnosed age 55 or older
Osteopenia--low bone mass T score -1.0 to -2.5
Osteoporosis-- T score less than or = -2.5
Diet, Exercise, Vit E and D, Vaginal lubricants, smoking cessation
Pharm: HRT: 20-60% of women choose this
Non-hormonal: Prozac, Paxil, Zoloft commonly used
Contraindications to HRT in menopause:
Estrogen absolute: breast, uterine, ovarian cancer, CAD, CVA
Progesterone absolute: DVT/PE, Liver Dz, Breast cancer, abnormal genital bleeding
Adverse effects of HRT in Menopause:
Estrogen: uterine bleeding, breast tenderness, nausea, bloating, h/a, dizziness, hair loss
Progesterone: Mood changes, increased uterine bleeding
Alternative therapy for Menopause:
Herbals: Ginkgo, Ginseng, St. Johns Wart
Isoflavones: plant based compounds with estrogenic effects, soy
Facts about Intimate Partner Violence (IPV):
It's all about control
Always screen, effects more women than men
IPV is higher with women living with men
Pregnancy increases IPV
Clinical Presentation of Ovarian Cancer:
urinary frequency or pressure
diarrhea or constipation
distinct abdominal pain
unexplained weight loss
cough or dyspnea
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NUR 353 Exam 1: Reproductive
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